PW-14-2686Miami Shores Villages-.-
Building Department DEC 10 2014
10050 N.E.2nd Avenue, Miami Shores, Florida 331388 c
Tel: (305) 795-2204 Fax: (305) 756-8972 - - -
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
FBC 200
BUILDING Master Permit No / / Y_ 6�6 c,> L
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
j �CO TRACTOR DRAWINGS
JOB ADDRESS: `--F G; l � �� � C� � �� ��
folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type: Flood Zone: BFE:
OWNER: Name (Fee Simple Titleholder): r" 6Q
Address: `�� 0 0 i k nc�L k- C
(2Cc=
NO
FFE:
Z91 cK ik
City: M � 1 Sl�� State: jFL Zip: (�
Tenant/Lessee Name: `` Phone#:
Email: C 0 ��C_ Cie rs- t '
CONTRACTOR: Company Name: Phone#: -_7 /f,,
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer:
City: State: Zip:
Value of Work for this Permit: $�) 2 �� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:,
Submittal Fee $
Scanning Fee $
Permit Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
(Revised02/24/2014)
CCF $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $ lam/ LJ
TOTAL FEE NOW DUE $
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
Zi
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 be approved and a reinspection fee will be charged.
Signature` 11
OWNER or AGENT
The foregoing instrument was acknowledged before me this
/,_ day of 9,e 20 Lf by
�&12ne,ek /3Ugz/4 who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
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:
Print:
$o ems^ Notary public State of Florida
ciano Seal:
Seal: Joanna M Feli
Expires 01/12/2018 My Commission FF
082753
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APPROVED BY 2 fPlans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)