DS-11-0700L - Ili .-Vio�&
Miami Shores Village
Building Department
10050 NX.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION.
FBC 20
Permit Type: BUILDING I'
OWNER: Warne I
Address: 1. U
City: r I I /Tr t
Tenn Na
Email: CTIPT
JOB ADDRESS:
City: A
Folio/Parcel #: I
Is the Building Historically Designated: Yes
tb A
APR 20•2011
Permit No. 1 '�
Master Permit No.
County: Miami Dade Zip:
e
CONTRACTOR: Company Name-", // a X3. 11 _ Phone# r
:g r/ 1
City: M I fud l
Qualifier Name: _
State Certification or
Contact Phone#:
�_ >'
111mr, .
DESIGNER Architect/Engineer. Phone#:
Value of Work for this Permit: $ SquarenUnear Footage of Work:
Type of Work: OAddress OAlteration ONew ORepair/Replace ODemolition
C LOR THROUGH ROOF TILE IS REQUIRED ae�iowledged by:
Submittal Fee $ V Permit Fee S CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Trainisg/Edueation Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
WA
state
zip
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 tai 's accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE I TQ RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN Y-Ot t�'; PAYING TWICE: FOR
IMPROVEMENTS TO YOUR ?PROPgii w: 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 goad 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
inspectio wi not be appr ved anO reinspection fee will be charged."
Signature - Signature
Owneryk Agent Contractor...
The foregoing instrument was acknowledged before me this 31 00
ent was acknowledged before me this
day of , 20 „ by Lft , day of . 20 (1__, by Q t Gt u 2 Lg-o s
who is personally known to me or who has produced 0, t who is personally known tome or who has produced r`- L-c.C)
As identification and who did take an oath.
NOTARY PUBLIC:
Aly
Sign: `\`1~�' o �. • �' �.... / //;
Print:
My Commission Expires:
APPROVED BY
rrr�. _
`
...
' oA
l / /llllllll�
@�r4r9r &9r�: sYBrkk��e: �•& �eaYfr�Ysh�r :t�Y3nY8e+1�t9eirs4�1n5
Plans Examiner
Structural Review
(Revised 07 /10/07XRevised 06/ 1042009)(Revised 3/15/09 )(rev6 /4/10)
as identification and who did take an oath.
NOTARY PJJBLIC:
, Sip:
Print:
My C
�a
• �tj�r &,,SdnY�4a4
/�rJr!IIt!I!%% �\Sning
Clerk