DS-13-0161Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
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PERMIT APPLICATION
Permit Type: BUILDING
JOB ADDRESS: I
City: Miami Shores County:
Folio/Parcel #:
(T-7-1
Rau JAN 2 22`3 �� f
FBC 20
Permit No. 1 �_)
Master Permit No.
ROOFING
F .
Is the Building Historically Designated: Yes NO Flood Zone: /!2`
OWNER: Name (Fee
Simple TiA
f 4�e Phone #:
Address:
City: l State: Zip:
Tenant/Lessee Name: o!/ Phone #:
Email: AdAFPAG I— C ; k4W)K
CONTRACTOR: Company Name: . ,0af ad 57'he Led 4-tJb S�ylaK /,j a Phone #: 5�
Address: 194P nfPJ
City: Pei`, 06AC9 Pfd jFC State: & Zip: 336
Qualifier Name: (rf Phone #:
State Certification or Registration #: C P C 151 �f ,(o,/ _ Certificate of Competency #:
Contact Phone #: Email Address: em4_e,,k )1 09 At Ede "e-(� a. tit
DESIGNER: Architect/Engineer. Phone #:
Sa �� S uat- e/Linear Foote f�Work: ll 3
Vaing. of Work for this Permit: $ y�i J q gir � C5 fc
Type of Work: ❑Addition OAlteration KNew LIRepair/I eplace ODemolition
Description of Work: R 0011V A. a T/ 0 / 10V ?
Colo" thru fete: .
Submittal Fee $ Permit Fee $
CCF
CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
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
City
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 CONDITIONIERS, ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is. accimrate',aaid',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 LEN TTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCE
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 Contractor
The foregoing instrument was acknowledged before me this
day of e4&1--) , 20 -L;5, by C. u fflc
who is sonally known to a or who has produce
As identification and% tl ;e%oath.
NOTARY PUBLIC:
Sign: I . V -,1
�
Print: � u
My Commission Expires: • Lt
APPROVED BY
tW' 016
The foregoing instrument was acknowledged before
` me this
day of el—a Q 20 �, by 0K) (3-S 4wb
who is ersonally to me or who has produced
Plans Examiner
Structural Review
as identification and who
NOTARY PUBLIC: /%A r ^,• � ,2o s
Sign: L-C 1Z V N We,
r
Print: 1 ''
My Commission Expires: aJ'
(Revised 5/2/2012XRevised 3/12/2012) XRevised 06 /10 /2009XRevised 3 /15 /09XRevised 7/10/2007)
Zoning
Clerk
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