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RECEWED
MAY 072014
BY:
1 ii ru_ t rc,) (1 F u--J5 11-- H01-
416,,
. _ 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
15,- (,fry
B IN
PERMIT APPLICATION
Permit Type.
JOB ADDRESS:
City: Miami Shores
Folio/Parcel #•
Is the Building Historically Designated: Yes
973
RECEINIFID
PR 212014
FBC20��
Permit No.
Master Permit No. WS -�
ROOFING
County: Miami Dade
Zip:
NO Flood Zone:
OWNER: N a m e (Fee Simple Titleholder): k V L d C. 17 v iS V
Address: c% 2 N. °Ls' S T.
City: M 1 earn l S 4-i tkrS State:
60c-- go2-c27
Zip: 3 r 3
Tenant/Lessee Name: Phone #:
Email:
CONTRACTOR: Company Name: J \ ,�
4,AI
Address. -� /-
27
f. City: Il %� State:
Qualifier Name: even t. (1
State Certification or Registration #:
Phone#: 77a' 4/4 - / :z9a
• Zip: 31-1,03
Contact Phone #:74' '// PION Emil Address:
Phone #: 7 72 Oi ✓
to of Competency #:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ DD , Q) Square/Linear Footage of Work:
Type of Work: DAddition� DAlteration ONew
Description of Work:
2 —P2 St\i bnD
Color thru tile:
****** *** ****** *** * * * * * *** * * * * ***,x * * *** Fees, , , * * * *, * * * *** *** *, , * *, * * * * *** * **** * * *** * * **
Submittal Fee $ �.�e � : Permit Fee $
his gr
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
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 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 COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building perm
promise in good faith that a copy of the notice of comment
whose property is subject to attach nt. Also, a certi
for the first inspection which occu' seven (7) days
inspection will not be approved and a reinspection fee
estimated value exceeding $2500, the applicant must
on lien law brochure will be delivered to the person
ed notice of commencement must be posted at the job site
wilding permit is issued. In the absence of such posted notice, the
e charged.
Signature
f r/
Owner or gent �, Contractor
The foregoing instrument as a 1 owledged before me qtis foregoing ins ent w acknowl ged before me this
day.of ► � %� , , by a lUit... 02 -1 t day of ► t 20 , by .il ' 426
,'me or who has produced � '1, who
f-' , , i'
As identification an o did,takc6 an oath.
NOTAI3X— UBLIC:
owl Muir,,
S s4Cd.
int ' 1 i w1G4T
may:
Commission
• . EE113069.:
44'rrru u n 40
to me or who has pr
dentification and
oath.
LIC:
APPROVED BY
Sign:
Print:
My Commission Expires:
********************************************
Plans Examiner
Structural Review
(Revised 5/2/2012XRevised 3/12/2012) )(Revised 06 /10 /2009XRevised 3 /15/09XRevised 7/10/2007)
Zoning
Clerk