CC-12-1545Miami Shores Village
Building Department
10050 N.E.2nd Avenue, 1Vliami Shows, Florida 33138
Tel: (305) 795.2204 Fes: (305) 756.8972
INSPECTION'S PHONE NUMBER; (305) 7614949
BUILDING
PERMIT APPLICATION
Penult Type:
JOB ADDRESS:
BUIL DING
AUG ,62
������ooaee°0000vom000°oe�
FBC 20
Penult No.
Master Permit No.
100mer
city: Miami Shores
Folio/Parce #: County. a ;an„ Dade � Z
Is the Buiag
h3tor1cal�y,Dtcd: Xes NO
-=-- - Rood Zone:
OWNER: Name (Fee Simple Titleholder).
I. ;1
- i
�I1 1
CONTs
Address:
city: r
QualifieIJame: ��JI t✓ ��Fa ��° �'p��_
State Certification or Registration (6e," 1,0 u� '
�-- - _Cemficate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Archiwct/Engineer.
Phone*
" r
n'
Va1me ofWorh foi?-41115 Permit: $ 0
Square [.inear Foo e'of Work:
Type of Work: OAddition i]Alteration ONew �D'� r
t►�.,_s..u......e m__.__ _, r .. 11 P A P A"Uplace ODemnim.,..
e�ee��e�ew* eeeeeees�e�e�eae�tese+ seeoeoF�« sv�we* o�oee�* e* �eeeeveeaeeeea�erl�a� +� *� *u� *s
Submittal Fee $ Permit Fee $
Scanning ! CCF $
Fee $ CO /CC $
ng Radon Fee $ DBPR $ Bond $
Notary $ Training/Educatlon Fee
$ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
StateP
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
conswction m this jurisdiction. I understand that a separate Permit must be secured for ELECTRICAL WORE, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, ,BOH ERS, 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
�. , FOR
COMMENCEMENT MAY RESULT IN YOUR.. _„ _.PAYING_ _ TWIG.
AIPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND 'TO' I BTAIN
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 occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspectioir fee w#1 be charged
Sig °store
Owner or Agent
The foregoing instrument was ac owledged before me this hi—
day o 20 IL by
who is known to me or who has produced
As iden
Qj4%gpfv4, � ft oath.
NOTARY PUBLIC:
Print: J
My Commission Expires:
Sidra D. Hut
WCaan issian $ Dl -7f
pP71, C,7, 2,1a1@
Contractor
The fore instrument was acknowledged ?before me. this '
day of 20 -, by
who is owa to me or who has produced
as identification and who did take an oath.
SOWN PM C-5fl F w- ,," ":S D"
NOTARY PUBLI dra D. HaA
PDD�
r' AP& 02, 20013
mo 0a_ mac.
Sign-
print
My Commission Expires:
W APPROVED BY 1� -Z6-O _ Plans Examiner Zoning
Structural Review Clerk
(Revised 3 /12/2012)(Revised 07 /10 /07XRevi -d 0&10/ AWXReAwJ 3 /15/09)