ACT-11-1212— W$n=\ attri _. mss- P4+0
o.w. Miami Shores Village
A2co 70 45R.,4, . 1 m
c9C7 ()t- bri,e1/44.01146, s R(Z wilding Department
' 2t1 it WO taillit.010050 N.E.2nd Avenue, Miami Shores, Florida 33138
tC ea-WA Rows . Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit Ty e: BUILDING) ROOFING
OWNER: Name (Fee Simple Titleholder):
kt 0
Rt^i
Permit No. ACT (1 -- 12%1
Master Permit No.
rRPNc3 E ve*R -e T j Phone #: 7Z7- 591 - To-7 q
Address: ' 8 D € Jo t3 D R. t us
City: C. (EAR. Wbz2Q.. Be Ac 4 State: ... Zip: 33 767
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 1 a N£ Z ,A vre
City:
Folio/Parcel #:
Miami Shores
County:
- PPAA4tt.l4 13e64-'1Je
Miami Dade Zip: 13
Is the Building Historically Designated: Yes ' . a, Flood Zone:
CONTRACTOR: Company Name: "4,6 - 40 Phone #:
Address: 114 6, 5 OC/0" (3 /�� r
City: /1/. it / r State: Zip: �.. J /
Qualifier Name: L�.c T )to -e YJ Phone #: .S` �97,„g5'o
State Certification or Registration #: CGsG IS-0 St 6 3 Certificate' : �� tency #:
Contact Phone #:
Email Address:
DESIGNER: Architect/Engineer: C- 0 of - P - E . Phone #: 78C ` 3 82-161S
Value of Work for this Permit: $ Oc�.J - Square/Linear Footage of Work:
Type of Work: &Addition DAlteration UNew URepair/Replace
❑Demolition
Description of Work: P b D 1 'a' i o N GF' OIL Mutt . 7-0? Co VCR—
ow PAR-t4-4 11J5 ‘_43r Et+ t U o q( (2 {sI E 2 AVG-
**,r** ** * * ** r** * * * *** *****:r ***: *** ** * ** Fees** * * * * *** * **** *** * * * ** **** ***** ** * * * * * * ** **
Submittal Fee $ 50 ,..., 0 Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
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 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 FAI TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPE ; IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YO "NDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF CO '/ a 'CEMENT."
Notice to Applicant: As a condition to the issuance of a `yg permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of come ent and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certi .y of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days ti ,f • the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection f< _ X ti be charged.
Signature,
The fo
day o
Owner or Agent
oing instrument was fowled
L by
me or who has produced
trument was ackn
,20 (1,by
ho is personally known to me or who has produced
as identification and who did take an oath.
dentification and who did take an oath.
NOT :1;, PUBLIC: '
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
V Sign:
11 print:
My Co ssion Expires:
e1,4 Cyb• • o' C
(4,,44.)
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APPROVED BY
(Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
#,(5 F;i $$
******** * * * * * * * * * * * * *** ****** *** *,F ****
Plans Examiner
Structural Review
7/s177
* * * * * * * * * * * * **
Zoning
Clerk