RC-13-705q54 ���� �j -19q
I)DUMETT'-,
\ � Miami Shores Village APR oa ij
'
� i1 Department
� 1p B u din g
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: 571 NW 112 street
City: Miami Shores County:
Folio/Parcel#: 11-2136-021-0940
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple Title
Address: 9933 E Broadview Dr.
City: Miami
Tenant/Lessee Name:
Dede Cohen
State: FL
c
Permit No.
1�
Master Permit N
ROOFING
Zone:
Zin: 33154
Email:
ck e1 ,b
CONTRACTOR: Company Name: LY Construction, Inc.
Address: 304 Indian trace # 254
City: Weston State: FI
Qualifier Name: Luis Yibirin
State Certification or Registration #: CGC# 1512157
Contact Phone#: 7542340922 Email Mc
DESIGNER: Architect/Engineer:
5
_Certificate of Competency #:
Luiyi@LYConstruction. US
754-234-0922
33326
7542340922
61e6 v
Value of Work for this Permit: $ i 6 ry (�r Footage of Work:
Type of Work: DAddition ;@Alteration ❑New ❑Repair/Replace ODemolition
Description of Work:
}0C
Color thru tile:
lfi"4I.Q, �
Iuttal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
TOTAL FEE NOW DUE $
r®u�
k
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
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 which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not a roved and a reinspection fee will be charged.
Signature lkaef Q -;v Signature
r Oer or Agent
The foregoing instru ent was acknowledged before me this
day ofC'y 11-' L' , 20` Z by o e
who is personally known to me or who has produced
As identification and who did to th.
NOTARY PUBLIC:
a
Sign:
Print: ,
My Comntrssi ra
APPROVED BY
Contractor
The foregoing instrument was acknowrle�dged before me this /
day of �' �'/ 20'x, by C31 rj lo' n ,
who is personally known to me or who has produced
Plans Examiner
identification and who did take an oath.
NOTARY PUBLIC:
gorre
Prin >; bo b
ommie Wn #F EE 840251
My
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)