RF-09-1764Miami Shores Village
Building Department
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
FBC 20
Permit Type: BUILDING ROOFING
Owner's Name (Fee Simple Titleholder)
Owner's Address A ->'.j,
City
Email
OCT 2 7 2009
BY---"------
Permit No. — 1 4 -
Master
Master Permit No.
Phone # 7 / �� --d
State ��.. Zip
Phone #
W
Job Address (where the work is being done)
City Miami Shores Villa County Miami -Dade Zip
P ?
FOLIO / PARCEL #
Is Building Historically Designated YES NO /' Flood Zone
Contractor's Company Name
Contractor's Address
City
Qualifier Name
State Certificate or Registration No.
Contact Phone s ''
State t'
Zip 1
Certificate of Competency No.
E-mail
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $_ Square / Linear Foot
Type of Work: QAddition Alteration []New eplace ❑ Demolition
Describe Work:
OCTlY ************x************** ***********Fees** x************* *************************
Submittal Femme $$ O� Permit Fee $— CCF $ �p • (%V CO/CC $
Notary $ / Training/Education Fee $ ' U v Technology Fee $ '
Scanning $ V.0
Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $
Total Fee Now Due
See Reverse side —�
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zip
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 wor�il be done in compliance with all
applicable laws regulating construction and zoning..:.
-,P r
"WARNING TO OWNER: YOUR FAILURE TO RECORD -A. TICE 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 v e exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lie aw brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded noti of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit ' issued. the absence of such�posted notice, the
inspection will not be�approved and a�*onfee will be charged..`
Signature o Signa
wrier or Agent
The rego ng ins ment was acknowledged before me this The fo:
da 'of O� , 20 , by day of
who' na y known to or who has produced W44
identificat' d who did take an oath.
NOTARY PUBL
Sign: i
Print:
My Co mis io4 es: My cO&IM 17 )517121
'� ®F EXP' Feb. I2 2010
(407) 338-01-53 Fidler kk _P S w:.a.com
APPROVED BY jo� Plans Examiner
Engineer
(Revised 07/10/07)(Revised 06/10/2009)
Sign:
Contrav
ctor
instrument was acknowledged before me this
20&!!?, by
or -who has produced.
'ARY
n�koie#ExR6 E LUIS MEDINA
My ( `:"MISSION # DD517121
e a %tom �s Feb. 12, 2010
< 1o91) 1 ��:� Florida F3olary Service.com
take an oath.
Zoning
Clerk checked