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DS-06-2956Miami Shores Village cif )119, Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING rizmEv° PERMIT APPLICATIO EC ©7 7 06 FBC 2004 BY: ----- Permit Type (circle): Building Electrical Permit No. Master Permit No. Plumbing Mechanical Roofing Owner's Name (Fee Simple Titleholder) 71410 � �.. 174/3 /L Phone # .5 ` 7-1-e9- 75.1 8 Owner's Address /2 7 av( /c) City o .1.--a ® S /t/o/� F T State �e Zip L`: / Tenant/Lessee Name Job Address (where the work is being do City Miami Shores Village FOLIO / PARCEL # Is Building Historically Designated YES NO p/ County Miami -Dade Zip .r3 /j d Contractor's Company Nat Contractor's Address Phone # City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 6 04 0) Square / Linear Footage Of Work: Type of Work: ['Addition ❑Alteration ❑N ❑ Repair/Replace ❑ Demolition Describe Work: S C ®4 ToY Submittal Fee $ Notary $ Training/Education Fee $ Technology Fee $ Scanning $ 9 caw -e k›-e. 10)n - S10 Permit Fee $ CCF $ CO /CC Radon $ DPBR $ Zoning $ Bond $ Code Enforcement $ Double Fee $ 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 issuance of a building perm promise in good faith that a copy of the notice of commencement whose property is subject to attachment. Also, a certified copy of th for the first inspection which occurs seven (7) days after t inspection will not be approved and a reinspection fee will an estimated value exceeding $2500, the applicant must ction lien law brochure will be delivered to the person tided notice of commencement must be posted at the job site permit is issued. In the absence of such posted notice, the Signature Signature Owner or Agent _. Contractor The foregoing instrument was acknowl � fore me this ! '-7 The foregoing instrument was acknowledged before me this day of J 2004 by bl y L. day of , 20 , by who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY 2 SIC: _ NOTARY PUBLIC: D .t Sign:, Air , ,� t. \I), S' Print: s a� voc, ,„,,.„o ),,_ r n: Pn My Commission Expires: ;;• <_ „r My Commission Expires: APPLICATION APPROVED BY: Plans Examiner Engineer Zoning (Revised 02/08/06)