MC-12-634Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: MECHANICAL
JOB ADDRESS: '35 31 N ` '- Ae 1) r—
112Qi2
By-_____.___.vavaemee°a
FBC 2010
Permit No. N C)
Master Permit No. I �- — &
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): L_< - c- -A,- L L Phone#: 3
Address:
% �>
City. V" ^ „"` State: Zip: 3 7
Tenant/Lessee Name: Phone#:
Email:
Company Name: "& Apt- ev
3nT3Zr92F3
City: State: ir—K Zip:
Qualifier Name: �� yy� ® Z _Phone#:
State Certification or Registration #: C,�± t �t7 C`c-? Certificate of Competency #:
Contact Phone#: 3 ®I = 3 2. S` Ii z P -3 Email Address: Ad-?. 6-e,`^ a 1 F- e.4 o L. (, a
Architect/Engineer:
Value of Werk for this Permit: $ U Square/Linear Footage of Work: rho
Type of Work: DAddress ❑Alteration ❑ ❑Rep ' epl a ❑Demolition
Description of Work:
Submittal Fee
Fee
Scanning Fee $
Permit Fee $
Radon Fee $
CCF $ CO/CC $
DBPR $ Bond $
Notary $ Trandng/Education Fee $ Technology Fee $
TOTAL FEE NOW DUE $
Double Fee $ Structural Review $
k \'
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
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
must
promise in good faith that a copy of the notice of commencement and construc ' ren law brochure will be a rvere erson
whose property is sub *eq to attachment. Also, a certified copy of the recor notice of commencement must be posted.at theJOA site
for the first inspection hick occurs seven (7) days after the buildin permit is issued. In the absence of such posted notice, he
inspection will not be ap roved a a inspection fee will be charge .
OP
Signature r Signature
Owner or Agent Contractor
The fore oin trument was ac ovule be re me this
g � g ,
day ofMl1 20 by
wh s pei onally known to or who has produced
As identification and who did take an oath.
NOT
Sign:
Print:
My Commission Expires:
APPROVED BY
V va Florida
NotatYn E 10
m• �
Commtiss Nalonat
gon�ed�rtou4h
The foregoing instrument was acknowledged before me
day of� 20 by l
ho is personally known to me or who has �ti►11i1�r
as identification an4�vho.df bel
NO. Y PUBLIC: 3106/pp
�OMirpa
Sign: �' _ • '9' 059
Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009XRevised 3/15/09)
Print: Z�''%i3OF FLOC
My Commission Expires:
Zoning
Clerk