RF-06-12214')V11,2 {0(0
BUILDING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 FFax:(3Os 756.8972
1 2006
PERMIT APPLICATION
FBC 2001 BY:
Permit Type (circle): Building Elec c Plumbing Mechanical
Owner's Name (Fee Simple Titleholder)
Owner's Address -' _-
City
Tenant/Lessee Name
Phone #hr_
Job Address (where the work is being done) 6 f5
City Miami Shores Village County Miami -Dade
Is Building Historically Designated YES NO
Contractor's Company Name /9/61--0//- 22a?
Contractor's Address /0
Zip.' J
City P n/4-� / tate Zip 2? %6r
State Certificate or Registration No. cc` CO-5---?9,06.
Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit /00
Type of Work DAdditiori DAlteration
Describe Work' ! L< 9 Z.
Square Footage Of Work: . SG7.
* * * **** * *** * * ** ************Fees******************************
Submittal Fee $ Permit Fee $ /06 CCF$ 1' , CO /CC
Technology Fee $ c�
Scanning $ Radon $ Zoning Bond $
Notary $ Training/Education Fee $ V .( )
Code Enforcement $ Structural Nan Review. $
Total Fee Now Due $ a go
(Continued on opposite 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 issu
promise in good faith that a copy e
whose property is subject to attac/ l
lestimated value exceeding $2500, the applicant must
lruction lien law brochure will be delivered to the person
�
s1"ed -co y jthe recorded notice of commencement must be posted at the job site
for the first inspection which occhxrs -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
Signature`
Owner or Agent
The foregoing, *nstrument was acknowledged be
20 04 by
Contractor
ore e thist The for. oing ? strument was acknowledged before me this
_/ 5'A, ' day of
20 by
o me or who has produced who is ers � all kn wn _ ye or w o has produced d "V • A�
As identific , t.. I
My Conunission Expires:
OTARY PUB
Sign:
Print:
My Commission Expires:
APPLICATION APPROVED BY: Plans Examiner
Engineer
Zoning
chc 05/13/03
"t s -
'1∎1;s *c vzs' 4Dco
'2,2. 1