RF-13-1283Miami Shores Village
Building Department
artment
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: /y® ?l,Y24 /n/' 3M I "4V'ge,
FBC 20 l
Permit No. `—' 13
Master Permit No.
ROOFING
City: Miami Shores County: Miami Dade Zip: 3.7/6v
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
u OWNER: Name (Fee Titleholder). 1r''A%Gy / e®�r L iN�
pp
Addrew 7!,/p '41RA'a 117 .101.0.
City: ^,*Mi State:
Tenant/Lessee Name:
Email: SXP"_S /ZV Af -rr. /✓e71' �I
CONTRACTOR: Com any Name:
Q
Address: e O o l
City:
e
QualifierName:
State Certification or Registration #:
Contact Phone#: � 6-
DESIGNER: Architect/Engineer
gip: 3 3 /,so
Value of Work for this Permit: q�L' %Csi0 Square/Linear
Type of Work: (]Addition ") (]Alteration ONew /I
of Work:
MV *'.e
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Submittal Fee $. s )_ 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 $
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
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 WITHOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OZ
M ENCEMENT."
Notice to Applicant: As a condition to the issuance 4building perm with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of toncement and -construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a ceifi copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) dr the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection feebe charged.
Signature Signature
Owner o Agent C for
The foregoing instrument was acknowledged before me this
�-7 ;GG
day of ►ottll , �20 Jli, by W ®1.K4 I l,t � ,
twhBo is personally known to me or who has produced
b!� �+e
t-^ C� As identification and who did take an oath.
The foregoing instrument
before me this`d
day of Na Y� ' , ? 1�, by PQ -s) , - 6
who is personally kno to me or who has produced 1
-01" k "� ams identification and who did tAr, an oath.
NOTARY PUBLIC: NOZ
S' Sign.
Print 1 V Print:
My Commission Expires:
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APPROVED BY
My Commission Expires:IvL J
TiLSON A RODRISM
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Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)