DS-14-1035Miami Shores Village
q 113114 _ Building Department
��. 90050 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 No.
C
FBC 20 tC)
Master Permit No Q5 I �l "
Permit Type: BUILDING ROOFING
JOB ADDRESS: dOS WE 103'A �-*
City: Miami Shores County: Miami Dade Zip: 1 •3
Folio/Parcel#: i` -?-I � W- Q 1 A- 0910
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): p� A`+ �% a'�9! ��� Phone#:
Address: 0 � 2-5 5 A f bn C -(o o- V-- -Tk ti t'
City: JLC) t twt t State: ` Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: t (-� 'CA -0 "03 J t r C-- 4r
954- 2y I -7S&.3
City: AcAa Ci IQ State: PI Zip: 20? C' U 9
Qualifier Name: k(v.,iP ¢ ku AAbl�.--, Phone#:
State Certification or Registration #: 1 �5 i 1K'A 1�s Certificate of Competency #:
Contact Phone#: ?)C'!!5 _ 316 4 �5 4 7 Email Address:
DESIGNER: Architect/Engineen
Value of Work for this Permit: $� Square/Linear Footage of Work: J
Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: ,(- t � � �` o C �t- v r 5 C,P-�, 1 2 Lon J-1 Cc 7
fr 2n?'?� E �� t• ��
Color thru tile:
Submittal Fee $�S® GP`l Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Robert Humbles
13255 Arch Creek Terrace
North Miami
Florida, 33181
September 23, 2014
Miami Shores Building Department
Dear Miami Shores Building Department.
To whom this may concern,
SEP 2 4 2014
I pulled a permit for a new driveway at my property located at 69 NE 103 Street, back in 5/29/14 and due to
difficulty reasons involved with 103rd street and the department of transportation, I would like to cancel the
permit. Please issue me a cancellation for permit number DS -5-14-1035
Sincerely,
Robert Humbles
3a5 3�0 4sc-�-3
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
Il"ROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COM ENCEMENT: '
Notice to Applicant: As a condition to the issuance of a building pel
promise in good faith that a copy of the notice of commence
whose property is subject to attachment. Also, a certifie
for the first inspection wfilch occurs seven (7) days aft iuldi
inspection will not be a roved and a reinspVctionfee will charged.
Signature
Owner or Agent
nA stimated value exceeding $2500, the applicant must
ction lien law brochure will be delivered to the person
recorded notice of commencement must be posted at the job site
ag permit is issued. In the absence of such posted notice, the
Si ature ,
Contractor
The foregoing instrument was acknowledged before
me this I A The foregoing instrument was acknowledged before me thii-L—
day of kms, 20 % by ^ 0604 � � kO � 1 k� day of U 20 A by
who is personally known to me or who has produced r who is personally known to me or who has produced
�- As iden '
c�wdid take an oath.
L
d
NOTARY PUBLIC:
p�' "'
`�°�para�e.;': N�iLLANEDA5ILVA
NOTARY
ADYLLANE DA SILVA
• `� Notary Public - State
�_ «�;
Notary Public - State of Florida
of Florida
'-� �' My 'res 5 230
y m . Expires Mar 5, 2016
sion # EE 163092
Sign
216
°F,�,�� Commission # EE 1r
Sign:
:F ,.
Print:
My Commission Expires:
APPROVED BY
C -f Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Print:
My Commission Expires:
—/P? ; ! �/ Zoning
Clerk