PT-07-142Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No. Pr 4 2
JAN 2 5 20071
BY:
BUILDING 0112q10`,i;�
PERMIT APPLICATION V1(ce_'
FBC 2004
Master Permit No.
Permit Type (circle): Building Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) A, C��,L, Phone #
Owner's Address £ ..</® /Ifs I (/ //c - / / R/rj _g t
f
City /PAW/ c k)RES State r2_ Zip 3 3 /
Tenant/LesseeName ,% 7 `l
CC /%
Phone #
7,5/ 9) 31 8-Y338
Job Address (where the work is being done
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES
-Dade Zip 3 3/ (',0
NO
Contractor's Company Name S/f/L/9cr,S' t
Contractor's Address '?e3 47 AY, /7:9Z Tf / ' CZ
City6 74/1l 'iN/W6S State F
° vv Pkoie # (7,0 g73--76'0/
e Zip 33/ 6,8
Qualifier Name S/ / &ZA C S O V
/
Phone # 7' (D 31 e 33E
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: QAddition
Describe Work: , f
/00.o0
'Phone #
['Alteration
Square / Linear Footage Of Work:
['New
❑ Repair/Replace ❑ Demolition
Submittal Fee $
Notary $ Training/Education Fee $
Scanning $ Radon $ DPBR $
Bond $ Code Enforcement $ Double Fee $
* * * * * * * * * **
* * * * * * * * *F ** * * * * * * * * **
* * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Permit Fee $ CCF $ CO /CC
Technology Fee $
Zoning $
Structural Review. $
Total Fee Now Due $
See Reverse side --->
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lend 'TA eiiaplicable)
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 wits, an c timated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice o c r ,n
ncccnt and constructio r) lien law brochure will be delivered to the person
whose property is subject to attachm s rtified copy_ of the .rdedLLnotice of commencement must be posted at the job site
for the first inspection which occur se}' �) da, s 'ofier'thL' hualding permit is issued. In the absence of such posted notice, the
inspections will not be approved and a �p 'etion fee will be charged.
Signature
0
Signature
Owner o Agent Contractor
The foregoing instrument was acknowledged before me this 1. The foregoing instrument was acknowledged before me this
day of J N s , 20 07, by , day of , 20 , by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
Sign: Sign:
Print: Print:
My Commission Expires:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
tail 2
Plans Examiner
Engineer
Zoning