ACT-13-664 (2) Miami Shores Village
,\ Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 7 qne
Tel: (305)795.2204 Fag: (305)756.8972
INSPECTION'S PHONE NU •(305)762.494 `= '-
FBC 20 (P
BUILDING Permit No.
PERMIT APPLIC CAN Master Permit No. ' r 1
Permit Type: BUILDING , ROOFING
JOB ADDRESS: 1 0V Al F- 0� S� fik, S'/40 s F1 .
City: Miami Shores County: Miami Dade Zip: 3.91119.
Folio/Parcel#: I I�9--�0 D �-O y 01 ®
Is the Building Historically Designated:Yes NO ,/ Flood Zone:
"Atzu rt 3c r> - 8-9 I -- � I
OWNER:Name(Fee Simple Titleholder):� J� S/V(73z0S 6W0fh1 ff1VP7 N$hone#: /� dlo 1 �V
Address:_702 e1166, 10
City: ,yYO//fir S&V1?,0,C-S State: Zip: J
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:AWL
A A W N o�4 K Q, Phone#: 3,3S'(S-1-1' Ta`
Address: V I® J v�C.
City State: A0. Zip:�/3 a 010
Qualifier Name: 9,jyw@S�'� YA® f a Phone#• -!39:�� �
State Certification or Registration#: Certificate of Competency#: �� e>a Q/I_Z3
Contact Phone#: 3 0 Email Address: Cow,
DESIGNER:Architect/Engineer: ISL tS Phone#:
Value of Work for this Permit:$ .e Square/Linear Footage of Work:
Type of Work: ❑Addition DAlteration r DNew ;ORepair/Replace ODemolition
Description of Work:
Color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
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 inadh 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law br chur wa l delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of com encem t ust a posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. I the a f s ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Si
Signature ,_!` gna
Owner or Agent c �
The foregoing instrument was acknowledged before me this ;Z�o The foregoing instrument was acknowledged before me this(,'v
day of ,20 ,by�Zd'L'� 1� m` -� day of ,20 L3,byo �A 'E> r
w,a,Bari-mca
who is personally known to me or who has produced yirN_ who is personally known to me or who has produced�l�
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: r ny�rP�i NOTARY PUBLIC: \`o`\\\\\\\utntttrrrr���/
Sign: „> •�� �>-p Sign:
Print: '�+ � Q
Print:
My Commission Expires: v; �\ My Commission Expires: �'%.
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 5/2/2012)(Revised 3/12/2012)XRevised 06/10/2009)(Revised 3/15/09XRevised 7/10/2007)
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Miami Shores Villa e
APPROVED BY DATE .
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