FW-13-467'Pe - k
Miami Shores Village
Building Department MAR 0 8 2013
90050 N.E.2nd Avenue, Miami Shores, Florida 33138 eA
Tel: (305) 795.2204 Fax: (305) 756.8972
�*AINSPECTION'SPHONENUMBER: (305) 762.4949� FBC 20 j 0
BUILDING Permit No.
PERMIT APPLICATION Master Permit No
Permit Type: BIALDING_ ,/�i ROOFING
JOB ADDRESS: C_` 01
City: Miami Shores County: ade Zip:
Folio/Parcel#
Is the Building Historically Designated: Yes NO ✓' Flood Zone:
OWNER: Name (Fee Simple Titleholder): -AF0t 3- P_We , - Phone#:
Address: 1V* S -s YNt F
City: tkligwy-1 State: T Zip: 33 13 $
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: ANA-om,10, Phone#: '_-Ne S -304-�S75{a
Address: 633� cn_k N-, 1C A t"lb
City: uKk6A&iiiik1PrCA State: Zip: _ 3(li
Qualifier Name: tz3L2e�yl i 1,bmwJ Phone#:
State Certification or Registration #: C&C— i3iSCmic Certificate of Competency #:
Contact Phone#: 99 — g� _?�:9 ). Email Address: ang��i�c�L %
DESIGNER: Architect/Engineer: 1 Aiti A -i- fttj wL0D V Phonek SEI- 3 S S- G I CA o
Value of Work for this Permit: $ Square/Linear Footage of Work: 2—
Type of Work: DAddition OAlteration ❑New ORepair/Replace ODemolition
Description of Work: � 3'� C ?X.;--C� E�
Color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Doable Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $� ?e�
I.._ V
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 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 commenceme t t posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the sence s h posted notice, the
inspection will not be a rrar einspection fee will be charged
r'
Signature Signature
Owner or Agent { C tractor
The fore �qminstrument was acknowledged fore me this The foregoing ins ent was acknowledged efore me this22
day of , 20 a, by 0.h l �� Vkv'rf— day of ]WN , 20 �2•by.
who is personally known to or who has produced Rd,400rwev' who
L1� ��� • �Asidentification and who did take an oath.
NOTARY PUBLIC•®P
®®®®®
SMS/
Si 11 o<r��P i 5,®
Print:
My Commission Expires:�4
�p d
produced
10
Sign:
Print:
My Commission Expires:
did take an oath.
APPROVED BY �"�Plans Examiner��- -
Structural Review - Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)