FW-13-0565�y.
Miami Shores Village
Building Department
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
PERMIT APPLICATION
Permit Type:
JOB ADDRESS:
BUILDING
Z+L
FBC 20
Permit No�
Master Permit No.
ROOFING
City: Miami Shores County: Miami Dade Zip: t
Foho/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER Name (Fee Simple Titleholder):1eyeoY -GI 1% -) C y C a, Phone #: fF6 a3 a) 60,41
Address:
City: Cam 1 1 CW- State: —Ft Zip: 1
Tenant/Lessee Name: Phone #:
Email:
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State Certification or Registration #:
Contact Phone #:
DESIGNER: Architect/Engineer: _
Value of Work for this Permit: $_
Type of Work: ❑Addition
Description of Work:
Certificate of Competency. #:
10,11 �&eiear Footage of Work.
❑Alteration ❑New
Color thru d1e:
Submittal Fee $ Permit Fee
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF
CO /CC $
DBPR $ Bond $-
Technology Fee $
TOTAL FEE NOW DUE $ S
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 fait that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is su 'that
to attachment. Also, a certified copy of the recorded notic of commencement must be posted at the job site
for the first insectio ' which occurs seven (7) days after the building permit ' d. In the absence of such posted notice, the
inspection will be proved and a reinspection fee will be charged. �®
Signature Wignature_
er or Agent
The forreg ' g instrument was ac ow dged be a 10e,th�s The foregoing instrument was acknowledged before me this
day ol 20 y AMM day of , 20 _, by
wrho_is peAsonallylpown tome or who has produced who is personally known tome or who has produced
Aentification and who did take an oath.
NOT PUBLIC: - NOTARY PUBLIC:
Sign: -s 2 X Sign:
G v 7�'�\axP``Q u E� �Zgat`10 Print:
Print: 1
Contractor
as identification and who did take an oath.
My Commission E e 1 ; . `:spy �om�
My Commission Expires:
APPROVED BY �JJ� Plans Examiner
Structural Review
(Revised 5/2/2012 )(Revised 3/12/2012) )(Revised 06 /10 /2009XRevised 3/15/09 )(Revised 7/10/2007)
zoning
Clerk