RC-11-014320 f 1- �e�t-o
`' Wd(,D '(-"'L- f -A20
Miami 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
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING
C
AN
Permit No. ®I o
Master Permit No.
OWNER: Name (Fee Simple Titleholder): U mn'Sec 4v"AC,eA Phone#:11 2 `1 5 41IN
Address: B 0 V, ?et f �L J r, U e,
City: -�9 tb4tnV, St Ca Zip: anlzq
Tenant/Lessee Name:
Email:
JOB ADDRESS: 9 *i 7V i-A e
City: Miami Shores County:
Folio/Parcel #: _ [ 1 --77 -20 S LD ( (0 v Cn at
Is the Building Historically Designated: Yes NO
CONTRACTOR: Company Name:
Address: �Z l coo W
�N�ZL� Si�rZtYS X1.115
33�
Zone:
72�0 S 2 j91 41L1�17"
City: State: 411- Zip: 3`
Qualifier Name: �l i� �� ��2- Phone#: .9 .4--109
State Certification or Registration #: 66C- O& D O01 Certificate of Competency #:
Contact Phone #: RUS 2-19 4101 Email Address:
DESIGNER: Architect/Engineer: �L. j %, L_ I & M ? L^-CJa't4 L l ^ Phone#: W<— _Z:55
Valve of Work for this Permit: $ 2-5 t Square/Linear Footage of Work:
Type of Work: OAddress alteration ORepair/Replace
Description of Work: Ue n L 2 e� C
aolvs r—> (-^i/
ODemolition \
y2�C'-1LO N
r Cc>uw- lo�
5op,7 ►-t nodM TzC��C,�/��D lVi;° V..% lam `i4 -��R� �► S 1 ��1 SIC,
C_V-keh, 'S
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
Submittal Fee $ 5a Permit Fee $ CCF $ CO /CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond
Technology Fee $
TOTAL FEE NOW DUE $
`71
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
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 CO CEMENT."
Notice to Applicant: As a condition to the issuance of a building peril
promise in good faith that a copy of the notice of commencement and co
whose property is subject to attachment. Also, a certified copy of the recorded
for the first inspection which occurs seven (7) days after the building permit
inspection will not be approved and a reinspectw fee will be charged.
Signature Signature
Owner or Agent t
The foregoing instrument was a�n ow""ledged before me this 1
day oilA=1''ID 120 W , by rliq p, � y 1`-& I � ,
who is personally known to me or who has produced
As identification and who did take
��1RY PUBLIC: dQ��; q� °/ ®�qt,
•° \ A •• i
•� r
s .
Sign:
°
Print: nn�;pire My C ommissi ••.:!O
tJ �•ae.�.•!'e
APPROVED BY
(Revised 07 /10 /07)(Revised 06 /1QaM)(Revised 3/15/09)
The fo
day of
ted value exceeding $2500, the applicant must
k law brochure will be delivered to the person
of commencement must be posted at the job site
A& In the absence of such posted notice, the
Itr�iment was ackn wledged before me this
�►—� . 20 by KQC> 12- -t—
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
.y.,.w �- ....zr
Plans Examiner
Structural Review
My
" mn" � Nw t3, i
mss D
733960
Naf WNueva
Zoning
Clerk