MC-04-147` Miami,,Shores Village P0 C l
Building Department
10050 N.E.2nd Avenue, Miianu Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
BUILDING ��VE® Permit No.l`'l� A —1 ` ')
PERMIT APPLICATION �t�4 aster Permit No.
FBC 2041
Permit Type (circle): Building Electrical Plumbing ecbanic Roofing
Owner's Name (Fee Simple Titleholder) Yb J ..,. , Phone # � !i f'-- �`i�' �% 9 S�Z
Owner's Address 34"C—
City l State d Zip 3 % 0
Tenn a Name Phone #
Job Address (where the work is being done) �y �1Y►►�.. ��1�`�
City NVfiami Shores Village County Mami-Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name 1,, Phone # ?w f — (0 a q0
Con or's Addressr' 16 hi,
City State
Qualifier „'.
Architect(Engineer's Name (if, applicable) , Phone #
$ Value of Work For this Permit V cc '9 Square Footage Of Work:
Type of Work: ❑Addition ❑AlterationTe ' Repair/Replace ❑ Demolition
Describe Work:
up 4
Submittal Fee $ �0,W Permit Fee $ CCF S nn
Notary $ Training(Education Fee $ m ' U Technology Fee $ .r.
Scanning $ Radon S Bond S
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 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 E"ROVEMENTS 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 commen ent must be posted at the job site
for the first inspection which occurs seven (7) days after the bu\ permit is issued the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be chaff' '
Signature Signature✓/ P--,
The foregoing instrument 01l iA Kd 1
day of
--40
�g—
yk
who is personallykmawn to me oar,?'*l% has pd
NOTARY PUBLIC:B4C' ST
Sign:
Print:
My Commission Expires:
me this The foregoing
day of
I who is person,
I take an oath.
NOTARY PUBLI(
Sign:
Print-••
My Commission
�,�.u (Certificate of Competency Holder)
State Certificate or Registration No. ( 1 �J S Certificate of Competency No.
APPLICATION APPROVED BY:
Contractor
before me this
take an oath.
Plans Examiner
Engineer
Zoning
Chc 10/14/03