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PT-07-163Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING 04)� PERMIT APPLICA'T'ION A FBC 2004 Permit No. PT — / b5 Master Permit No. Permit Type (circle): / : uildin Electrical Plumbing Mechanical Roofing Owner's Name (Fee Simple Titleholder) C vi2SSTC P•4 LS'‘11" 4=- -' Phone # 3o'S"1 s `'1" 7 D'S'O Owner's Address 17 Oto ST- City Mr Atikr S+% diae5 State r Tenant/Lessee Name Zip 33150 Phone # Job Address (where the work is being done) •? 7 City Miami Shores Village FOLIO / PARCEL # 11- ,a 13 (o 0 tiJ W le to SI.. Is Building Historically Designated YES NO X Contractor's Company Name & AO Phone # Zip '331 S +a Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 11 9,0 0 Type of Work: ❑Addition Describe Work: Square / Linear Footage Of Work: ❑ eration New © Repair/Replace ❑ Demolition i.e w1 e ******* * * * * ** * * * * * * * * * * * * * ** * * * * ** * * ** bps* * * * * * *, , ** ** ** *. * * * * * * *** * ** * ** * * *** *** * ** Permit Fee $ ✓' Submittal Fee $ Notary CCF $ 0 12- CO /CC Training/Education Fee $ (' 24 Technology Fee $ ) -Op Scanning $ Radon $ DPBR $ Zoning $ Double Fee $ Bond $ Code Enforcement $ Structural Review. $ Total Fee Now Due $ C 7 . See Reverse side -* Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that.no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of comme a /tructi' brachure will be delivered to the person whose property is subject to attachment Also a certi dpy-Qded notice of colremencernentmnust be posted at the job site for the first inspection which occurs seven (7) days after 'the brill ppf'mmnt i k, is.suettz JJ e ul'senbe of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Contractor Tit The foregoing instrument was acknowledged before me this z- The foregoing instrument was acknowledged before me this day of 20 ®a by c Z °t 1f° 1 I 6, ° 0 , day of , 20 , by who is personally known to me or who has produced 6. P101 031-K - who is personally known to me or who has produced As identification and who did take an o as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: NOTARY PUBLIC: Sign: Print: My Commission Expires: ***** *** * * * * * **** * * * *,* * * * ** * * * * * -Y: ******************************************* * ** **** * * * * ** * * * * * ** ** ** * * ***** APPLICATION APPROVED BY: (Revised 02/08/06) .3 6 7 Plans Examiner Engineer Zoning