RC-10-1449ai l
Miami Shores Village a ;
Building Department AUG 11 2010
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING PermitNolk.'10 I "9 9
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: BUILDING
�.� � ,
OWNER: Name (Fee Simple Titleholder): G6 �yt A14 y �j C �� Q� 0. Phone #: 367
Address: � (2 I
City: M ; 4 M , State: 'F� L Zip:
Tenant/Lessee Name:
Email:
JOB ADDRESS: 122 NE 101 STREET
City: Miami Shores County: Miami Dade Zip: 33150
Folio/ParCel #: 11-3206-013-2010
Is the Building Historically Designated: Yes AM a NO Flood Zone:
CONTRACTOR Company Name: Quality Home RepaiXULED Phone #: 786- 797 -2797
Address: 450 Northeast 178th Street
City: North Miami Beach State. FL Zip: 33162
Qualifier Name: Sender Kagan Phone #:
State Certification or Registration #: CBC1254448
Contact phone#: 786-797-2797 Email Address:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ 700 Square/Linear Footage of Work: 150
Type of Work: OAddress OAlteration ONew ORepair/Replace ODemolition
Description of Work: Replace three drywall patches
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
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)
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 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.
"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 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 co f recoTij notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after t d d In the absence of such posted notice, the
inspection will not be approved and a reins ection f be ,
Signature
Owner or Agent A
The foregoing instrument was acknowledged before me this
day of /,� Q s , 20 _k, by t� f��v J. k
who ikpersonally known t� me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Contractor
The foregoing instrument was acknowl before me thisL
day of sf 20 Lo, by SPl P,—
who i ep rsonally known me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: WAL A OATES Si
Print: �2 0- (total► p1d{Sc -State of tidal t: A�?�/ (r -0491
29,
My Commission Expires: ® t`� 9 Oomm"O" 0 DO 656216M Commission Expires: 0
.. a -:0
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09 )(rev6 /4/10)
Plans Examiner
Structural Review
Zoning
Clerk