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BUILDING
PERMIT APPLICATION
FBC 2004
Miami Shdres Village
Building Department
2.0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No. Da & ° 6‘
ter Permit No.
Permit Type (circle): Buildin: Roof
oS 72--k-k-57 (6 3
Owner's Name (Fee Simple Titleholder)
Owner's Address
City 1 54017-e,
Sta '
w-
Tenant/Lessee Name 0 I�
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL # 1 b2.4)COV 70 0
Is Building Historically Designated YES NO
oft
Co ctor's Company Name
3sE
ZZ4-073
qb/7 K 914+ pL
Zips" �� a
Phone # 5 5-( —041 6
Contractor's Address
City State Zip
Qualifier Name Phone #
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phon
Value of Work For this Permit $
Type of Work: ['Addition
Describe Work:
DAlteration
g Of Work: a� I (a) I R
❑ Repair/Replace
ber
El Demolition
***************************************F ** * ****** *** :** * *** * ** *+x**** * ** * *** ********
Submittal Fee $ Permit Fee $ l/�ce.) CCF $ 1 'O CO /CC
Notary $ Training/Education Fee $ 0(00 _ Technology Fee $ 39.3
Scanning
Bond $
Radon $
Code Enforcement $
Structural Review. $ D
c c cc�s .
2- Eieerrn iv 4- A ezoyas
5-- ; 'rL4J4t --
24
1— o(i► tTcvi MIAMI BLOKES `aL
See Reverse side -,
p� C
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.
"VVARNING 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 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 m be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the a ' of ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatur Owner or Ag
Contractor
The foregoing instrument was acknowledged before me this (2,, « The foregoing instrument was acknowledged before me this
day of 1-t , , 20 a, by Cc,,,, lloLz /t &I,e . , day of , 20 _, by
who is personally known to me or who has produced F( Divb1 who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
As identifieation'and who did take an oath.
Sign:
Print:
aQ4
MICHAEL KAUFMAN
* MY COMMISSION # DD 839381
My Commission Expires:0,, "'° oe EXPIRES: Mash 4, 2011
r F � R p C Bonded Thm BIRO W yServices
* * * ******** **** * ** axe **** d: e::*e:: x*+ x+ x*** 31t*****e< *************: x***** ************: x*****e<* *:x**:x **** * * * * ****** **** **
Sign:
Print:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 07/10107)
Plans Examiner
Engineer
Zoning