PL-08-1632Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 .Fax: (305) 756.8972
BUILDING
PERMIT. APPLICATION
FBC 2004
Permit Type:
Owner's Name (Fee
Owner's Address G
City ( I A S ft-4,
Tenant/Lessee Name-
E-MAIL:
Job Address (where t
City Miam
FOLIO / PARCEL #
Is Building Historica
Permit No. 6601
Master Permit No. iS l
Titleholder)
KW aZ ST,
State d Zip 33 Z
r
work is being done)
_796.307., 909�
County Miami -Dade Zip _
Designated YES NO
Contractor's Company Name Phone #
Contractor's Address j
City State Zip
Qualifier Name Phone #
State Certificate or Registration No. Certificate of Competency No.,
E -MAIL:
Arch itect/Engineer's Name (if applicable) Phone # ;';`'
Value of Work For this Permit $ Square / Linear Footage Of Work:
Type of Work: ❑Addition ❑Alteration FINew
Q Repair/Replace F1 Demolition
Describe Work: l>UMP sKI wAF- -
I
I
I
* Fees** *** **** **, r���, �, �x�xx�xx����xX ,x�xrx�xx�fx�fx�
Submittal Fee $ Permit Fee $ S CCF $ CO /CC
Notary $ I Training /Education Fee $ Technology Fee $.
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side -�
i
Bonding Company's Name (if applicable) _
Bonding Company's Address
City State
�
identification and who did take an oath. - as identification and who did take an oath.
NO ARY P L,IC: 4�~",��o�� NOTARY PUBLIC,
'® d 41's
Sign: Si:.
Print:
My Commission Expires:
APPLICATION APPROVED
Print:
My Commission
lans Examiner
Engineer