RC-06-1216MOMII1�7g�
MAY 10 coos D
BUILDING
Miami Shores Village 4 36 Prn
BuildingDepartment p artment
1 q [c)(0
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972 A Ar.
PERMIT APPLICATION
FBC 2001
Permit Type (circle):( Building` I Electrical
Owner's Name (Fee Simple
Y
Permit No. 2 4�J
Master Permit No.
Plumbing Mechanical Roofing
SU� Phone # 5 _ _7S(4 Q (oq Z
Owner'SA�ddress /2 (:j 9V� k2 -t
City I ll ��} 1; J „tate Ff Zip
Tenant/Lessee Name Phone # -71 Z
Job Address (where the work is being done)
City Miami Shores Villaee County Miami -Dade Zip
Is Building Historically Designated YES NO
Contractor's Company Name _(OUjj) ZJ2, Phone # WS— %S4 — ®G q?_
Contractor's Address
City State
Qualifier
State Certificate or Registration No.
Zip,
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit x 460cro '
Type of Work:
Describe
Alteration E]New
No.
Square Footage Of -Work:
❑ Demolition
Submittal Fee $ Permit Fee $ X5-00 6- `- CCF $ �Z . 4 CO/CC.
Notary $ Training/Education Fee $ Technology Fee $ '
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $ e ---j , d
(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 re > 4 notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the buil tis issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be c"�
Signature?PW
Signature
Ownerr Agent Contractor
The forego' g instrument was ac wledged before this The foregoing instrument was acknowledged before me this
day of AL by Y- J �
1 � t ��� , day of . 20 by
who is persony known to me or who has produced �� _ who is personally known to me or who has produced
As identification and who did take an oath. as identification and, who did take an oath.
NOTARY
Sign:
Print:
My Corhmission Expires:
APPLICATION APPROVED BY:
NOTARY PUBLIC:
J �,:F
MaWcBondinoCo,: Inc
Sign:
Print:
My Commission Expires:
5�O- _ Plans Examiner
Engineer
Chc 05/13/03
Zoning