EL-06-2976Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING 1211 1OCP
PERMIT APPLICATION
FBC 2004
Permit Type (circle): Building
Electrical
Owner's Name (Fee Simple Titleholder) /
Owner's Address ® y 7 6
City d"'"1/4-1/ 5I(I®ttS State
Tenant/Lessee Name
Permit No.
Master Permit No. £ OC -r
Plumbing Mechanical Roofing
843 Phone # 3°5' 7 5-471 SSP
/ 0.3 57
zip 35/3
Phone #
Job Address (where the work is being done)
City Miami Shores Village
FOLIO / PARCEL # /
Is Building Historically Designated YES _ NO V
y 7
County
03 S7.
Miami -Dade Zip ..?3/ tt
Phone # ®.g- Z$ l � -77
Contractor's Company Name s: r L/ (, L�
Contractor's n Address lit / 4 (i r -5j'; �j ��i1 � c.� At /
City ( 6State F
Qualifier Name m t y L j 0 Phone #
State Certificate or Registration No. ( C. f 300 f Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
efi
Value of Work For this Permit $ /0-$0
Square / Linear Footage Of Work:
Type of Work: ❑Addition ['Alteration ['New
Describe Work:
❑ Repair/Replace ❑ Demolition
******* * * * * * * * * * * ** * * * *** * * * * * * * * ** *** *Fees * *** * * * ** * * *** ** * **
Submittal Fee $
Notary $
Scanning $ �' CO
Permit Fee $ 5 i (D®'
00
Training/Education Fee $
Radon $
Bond $ Code Enforcement $
DPBR $
* * * * * * * * * * * * * * * * * * * * * **
CCF $ CO/CC
Technology Fee $
Zoning $
Double Fee $
Structural Review. $ Total Fee Now Due $ .254 4.4).
See Reverse side —*
Bonding Company's Name (if applicable)
Bonding Company's Address
City w State Zip
e r.
Mortgage Lender's Name If applicable)
Mo0age Lende s- Access
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 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 must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is • s absence of such posted notice, the
inspection will not be approved and a reznspection j i[ e c air ed
idist
t Owner or Agent
The foregoing instrument was acknowledged before me this 8
day of De i_ I ' L by
who is p onally kno R to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign : -
.,,., ,.
Print: ]. ,
The foregoing instrument was acknowledged before me this e
day of -De-c-- -, -, 20 oks, by
who is personally knowo me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Farley Print: ,e 1 e
# DDie9324 EXPIRES �ti; •• L• ra Farley
My Commission
March 16, 2007 My Commis_,_, :�.� +ii1l�eon�MnISSION DD189324 EXPIRES
TROY FAIN INSURANCE _ rch k
APPLICATION APPROVED BY:
(Revised 02/08/06)
e-c Plans Examiner
Engineer
Zoning