RC-08-549tj°l mpzc If� ,
O—A
I
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores,.Florida 33138
Tel: Q05) 79512204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Owner's Name (Fee Simple
Owner'sAddress
1215
City
Job Address
City
is
Contractor's Company Name
_ State
is being
BYE ..
Permit No. W_,/Z f?J9
Master Permit No.
/U Phone
zip -33155
Phn e # "(4— 3611' r 3 to
State Certificate or Registration No. Certificate of Competency No.
Value of
Type
Submittal Fee
Notary $ Train[
Scanning $ Ra
Bond $ Co
Structural Review. $
K411Y(�A � 1�
❑ Demolition
$ CO/CC
*otogy Fee $
Zoning $
Now Due $
See Reverse side -�
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address -
City 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 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,VIAY 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." `y
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 inspecti which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection �willof approved and a reins ection f will bee ged
SiLynature Si nature
Owner or Age U
The fore oing instrument was a owledged before me is Z
lin Q
day of , 20Q b ,
wh is personally known to me or who has produced
As identification and who did takean oath.
NOTARY PUBLIC:
•c ���v`�gh1®�
Sign:
Print; coo
My Commission Expires: 1dur
�,
APPLICATION APPROVED BY:
(Revised 07/10/07)
g
Contractor
The foregoing instrument was acknowledged before me this
day of . 20 _, by ,
who is personally known to me or who has produced _
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Plans Examiner
Engineer
Zoning