DEMO-13-2501Miami Shores Village
Building' Department
91050 N.E.2nd Avenue, Miami Sham, Florida 33138
Tel:: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
' 1BUILDING
PERMIT APPLICATION
t
FBC 20
Permit No.
Master Permit NoAeW l
Permit Type: BUILDING ROOFING
JOB ADDRESS:
City: Miami Shoves County:iVliami Dade Zap:: 3 / 38
Foliaiparcew.
Is the Building Historkally Designated: Yes NO
Flood Zone: A,"&
OWNER: Name (Fee Simple Titleholder):X l W P.u.e` ,4 98h a , Phone#: &
Address: NW rf� �A c .l•
City: AT aw3 A44 w State: zip: 3 3 3 $
TenanVLessee Name: Phone#•
Email:
CONTRACTOR: Company Nam:,��
Address: W C :�
City : state• zip: 3 1
Qualifier Name: Phone#:
State Certification or Registration t C. G C_ /SO a €n; 8 Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: ArchitectiEnginee: Phonet
Valve of Work'for this Permit: <--'*� SquarelLinear Footage of Work:
Type of Work: OAddition OAheration Mew ClRepair/Replace emoMion
Description of Work: _ 'l NN �� . �C�`i� �s� VAPO
e -
Color am tyle:
Submittal Fee $ Permit Fee $ CCF $ COICC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ on Fee $ _______ Tedmology Fee $
Double Fee $ Sbvdmal Review $—
TOTAL FEE NOW DUE $ `
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
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 met 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
1WROVEMENTS 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 certfied 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 U7. Te ence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
e 0 rfigo'''%,, t9e.Ortigo''%,,�
Signature 1��'1IM_�IV •� ,°.•��Q���s'•• 'S�e �� �:•c��.Air�s•.d
021071201Y• 6'
Owner orAgent - NOi �YIIC con = NOTARY LIC
The foregoing instrument was acknowledged More -pit ia5�or-1 ;' 7Wfotegoing instrument was ackno ledged �fO�.�11�i
�y �; �,\®� 20 by -. &�; .f E i Ann
0440
is personall a or who has produced'i P.�r;\< ho is personally kmo ' me or who has prod ruci.dr FOF F
C��a��`��\
/111M.-
As identification and who did take an oath. as identification and who did take an oath.
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��ij�. ,1O 11M
My Commission Expires:
APPROVED BY
/j Plans Examiner
Structural Review
(Revised 3n212012)(Revised 07n0/07)0kev1sed 06/10/2009)(Revised 3/15/09)
NOTARY PUBLIC:
My Commission Expires:
Zoning
Nov o 5 2013
SKTrQI OF SURVEY
scale P=201
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146 5� N L L E -Y
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