FW-13-2804_• % r
Miami 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: BUILDING
JOB ADDRESS: 1 4 P\) c-, I I c
Permit No.
DEC 18 9013
FBC 2010
Master Permit No.R"i I?> — 2 Voll
ROOFING
City: Miami Shores County: Miami Dade Zip:
-Folio/Parcel#:
Is the Building Historically Designated: Yes
NO
Zone:
OWNER: Name (Fee Simple Titleholder): Q L009—S Phone#: w 0'
Address:�Lf%0 El 1(9
City:State: Zip:
Tenant/Lessee Name: S-GL-v�moi -fes - Phone#:
Email: O NV Cc a
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name: Phone#:
State Certification or Registration #: - Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ 'q 5a Square/Linear Footage of Work:
Type of Work: Addition ❑Alteration ONew ORepair/Replace
Description of Work:
Submittal Fee $
Scanning Fee $
Color thru tile:
Permit Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $
CO/CC $
DBPR $ Bond
Technology Fee $
TOTAL FEE NOW DUE $
ODemolition
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.
. d.
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 estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of com e e c n�qt on lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a cern ed 8 V e r notice o commencement must be posted at thejob site
6rri i P j
for the first inspection w occurs seven 7 days a� 1� is issued. In the absence of such posted notice, the
inspection will not be ap oved a a r nspection ill be charged. , ''*;
4:
Signature Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
dayof 1�>rC ,200,by�1n,f-,3 aZS®"� day of ,20_,
by
who is personally known to me or who has produced, t .7 who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
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\2i 01,4 �0
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
\
My Commission Expires:�0 ��f p c` My Commission Expires:
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APPROVED BY
Plans Examiner
Structural Review
(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Zoning
Clerk