PT-07-127Miami Shores Village
Building Department OiZ
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
JAN 2 3 Permit No.
Z00Mer Permit No.
Permit Type (circle Building ; Electrical Plumbing Mechanical Roofing
t< Owner's Name (Fee Simple Titleholder) c{ ��f C, (G( Phone # Cc-'" I- cif --VIZI
Owner's Address f9( 7
City ,
Tenant/Lessee Name
State
Zip 3( "g
Phone #
cJob Address (where the work is being don
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES NO
> Contractor's Company Name
Contractor's Address
c
Phone #
City State Zip
Qualifier Name
Phone #
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable)
Phone #
ar Footage Of Work:
epair/Replace ❑ Demolition
Type of Work: ❑
Describe Work:
ition
ca
['Altera
d
n ['New
***** * ** * * * * * **** * ***** * **** ** * * **** **Fees********************************************
Submittal Fee $ Permit Fee $ O CCF $ (00 CO /CC
Notary $ Training/Education Fee $ 20 Technology Fee $ 3O
Scanning $ Radon $ DPBR $
Bond $ Code Enforcement $
Double 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 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 issuan uilding permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of corona meat and construction lien law brochure will be delivered to the person
whose property is subject to attachment Also a cert of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days aft' alding permit is issued In the absence of such posted notice, the
inspection will not be approved and a rei pection fee will b d
cf Signature �° i� V ,$iature
Owner or Agent Contractor
The foregoing instrument as a w edged before a this .�-�.l The ezeg'o js g instrument was acknowledged before me this
day of ,2 by �o .day of ,20 ,by ,
who is nally known to me or who has produced who is personally known to me or who has produced
o.--/ As identification and who did take an oath. as identification and who did take an oath.
NOTARY
Sign:
Print:
My Co
0,1, „U 4„ Main! VaYg:^;,e NOTARY PUBLIC:
5�� P
Commission #DD2319,
it 113,2007
onded M
q IM
fission Expires:
* * * * * * * * * * * * * * * * **
Sign:
Print:
My Commission Expires:
*************************************** * ** ** * * * *** * * * * *** * * * * * * *** * * **
APPLICATION APPROVED BY:
(Revised 02108106)
Plans Examiner
Engineer
Zoning
Aff
y 4
A
Miami Shores Village
Paint Color Approval and Agreement
Date:
Owner's Name: co Phone #: e�.0 - - 7314 7
Job Address (where the work is being done): jc:2 j( `%
City: Miami Shores Village County: Miami -Dade Zip: '27 -1 f
Is Building Historically Designated ?:
YES NO
Contractor's Company Name (if applicable): Phone #:
All elements on the site must be listed and indicate the color to be printed
Walls: - 6t4- #14.-‘901"
Fascia:
Drip Cap/Drip Edge: Sip (
Soffit: W
Roof: °k e
Flower Bins: C---ti%`Citi:
0—)
Shutters: iti,
Awnings: *q G 9/(1/e5',
Chimney: '5 ,� ,-� =� `:%war` a. �► =' M
e,(r(e
Doors and Door Jams:
Garage Doors: 641.9 e a t E
Railings: (9tM L ?Q — td`s' i'(
Fences:
Decorative Metal:
All brick (simulated or regular):
Stucco Banding:
Any other Stucco Features:
Accessory Buildings:
Other:
Attach color Samples
with numbers
400D -4
Corn Husk Green
Aceituna Pica nte pp
Spicy Olive PPH 617D
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with all ap . licable laws regulating construction and zoning.
Signatur
te:
Owner .' Agent
APPLICATION APPROVED BY:
P & O ICIAL
Date:
* *MUST BE ATTACHED WITH PURPLE BUILDING APPLICATION **