BP-03-1675RECEWED
OCT 13 2003
BUILDING.
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Nam! Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
PERMIT APPLICATION
FBC 2001
Permit No-OXXZ 7 n 91
Master. Permit No.
Permit Type (circle): Building j!lect!Z Plumb' g Mec2hanical Roofing
Owner's Name (Fee S' le Titleholder) O
?1 v- . Phone # 7 '15'
5
's Address
City/' ✓ 'State zip
`�
Tenant/Lessee Name �` Phone # O
doneJob Address (where the work is being )
City _ 1VFiami Shores Village County Nflami D de Zip
Is Building Historically Designated YES NO
Contractor's Company Name Phone #
Contractor's Address
City State � Z -
p
rbialifier 11
Architect/Engineer's Name (if applicable) v Phone #
$ Value of Work For this Permit 1 /
Type of Work: []Addition ❑Alteration 4 ❑�N,eew�
Describe Work:I�2�1�2�`�����`�'
Square Footage Of Work:
❑ Repair/Replace ❑ Demolition
Submittal Fee $ 5 ® Permit Fee $ Q CCF $
Notary $3- M D Training/Education Fee $ =a 0 Technology Fee $
Scanning $ Radon $ Bond $
Code Enforcement $
Structural Plan Review. $ _ OCT 2 TWO ; 5l S�
Total Fee Now Due $ , 0 D
X1,30
(Continued on opposite side)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
zip
City State Zip
0 - e4
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 occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection w"ot be approved ald a reinspection fee will be charged .
er or Agent
The fo�yoing ' =ntas acknowledged before me thio
aay c(f/. 20
who is personally known to me or who has produce
As identification and who did take an oath.
NOTAR PUB IC:
Sign:
Contractor
The foregoing instrument was acknowledged before me this
day of . 20 by
who is personally known to me or who has produced
as identification and who did take an oath
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires 7- My enter ra. My Expires:
xpires: .
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
*************************************************************
APPLICATION APPROVED BY:
*****************
Plans Examiner
Che 10/14/03
����-g� 5 _. Zoning