MC-13-805KA
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fag: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: MECHANICAL
C;�
APR 1
Permit No.
Master Permit No.j ¢—
OWNER: Name (Fee Simple Titleholder) C'— ( Zd76W1 Phone#:
Address: 5 71 0 W1
City: State: Zip:
Tenantil-emee Name: Phone#
Email:
JOB ADDRESS: 5`7 I W
City: Miami Shores County: Miami Dade Zip: -
Folio/Parcel#:
Is the Building Historically Designated: Yes ° NO Flood Zone:
CONTRACTOR: Company Name: / �C il I , Phone#:
Address:
® a S%rf�-
City: State: zip: X3/7,3
Qualifier Name: // 9 + hone#-i�"��-%
State Certification or Registration #: �A�� �� �/ _Cert`ificate oiiincy
#:
Contact Phone#: 3 D� `d°� Email Address: C'���?r L�,� Xr17/
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: DAddress DAlteration ONew&di e` o ODemolition
Description of Work:
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i`:
WA
Submittal Fee $ Permit Fee $ dr: CCF $ CO/CC $
Scanning Fee $
Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
"V�1�
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State 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 commencement must be posted at the job site
for the first inspection 'ch occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be pro�ed and a reinspection fee will be charged.
Signature '�C� Signature
-
0 er or Agent Contractor
The foregoing instrument was acknowl a ore me this The forego' g instrument was acknowled re me thisL
day ofQ,'' � ®4 , 20 / ;by C -IL) day of 20/ 3 by l'
who is personally known to me or who ]1 s produced �- who is personally known to me produced 9- � Av'o
NOI
Sign
Print
My(
As identification and who did take an oath.
APPROVED BY
(Revised 07/10/07)(Revised 06/1W009)(Revised 3/15/09)
as
NOTARY PUBLIC:
Sign:
Print:
my
who did take an oath.
COM OSSION # DD927924
PIM: September 24,2013
Fl. N=y Df @wd Aesop. Co.
1 ner Zoning
Structural Review
Clerk