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RF-10-1629q0110---irtamec Miami Shores Village Building Department 0 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY :....0 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No. V-C 10 .. Itta `I BUILDING PERMIT APPLICATION FBC 20 Permit Type: BUILDING OWNER: Name (Fee Simple Titleholder Address: ) 1 ( l fl City: Vtt dLv t IZ 1A0 #'U S 00400.04.90000 Master Permit No. Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 1 City: iAotiw' Miami Shores County: Miami Dade Zip: 331 6 Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: A \ ® 4 ( Address: t4 AD C&Qe* R City: L.01/4, t 0 State Qualifier Name: C 69 -H \-1 State Certification or Registration #: C ° 3 %�7,� t Certificate of�Com Contact Phone: 5 6.); 19 a j Email Address: iftilaltiL DESIGNER Architect/Engineer: Value of Work for this Permit: $ Type of Work: OAddress Description of Work: Aare O ratio = ' .(Z.1)0.11— e-ei "Le Phone #:. 3 8 9 - 0 . 3 p� Phone #: 56t— tency #: fl-v Phone #: of Work: ©® /Replace ❑Demolition COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: e************* * * * * * * * * * * * * * * ************ Fees****************** ** **e **+x************** * * ** Submittal Fee $4a . Permit Fee $ ROI Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ CCF$ CO /CC$ DBPR $ Bond $ TOTAL FEE NOW DUE $ 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 in commenced prior to the issuance of a permit and that all work will be perfo construction in this jurisdiction. I understand t • : a ,;. ar WELLS, POOLS, FURNACES, BOILERS, dicated. I certify that no work or installation has t the standards of all laws regulating CAL WORK, PLUMBING, SIGNS, OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and 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." that all work will be done in compliance with all 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 commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent -� The foregoing instrument was acknowledged before me this t L-� day of FILV 1.20 IP3 by who is personally known to me or who ha As identification and who did take an oath. NOTARY PUBLIC: Contractor ent was acknowledged before•me , 20 IC, by (vie,, rio42 Sign: Print: My Commission Exp 10 who is personally known to me or who has produced ee L1 () as identification and who did take an oath. NOTARY PU1'�",tn +�� / 1. �m L. Sign: Print: = bOTARV PORL. LE- My Commission 3 SOn 4.1c).%‘.- • °' , •.... • \.� %qr� O F ,CO * *** w****** w***** w* w* w *w *ww *** *ww* * * * *w *sl*�p�* yw *w ** ** * **w* * * * *** *** * ** ** �....* ** *w * w * **** * * * * * *** ** � APPROVED BY Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)(rev6/4/10) Zoning Clerk