BP-04-1367Y Miami Shores Village
s
` Building Department artment x�`° 113/cg"
10050 ME. AdAvenue'ami�Sh , orida 33138
Tel• (0 y - 1 1 S 7 6.8972
BUILDING OCT 15 20 3 Permit No.'s— 3G_7
PERMIT APPLICATION --- - -®-- - , aster Permit No.
FBC 2001
Permit Type (circle): uildin Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simple Titleholder) � I,�I ( � &LA Phone #
Owner's Address �13 &); 9l4SIM -5,7 cFi
City dl� F,t(C G State(. Zip
Tenant/Lessee Name Phone #
Job Address (where the work is being done) ��j YV 6 STAT
City Miami Shores Village County Miami -Dade Zi �J -3
Is Building Historically Designated YES NO
Contractor's Company Name aau& ` Phone #
Contractor's Address
City
Qualifier
, State Certificate or Registration No. Certificate of Competency N
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit :71 Square Footage Of Work:
Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair/Replace ❑ Demolition
Describe Work: 1C4 Cobine
MnIg��y�����
Submittal Fee $ Permit Fee $ 0 — CCF $ erg 1CO/CC —�
Notary $ Training/Education Fee $ 44 Technology Fee $
Scanning $ Radon $ Zoning .. Bond $
Code Enforcement $ . Structural Plan Review. $
Total Fee Now Due $ 4
(Continued on opposite side)
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 commencement must be posted at the job site
for the first inspection which oc,9drs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appyved _ d a reinspction fee will be charged.
owner or A en
The forego ing ' stnunent was a o 1 ged befo me this AS -
day of�JC� , 2004, by %i
who is personally known to me or who has produ
As identification and who 'd take an oath.
NOTARY LIQ_
Sign:
Print:
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of . 20 by
who is personally known to me or who has produced
as identification and who did take an oath
NOTARY PUBLIC:
kv Iyiabel Va,1° as Sign:
Commission #DD2311
:.= a„aa_ I ')A()7 Print:
My Commission E fres: 9aF�oQ°� QondedThru M Commission Expires:
' Adantic Bonding Co., Inc. Y xp.
APPLICATION APPROVED BY:
Cho 05/13/03
2 3 200 plans Examiner
Engineer
Zoning