BP-03-1838� Miami Shores Village
Building Department
Ca.E.2nd Avenue, Miami Shores, Florida 33138
4� 1. (305) 795.2204 Fag: (305) 756.8972
BUILDING
Permit No.
PERMIT APPLICATION Master Permit No.
FBC 2001
Permit Type (circle). Building Electrical Plumbing Mechanical (Roofing
Owner's Name (Fee Simple Titleholder) Phone #
Owner's Address
City
State
zip—
Tenant/Lessee
ip_
Tenant/Lessee Name Phone #
Job Address (where the work is being done) 4,5,5 A14, D
City _ Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO�
Contractor's Company Name
Contractor's Address
City
Phone #
State Zip
_tee Architect/Engineer's Name (if applicable) -Phone #
S Value of Work For this Permit®®� Square Footage Of Work:T ®�
Type of Work:
Describe Work:
❑New ❑ Repair/Replace
19- � _ v
Submittal Fee S Permit Fee S 4WO ® CCF S
Notary S Training/Education Fee $ Lao Technology Fee S
Scanning S Radon S Bond S
Code Enforcement $ Structural Plan Review. S
Total Fee Now Due S
(Continued on opposite side)
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 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 reinspection fee will be charged.
Signature Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this Tba fig oing instrument was acknowledged before me this
day of , 20 _, by _ , c _ 20 _ , 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. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:
Sign:
Print: Print:
My Commission Expires: My Commission Expires:
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
APPLICATION APPROVED BY: flIT - K Infil Plans Examiner
Engineer
Zoning
Che 10/14/03