RF-10-1752101 lttl 1p -' P-AKirtT'
Miami 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
OCT 0,4 2010 g
BY:
BUILDING Permit No. PC I l 0 f5(
PERMIT APPLICATION = Master Permit No.
FBC 20
Permit Type: BUILDI
OWNER: Name (Fee S' D Phone #: c9 O,% 772 ‘ F')'°
Address: %/Za /I-L, " ✓ �3 -c-
City: /4//Lt / / State: 'ft Zip: 3'3 /
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: Net
City: ✓ Miami Shores
Folio/Parcel #:
County: 17 Miami Dade Zip:
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name:
NO Flood Zone:
Address:
City: State: Zip:
Qualifier Name: Phone #:
State Certification or Registration #: Certificate of Com
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ oo -o0 Square/Line,ar Footage of Work:
Description of Work: 1
Type of Work: OAddress
OAlteration
ODemolition
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
Submittal Fee $ Permit Fee $ / 2caci CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 1114(00 •
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 H YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOT CE OF COMMENCEMENT."
Notice to Applicant: As a condition to the is e o a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice o "mencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a : '. copy of the recorded notice of commencement must be posted at the job site
for the first inspectio ich occurs seven (7) da ,��; the building permit is issued. In the absence of such posted notice, the
inspection will not s - appri ved and a reinspection fee .'h - harged.
Signature
` rz , m‹.6 ° &�/•47‘ Signature
ner or e
Ag nt
The for o instrument as a ,j"�+ ledged before
day of ,20) ,by 1,.t O
who is personally known to me or who has produced
As identification and who did take an oath.
NOT ' . PUBLIC:.. 'N
Sign:
Print:
My Commission Expires:
v, 7
<j W
a �°a:•��zf ,t0
yew
Contractor
foregoing instrument was acknowledged before me this
ay of ,20_,by
who is personally known to me or who has produced
as identification and who did take an oath.
„- NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
* * * * ******** * * ** ***** ** ***** ************** ************ **** * ***>s***** ins= ****** ******** ***** *******************
APPROVED BY / JC! Plans Examiner
Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6 /4/10)