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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)