BP-03-1871Miami Shores Village
RFCIEQVED Building Department
E G
7- 2003 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUII�
® _ _ ® Permit No.,(,)PZM g�
PERMIT APPLICATION Master Permit No.
FBC 2001
Permit Type (circle): Building Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder)� K�ei," I I , MC -FO'(- Phone # 3 o6 -7 57-570
Owner's Address Q Q S-3 �' ' I
City tcsa �'t State I J. Zip l
Tenant/Lessee
Job Address (where the work is being done) cz:�
City_ft,a- Nami Shores Village County
Is Building Historically Designated YES
Contractor's Company Name
Contractor's Address
Phone #
City. \' State Zip
Architect/Engineer's Name (if applicable)
�( $Value of Work For this Permit
Square Footage Of Work: t a
Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair/Replace ❑ Demolition
X Describe Work: RE 7—D. g ) e. -:Z H7� A i INT e X— —r jS�Z ® Q--> 1ff,
Submittal Fee $ ® Permit Fee $ (00 • IJIJ CCF $ • 600,
Notary $ Training/Education Fee $ Technology Fee $
Scanning $ Radon $ Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $
(Continued on opposite side)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
�Y
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 occurs seven (7) days ager the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspectionfee will be charged "
Signature
Owner or Agent Contractor
The foregoing instrurnent ac lowledged before me this The foregoing instrument was acknowledged before me this
day of� 201,C.�, b ((1 C(Iday of -.320 � by
who is perso y own to me or who has produced who is personally known tome or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOT Y P L NOTARY PUBLIC:
Sign: Sign:
Print: _ Commissi #®®231984 per;
:;a• aQ,xplres: ,
My Commission Expires: '`;nova Bon ed Mru My Commission Expires:
Atlanti onding Co., Inc.
�it�r�i*�e�t�ies�tte,rie�i&sic*a�sratrstr*****&***�**�ir�it****t�*�xt*vr�ttts�ittt�t****kirTisk�****�iteit**skir*tr�i�r**tatrh&s*&a�*,sie&ir�r�iia*
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
APPLICATION APPROVED BY: DEC — 4 2003 Plans Examiner
Engineer
Zoning
Chc10/14/03