RF-13-1284N
Miami Shores Village
Building Department 13
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
INSPECTION'S PHONE NUMBER: (30jq) 762.4.949
BUILDING
PERMIT APPLICATION
Permit Type: BUILDING
JOB ADDRESS: _ / / Y e )y,9xA A,
FBC 2010
Permit No. X13 —'�i
Master Permit No ] � ®�
-ROOMG
qty: xNami Shms
county.
Fono/Parcew.
Is the BaUdieg wstortca y,Des ted; y� NO
now Zone:, -
OWNERa Name (FeeSimple Titleholder): /9Z� C ®I
/x
Address: 1/ r jke
City: -qZ 4 Ste,
Tenant/lessee Name:
Address: —
City: e4
Qualifier Name:
State Certification or
Contact Ph -5
DESIGNER:
Value of Work for thfs Permft:
Type of Work: ClAddidon r
Desc*tion of Work:
- 7.r/- 0a
366a 1,,? - f'2 6
e. f Phone#:.,
Certificate of Competency�-
�yr Email AdAr�e.
e/Lhmr Footage of Work:
ORepau/RePhtce tv emolition
e�,�tx�u��+a�ot�m*�wse*�e���ee�*e��+eta*waeF�«s**w*�re�+s+�aret�eavkpeee��aeeextwe�e*t*oeoe
Submittal Fee $ Aso, Permit Fee $CCF $ CO/CC $
Scanning Fee $ Radon Fee $
Notary $ DBPR $
Bond $
Trains lg; Educatlon Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
stateP
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 m this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDMONERS,-I;TC... ,
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 R PAYING TWICE FOR
MIPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND 10� OBTAIN
FINANCING, CONSULT WITH YOUR LENDER O ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMIIIENC .
Notice to Applicant: As a condition to the issuance of a building p 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
for the first inspection which Occurs seven (7) days after the building permit is iss
inspection will not be approved and a reinspection fee will be charged
Signature
Ownct or Agent
Theforeg ' 9' nt was acknowledged before me this
day of 20 � by A=
who is nally known to we or who has produced-aA.. 2;
/2.AIA,24 As identification and who did take an oath.
of commencement must be posted at the job site
ted In the absence of such posted notice, the
The foregoing ins rumepiwas acknowledged before me this„�t
day of to v%v /. 20L, by&,\2s0-ar,,�1 M &v9A
who is personally >yvn to me or who has produced �L P^ -
36
461Y.olo-y�
identification and who did take an oath.
NOTARY
Sign: Sign:
Print:7ftpims.
( Print:
fie
Notary
GODUR
My Com, o My �
Nota Public - State of Florida
• •= My Comm. Expires Apr 9, 2014
Commission # DD 949187
SNA Q:
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APPROVED BY a��Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
f thN
ndeW
Zoning
Clerk