PT-07-79Permit No. 5
01- ig
Waster Permit No.
Miami Shores Village 0I1I1rp� ..
Building Department �'�
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle): C� %'/ ,g
Owner's Name (Fee Simple Titleholder) jP Sit D V ( U( Ptk Phone # 'Sa5 - 1 ((D �[ t 4
Owner' Address 51-r NL' er ,�('.
city {;� g p (:a State
ty�l� � �
RECEIVED
JAN I� i 2007
BY: r w "I (yl .
Electrical Plumbing Mechanical Roofing
Zip
TenarftiLessee Name Phone #
Job Address (where the work is beug d$
City Miami Shores Village
FOLIO / PARCEL #
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address
City State Zip
Qualifier Name Phone #
State Certificate or Registration No. ; ,�1 }° .` Certificate of Competency No.
Architect/Engineer's Name (if applicable) e .
•
Value of Work For this Permit $
Type of Work: DAddition ['Alteration
Describe Work: MallA lv
Square 1 Linear Footage Of Work:
New:
❑ Repair/Replace ❑ Demolition
r ** r**** * ** * * *** * * * **** * * * * * ** * ** * * ** ** Fees * * ** * ** *, rat*** * * ***** * ** * * * * * * *** * * * * ** * ** * **
Ce
Submittal Fee $ Permit Fee $
Notary $ ''((�� Training/Education Fee $ Q-
Scanning $ 5 '(J 0 Radon $ DPBR $
CCF $ / CO/CC
Technology Fee $ "0
Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $
Total Fee Now Due $
See Reverse si e -+
�,cCbl)
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 BEF'. RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an`est faated value exceeding $2500, the applicant must
promise in good fait that a copy of the notice of commencement and cons u ien law brochure will be delivered to the person
whose property is s oject to attachment. Also, a certified copy of the recorded no : e of commencement must be posted at the job site
for the first inspec n wh occurs seven (7) days after the building per lizit, t r issued. In the absence of such posted notice, the
inspection will t 7 appr d and a reinsp- -e will be charged.
qi
Signature ' ' If
Own, •srAgen
The foregoing ins 7t t ew, . • ckn wledged before me this
day of— �i'-� =� ®f , by 4fSSl1s4w 1/11//a
�Awho is personally known to me or who has produced
V1 y 54 5' LZ3 0 As identification and who did take an oath
NOTARY PUBLIC:
er 15)
Signature
Contractor
The fo egoing instrument was acknowledged before me this
'day ;f , 20 , by ,
if&
o is personally known to me or who has produced
as identification and who did take an oath.
Sign: /l.�►
Print: /7oN& /wig__
My Commission Expires:
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPLICATION APPROVED BY:
(Revised 02/08/06)
Plans Examiner
Engineer
Zoning
Date:
Owner's Name
Job Address (whe
Miami Shores Village
Paint Color Approval and Agreement
Jd
e the work is being done):
City_ Miami Shores Village
Phone #: '3OJ - ?STC 4 rf
County:
Is Building Historically Designated ?:
Contractor's Company Name (if applicable):
Miami -Dade Zip:
NO
Phone #:
YES
Walls:
All elements on the site must be listed and indicate the color to be painted
Fascia:
tba
re
Drip Cap/Drip Edge: du 1(c
Soffit: Arf
Roof: E./1a1L- (`('
Flower Bins:
Shutters:
Awnings:
Chimney:
� sr�
tor cc f
Doors and Door Jams:
Garage Doors:
Railings:
Fences:
Decorative Metal:
60.41,4-
tatta
A rtj
Art
N-1
'lift (f
All brick (simulated or regular): 6041 re
Stucco Banding: Oita re
Any other Stucco Features:
Accessory Buildings:
Other:
but
OWNER'S AFFIDAVIT: I ce + at . the foregoing information is accurate and that all work will be
done in compliance with all . 1 -, regulating construction and zoning.
A i tek
■ 4'''rrorA.;
Signature:
APPLICATION APPRO
Date:
P : Z O " FICIAL
Date:
* *MUST BE ATTACHED WITH PURPLE BUILDING APPLICATION **