RF-11-935 S
Miami Shores Village r ,rn ]5,
Building Department "I MAY ?, 3201
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax: (305)756.8972 Y: ... a
INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING Permit No.
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: BUILDING ROOFING
OWNER:Name(Fee Simple Titleholder)jL Q-f cl"5 46�'400-1()U Phone#: 37nS 3,
Address: ® ic -/—
City: State: sC Zip: 3
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: � AIC
City: Miami Shores County: Miami Dade Zip: L�
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR:Company Name: i �� �p ® i_�C; Phone#: y�cn 3 lo�
Address: �'f�
City: State:
Qualifier Name: 7/V y � � �S'- Phone#:
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
a �
Value of Work for this Permit: $ "i quare/Linear Footage of Work:
Type of Work: ❑Addition DAlteration r� /^ew ORtepair/Replacee ODemolition
�
Description of Work: , � /�® ��/�! 1 ► AN i
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) P `
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 inform ' 's accurate and that all work will be done in compliance with all
applicable laws regulating construction and zonin .
"WARNING TO OWNER: FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESUI`T, IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR ''PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WIT 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 issued. In the absence of such posted notice; the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Owner or Agent G U S—f' Lla contractor
The forego' instrument was acknowledged before me this ��' The forego' g ' strument was acknowledged before me this Z73
day of ,20 1/_,by Ar e,&r 6r.-wc���[A�t day of ,20 ,by
who is pers ally known to me or who has produced �G A,,0 c® 'who is perso . own to me or who has produced
identification and who did take an oath. as identification and who did take an oath.
NOT P TAR C:
Y P ec . ALEJANDRA BRITO ALEJANDRA BRITO
ign: _ ».= Notary Public-State of Florida Si :° Notary Public-State of Florida tin. Exphesjun! 2014
� o� Commission#DD 1000541 t My Comm. Expires Jun 10,2014
rmt. OF Ft„��� % P
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ommission pires: o s ' E "�°" W wow
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
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