PL-13-0784Miami Shores Village,
Building Department
10050 N.E.2nd Avenue, Miami Shofts, Florida 13138
. Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
83 CL91 I E79 I Z11
l
APR 16,., 6 6 1
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PIZ-
BY------ ... ........
Permit No. �+
Master Permit No.
, - - ' . -
OWNERS , Name (Fee Simple Titleholder): 1 561- 104 7-
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7, -77
Address: �e e
City: 114 f Apm, t
Email:
Ps State:
7777
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Zip
JOB ADDRESS:
City: Miami Shores County: Miami Dade —zip:
Folio)parccl#-.
Is the Buililin Olstorfcau* b ignated ;Yes-
?
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CONTRACTOR: Company Name: '_Sr- i9G.44419?06 C_ :kt2c_ Ph one#- -3
Address: '-3 6�lid zua,, /� S* CkT -7 4-23 D V
City: 044 — L- 61 C ot State:
Qualifier Name: p�vxb a> 6 ce 2 e,_"
' "gi on
StateCerdAcafii on of te"ittati #-_C'Fe /C,(?_C?_j?,Ceztifjcate of Competeno '#'
Contact Phonet JqO'YW _S_ _�,244-1- Email Addmss:
DES1GNk16'AichftecAne66ii`
Yh' ik
Value of Work for this Permit., oe'--f' 4°° - SquareiMinear
Type of Work: DAddress ClAlteration ClNew
of Work:
I X
Of Work j
/Replace CIDemolition
2"Ll /0
C—
Submittal Fee Permit Fee CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond
Training/Education Fee $ _ Technology Fee $
��$
u �L'Structural Review $ TOTAL FUNOW DUE $ WD250
0
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State zip
Mortgage Lender's Name (if applicable) -
Mortgage Lender's Address
City
stateP
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 ELECTRV -1 WORK, PJAlm$ING,, SIONS,
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.
irwARNING 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 roe is subject to attachment. Also, a certi ed co o the recorded notice o commencement must be osted of the job site
property m' � 1 .�+ PY .f f P J
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 d- - Signature
Own r Agent qaactor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged beforre° me thi
day of , 20 by . —� �d64� ��� 0� �� , day of A2n , 20', by
who is personally known to me or who has produced who is personally known to me or who has produced
F2 As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC
Sign: Sign:
Print: Print e-
M Commi ion Ex ires410trlo s
My C mission tu0 se�{dx3 a+"°+,��
Y t01L1L33 te�3�W >.
epl+atd 1a °3°i,'H4^d tie1Wd 'n� ►�` o1813d si�j ow �1i dt
ePPOW W Slats gMnd 41 1 *oa A*0
APPROVED BY MI% Y-_/:3 Plans Examiner 7m;iag
Structural Review Clerk
ro, ,
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)