RC-13-446Miami Shores Village
Building Department t �3
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 •
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
W2103
BUILDING Permit No.
PERMIT APPLICATION Master Permit No. 1
Permit Type: BUILDING ROOFING
JOB ADDRESS: 99cxp COL !-5 A°,--
City: Miami Shores County: Miami Dade Zip: 33135
Folio/Parcel #: 1 t - 3_-Ic:�,S —n-19 -D 1fYz��
Is the Building Historically Designated: Yes NO %Z Flood Zone:
OWNER: Name (Fee Simple Titleholder): Phone#:
Address: 1'\k3 1-3 /Ay,
City: M+,M" State: l Zip: 331
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Phone#:
Address: W--> uol
City: m yc 61 State: 1- t Zip: -1-6 G r
Qualifier Name: Phone#:
State Certification or Registration #: GVG�5(.o `7&1 Certificate of Competency #:
Contact Phone#(��_)8a _7 -lc��,� Email Address:,:::f
DESIGNER: Architect/Engineer: Alien c- Inca -ri Phone #:
Value of Work for this Permit: Square/Linear Footage of Work: U4
Type of Work: OAddition Alteration ONew ORepair/Replace ODemolition
Description of Work: 4 spca � nna
Color thru tile: C2 "
a
Submittal Fee $ 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 $
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 copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occyt�S'sey 7) days after the building permit is issued. In the once of such posted notice, the
inspection will not be approved-0 a're' spection fee will be charged.
r
Signature l Signa
Owne7R-12---k The foregoing instrument wadged before me this 'S The foregoing instrument was acknowledged before me this 5 day of ila�c,� -, 20 i?, , Q day of 20d , by
who is personally known to me or who has produced. who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
as identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
'y ELL
Print: MY COMMOSION 8 E 1 4 Print: f c.rl 177745
My Commission Expires:. EXPIRES March 11. 2016 My Commission Expir w. EXPIRES March 11, 2015
X0188 Notary8eniae ern wi/s aam
APPROVED BY _ *— rI j7 Plans Examiner Zoning
Structural Review Clerk
(Revised 3/ 12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)