DS-15-61Address: City: State: Zip:
Value of Work for this Permit: $ '-f C13 2- Square/Linear Footage of Work: LAOLD
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: m v� G� ft <��"r L*_ — dyt V'( `'`L' -j
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 $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �� • S 0
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
JAN 132o'S
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 A3
BUILDING
Master Permit No. DSOS^0
PERMIT APPLICATION Sub Permit No.
UILDING ❑ ELECTRIC
F-] ROOFING ❑ REVISION ❑ EXTENSION
❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS:
yl
City: Miami Shores
County: Miami Dade Zip:
331
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO
Occupancy Type: Load:
Construction Type: Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder):�''� �`'� Y� Phone#:
Address: a4--) L_C;'_
qn S!
M �-
City: _ I �I4vri� �1� �c > State: F( --Zip: JJ (3B _
Tenant/Lessee Name: 1'✓1� Phone#: r]�� `43 b .,
Email: �i"``jLU
GLo I , Ccyr1
CONTRACTOR: Company Name:'
'" Phone#:
Address:
City:
State: Zip:
Qualifier Name:
Phone#:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ '-f C13 2- Square/Linear Footage of Work: LAOLD
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: m v� G� ft <��"r L*_ — dyt V'( `'`L' -j
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 $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �� • S 0
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 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 P P Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
'� day of A'''r 20 15 by day of , 20 by
who is personally known to
me or who has produced %- f as
identification and who did take an oa%Aiitiiiiiiiiriej�
NOTARY PUBLIC: \�SIl
16 -_
Sign:i)"�, �L�G
Print: ,I,s!sslon #
Seal: 0E- r Cj�\`.
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: G!__ Lk l" DATE:
ADDRESS: `r4�i ��—Ucaw1 'S�n
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have
read and understood the following disclosure statement, which entitles me to work as my own contractor, I further understand that I as the owner
must appear in person to complete all applications:
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption
allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one -family or two-family residence. You may also build or improve a commercial building at a
cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or
lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built
for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make
sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on
your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and
with -holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an
exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain
restrictions even though I do not have a license.
Initial
2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and
is not hiring a licensed contractor to assume responsibility.
Initial
3. 1 understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential
financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the
contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts.
Initial
4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve a commercial
building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially
improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the
construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption.
Initial
5. 1 understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
Initial
6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance.
Initial 91"
t
7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously
implies that the property owner is providing his or her own labor and materials. I, as an owner -builder, may be held liable and subjected to
serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner -builder and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial
8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the
work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by
me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the
Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow
these may subject to serious financial risk.
initial_
9. 1 agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and
requirement that govern owner -builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations.
Initial
10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry
Licensing Board at 850.487.1395 or http:/http://www.m�loridalicense.com/dbpr/pro/ciIb/index.htmI/dbpr/pro/ciIb/index.htmI
Initial-
11.
nitial
11. 1 am aware of, and consent to; an owner -builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Initial`
12. 1 agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information that I have provided on
this disclosure.
Initial
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial
loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or
employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder
permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of
the contractor's workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local
permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property
owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued.
Was acknowledged before me this day of , 20
By
� ,,Yrti kz-)
who was personally known to me or who has
Produced there License or k"� as id18r,�f
E P
03/�6/p
OWNER NOTAJ pon
SeoR,Es loo R E MM - PERMIT APPLICATION
MAR 18Q4 Master Permit No.
Subsidiary Permit No.
Step 1. Complete the attached permit application which must be sigma by the aLo-Ucr y owner and qualifier. Both signatures must be notarired. Please
print or type to fallow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submit-
ted along with this permit application.
Step 2. Submit the completed Mp is with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
Job Address:S 31c/
Address Apt. City State n Zip
Folio Number escripVn of Work _ 'i � a
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
ARCHITECT
Name
License No.
Address
Telephone
Fax
PROPERTY OWNER
Name
A
Home Telephone
Business Telephone
Fax
Zoning Linear Feet
Square Feet A �� S P Units Floors �
Value of work A,"932 Bldg Value
Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
X
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interiorpon
Demolish
Relocation of Stru
Shell Only
Foundation Only
Add'l Attachment
Other
Add'1 Detachment
Other �...��
ENGINEER
Name
License No.
Address
Telephone
Fax
1 ' Ell
MIA
Ow
Page 2
PEP IIT APPLICATION
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the streettsidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, certify that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
are required for ELECTRICAL, PLUMBING, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent r
) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for. finished floor ele.r am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percen i. Wf the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Buildin
WARNING TO OWNER; Your failure to record a NOTI OMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2, or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1� Floor, (305) 679-1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713-35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STA O OR OUNTY OF MIAMI -DADS
'Signature of Owner
i'�
�i�
Print Name
om to d subscribed before me this 2�7 day of
Signature o otary Pu is - tt�;of Pprij(,) OPpaS
*DD 023275
SEAL: j.
a c ' 2005
Tknn
tilantle Bonding Co., Inc.
Personally known OR, Produced Identification
Type of Identification Produced:
OF
subscribed before me this -- day of
mature ofN6tary Publi State pMorida
�uu
^,aQ�.P�� ;
Alfredo F.
SEAL: Ci
n.�� c commission # DD 023275
y :, o� June 10, 2005
1A,
�.*� Bonded T1=�,OF X00 BOIldiDg Go, jIIO.
Personally known OR, Produced Identification
Type of Identification Produced:
Page 3
PERMPT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
M1"111MINES'lum
Minimum Fee
Dryer
Outlet, Appliance
Service Repair
A/C Central 1-3 Ton
Fan
Outlet, Wall
Service, Temporary
A/C Central 4-7 Ton
Fire Pump
Outlet, Switch
Signs
A/C Central 8-15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (pJPH)
Temp Sere, Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Hemp Service
Utility - Water
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Vacuum Pum
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Closet
RECEIVED AND REVIEWED BY: ______ -_ DATE:
MECHANICAL
TYPE
PlAIMBING
Minimum Fee
Condensate Drain
Generator
Refrigeration, Toms
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wallin. Tons
Dryer Vents, Number of
Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
ping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
cess/Pressure Piping
S er em
Bath Fan -Vented, #
Fireplaces, Number of
ure Vessel
Supply, AC Well
RECEIVED AND REVIEWED BY: ______ -_ DATE:
PlAIMBING
'1-N
TYPE
A/C Condensate
QTY. TYPE
Drains, Roof
Q,FN-.
Miscellaneous Fixture
Soakage Pit
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler
Cap - Fixture
Fountain
Pump and Abandon
S er em
Ca -Water
Gas -Appliance
Pump, Domestic
Supply, AC Well
Ca - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re -circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pum
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas) '
Sewer Connection
Water Re -pipe
Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
RECEIVED AND REVIEWED BY: ______ -_ DATE:
Page 4
PERMIT APPLICATION
OFFICE USE ONLY l
❑ OWNER -BUILDER FORM
❑ PROOF OF OWNERSHIP
❑ CONDO ASSOCIATION APPROVAL
(Attach)
(Attach)
(Attach)
❑ FIRE DEPARTMENT
❑ HRS / DERM APPROVAL
❑ BPR APPROVAL (Restaurants)
APPROVAL (Commercial /
(Septic / Sewer)
multi -family)
❑ CONCURRENCY
❑ IMPACT FEE
❑ CONTRACTOR REGISTRATION
(New Construction)
(New Construction)
(On File)
❑ OTHER
❑ OTHER
(Specify & Attach)
PERNIIT FEES
(Specify & Attach)
$3.00 per page (Scanning Fee)
$
Miami Shores Village
$
Bond
$
Metropolitan Dade County (C.C.R)
$
(sq.fr. = x/1000
Inspector State Educational Fund
$
x ¢so)
(¢.005/sq.ft.)
> O
State DCA (Radon)
$
(¢.Ol/sq.fr.)
((�
Code Enforcement Fine
$
Zoning Review
$
Notary
$
TOTAL $
SECTION BY DATE
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
FOO TZV
3 4/a�
7 �
Revised July 2001
10050 N.E. 2- AVE., MIAMI SHORES, FL • (305) 795-2207 • FAX (305) 756-8972 • http://www.miamishoresvillage.com
Miami Shores Village
�Oo tBuilding Department
artment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING Permit No. �(-
PERMIT APPLICATION
FBC 2001
Permit Type (circle< Building ectrical
Owner's Name (Fee Simple Titleholder)
Owner's Address 11 4�
City—,a I Com,_
Tenant/Lessee Name
Master Permit No.
Plumbing Mechanical Roofing
Phone # -7tL 44 3 AJC? 6S
State Zip �J 1 ?3'
A- , :YN o Phone #�'-
Job Address (where the work is being done)
7 A/2 �?7 -5 t
City Miami Shores Village County Miami -Dade Zip _
Is Building Historically Designated YES NO_
Contractor's Company Name ^ \7�,� 1/' SLC! Phone #
Contractor's Address
City
Qualifier,
State
it o o
4 ,--i
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit22� 2 Square Footage Of Work: _, 44520
Type of Work: ❑Addition ❑Alteration
Describe Work: _ <
❑ Repair/Replace ❑ Demolition
Submittal Fee $ 50 Permit Fee $ ® CCF $ J CO/CC
Notary $ l— Training/Education Fee $ r Technology Fee $"-
Scanning $ Radon $ -L--- Zoning �~ Bond $ 3019 —'
Code Enforcement $ Structural Plan Review. $
p
Total Fee Now Due $ri3
(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 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.
Owner or Agent
The foregoing instrument was acknowledged before me this
day of 20 _, by
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by ,
who is personally 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.
A
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: �� Print:
My Commission Expires: My Commission Expires:
(Certificate of Competency Holder)
State Certificate or stratigi Certificate of Competency No. _
APPLICATION APPROVED BY:
He
Plans Examiner
Engineer
Zoning
Che 12/15/03
7 --r
• I w
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305-795-2204
Building Inspection Request
Date
Type Insp'n f
Permit No. F) b 4- 44Q
Name I r �
Address ! 14-7 ' y �' `' `7
S+ -
Company �� (G n&
Phone #
Inspection Date
Approved ❑
Correction
Re-Insp'n Fee ❑
STATE OF FLORIDA, COU -i"' Y
I HEREBY CERTfFy that this is a tr/Y
on at fired in this office on'A
yy'fT SS my hand apdOfffclalSeal C`
HARVEY of uit
.C.
B
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME of RRST INSPECTION
PERMIT NO. 66X FOLIO NO.
STATE OF FLORIDA:
COUNTY OF MIAMI-DADE:
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real
property, and in accordance with Chapter 713, Florida Statutes, the following information
is provided in this Notice of Commencement.
1.
of property and
�Z
2. Description of
3. Owner(s) name and address:
//lam�'/b:'z',--ggv-/9
Interest in property:
Name and address of fee simple titleholder.
4. Contractor's name and address:)
/369v� <al 192Ae?1_ c/
5. Surety: (Payment bond required by owner from contractor, if any)
Name and address:
Amount of bond
6. Lender's name and address:
1 I11111 Itll1111i 11111 Ifl1i �I#11111i1111� 1111
.C -FN 2004RO` 36912
OR Bk 22133 Ps 33617; (1tz9)
RECORDED 04/ 06/2004 13:26:13
HARVEY RUVINr CLERK OF COURT
MIAMI-DADE COUNTYr FLORIDA
LAST PAGE
i
C
7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as
provided by Section 713.13(1)(a)7., Florida Statutes,
Name and address:
8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided
in Section 713.13(1)(b), Florida Statutes.
Name and address:
9. Expiration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a
different d e i )
Signature of Owner
Print Owner's Name `/" � to d
Swom to and subscribed before me this - 7_ day of , 20
Notary Public ell
1fr DUOS
Print Notary'same <�
My commission expires:
Pre ared by
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Address:1�3 6/.
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AFFIDAVIT
STATE OF FLORIDA)
COUNTY OF DADE)
The undersigned Affiant, , does hereby attest that the
(property owner)
attached survey, performed by
(name of surveyor's company)
performed on. t is an accurate representation of the existing conditions and
date o survey)
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the
property without first providing a survey less than six (6) months old. The Affiant, as property owner, further
agrees to remove or obtain permits for any structures which now may exist on the property which are not
permitted or which may violate zoning or building code regulations. The Affiant further understands that the
existence of any such structures may affect final inspections as applicable to this or other permits..
, Affiant sayeth naught.
Witness(sign and Print)
SWORN 0 AND SUBSCRIBED before me thisday of(�
Avant is personally known tome, _produced as identification.
,,Pva4,,, Alfredo F. Corpas
e Commission # DD 023275
Expires June 10.2005
Bonded
ii `�� Mantic Bond q bC o
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305-795-2204
B ilding Inspection Request
Date
Type Insp'n
Permit No. iJ� V `1 44
Name
Address
Company 51n Y- -rslc4-i1J1
Phone #
Inspection Date
Approved ❑
Correction
Re-Insp'n Fee ❑
CRITIQUE -SHEET
JOB AODRESS ---r-t f t� 7 /lt ` 7 S '
APPLICANT
PHONE #
APPLICATION
SHEET —OF A
MISCELLANEOUS.—
PERMIT NO.
ADDRESS:
MIAMI SHORES VILLAGE
BUILDING / ZONING DEPARTMENT'
SECTION
BY DATE
ZONING
ELECTRICAL
MECHANICAL
I PLUMBING I I
FIRE
PUBLIC WORKS
STRUCTURAL
I BUILDING OFFICIAL l I
t. Subject to comptlancs waft eft' Federal, State.
Coady, Vamps lutes sad reputations. Village ssumm
no responstbulty for accutecy oflor results from
btese plans.
2. Thts copy of plans moat bo avahbl4 an
buEding site or no lnapection rdit be conducted.
DATE Z0,YI G ' COMMENTS INITIALS
3 3t o
UM ■
s
Miami Shores Village
g
Building Department
10050 NE 2 Ave, Miami Shores, Fl 33138
Tel: (305)795-2204 Fax; (305)756-8972