EL-05-391Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
O
BUILDING
PERMIT APPLICATIO
FBC 2001
Permit Type (circle): Building
N®V 5 Permit No. E LOIS —Scl I
--- Master Permit Nom
Plumbing Mechanical
Owner's Name (Fee Simple Titleholder) CCDL-19FY Phone #
Owner's Address _Z KI LC) U0 4 S%
City_Mt O rYU S hu to ' o y i C -MLO zip 3 3 ► 3(S
Tenant/Lessee Name _ Phone #
Job Address (where the work is being done) �1 `Z t°"' W f ®1 S4 -
city Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Roofing
Contractor's Company Name 4,. Ai ar� (�a, i Phone #
Contractor's Address To o o&2j f- e..
City, ^n o j State kC- / Zip 3'313e
Qualifier
State Certificate or Registration No. Certificate `�Fcrpetency No.
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit Z 1-2,0 0 It
Type of Work: ❑Addition
❑Alteration ❑New
Square Footage Of Work:
❑ Repair/Replace
❑ Demolition
Submittal Fee $ Permit Fee $ r CCF $ 1 CO/CC.
Notary $ Training/Education Fee $ Technology Fee $ 3 . _7S
Scanning $ %3- Radon $ Zoning 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
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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 certfed 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
Signa
Owner or Agent
The egoing instrument was acknowledged before me this
day of pI Oil , 20 D, by t1iP`tA i iCoYI Ara
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY P LIC:i
®ooa Col
00 Ls
Commisdon 067
Print:,➢_ /- .a`=Bonded Tiuu
My Commission Expires:
Signature
Contractor
The foregoing instrument was acknowledged before me this 1Y
day of A20V 2001 -by c a
who is personall00
y known to me or who has produced
Print.
My Commission
identification and who6di� e an oath.
• ,comwo
9a #DD3 OW
APPLICATION APPROVED i / �la..L����/��-�� �= fir ir:�n���1n�tH■
Engineer
Chc 05/13/03 Zoning