FW-11-737Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit No.
Master Permit No.
Permit Type: BUILDING ROOFING
OWNER: Name (Fee Simple Titleholder): ,7 4y _,, / L ,444 � � h #:
Address: JJ- /t/C. , ee /
City: /4 P � 2
Tenant/Lessee Name:
la APR 2 6 2011
cutt -731-
State:
Zip:
JOB ADDRESS:
City:
Folio/Parcel #:
Miami Shores
County:
Miami Dade
Zip: 1. r�
Is the Building Historically Designated: Yes
NO r�
Flood Zone:
CONTRACTOR: Company Name: C9 (P,f/
Address: r 3 �� ri
City: b�� /'
C.- State: L,
Qualifier Name: Phone #:
State Certification or Registration #: Certificate of Competency #:
Phone #: ,_Art ( %1: —
Zip:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ .1�(s, Square/Linear Footage of Work: ef�
Type of Work: Addition f OAlteration
Description of Work:
ONew
if
/Replace ODemolition
f Ae
** * * * * * * * * ** * * * * * * * * ** * * * * * ** * * **
Submittal Fee $c� Permit Fee $
Radon Fee $
x ees* x: x�* �x�x**** �xa��x ******** * **** *** * **** *** *******
ei
CCCF $ CO /CC $
Scanning 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 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 ORS AN ATTORNEY BEFORE
RECORDING YOUR NOTICE, OF COMMENCEMENT." r
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 subtelrt'to taekment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection whte 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.
Signat
Owner or Agent �a /
The foregoing instrument was acknowledged before me this °`�1i.
day of L ,20 `� ,by�drg Lt./ NJ 41--Ui -
who is personally known to me or who has produced
As identification and who ciisl an oath.
,:•\ °.\ \lera 0/1/4 /4i
Sign: �. - .�
Print:
v
NOTARY PUBLIC:
My Commission Expires:
APPROVED BY
/ / /) /,,,STA1
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
Sign: t , \�'
Print:
' Commission Expires:
Zoning
Clerk