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Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
BUILDING
PERMIT APPLICATION
9BUILDING ❑ ELECTRIC ❑ ROOFING
rrSUZUlo
Master Permit No. VGT I L3— I
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
F-1 PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
A CONTRACTOR DRAWINGS
JOB ADDRESS: //65 / V � i 6'� e a-4
UL . rvnd1111 311vrea wu t : rvndrm udae 4.1 Fj. - 1, j I - vJ
Folio/Parcel#: Is the Building Historically Designated: Yes NO Ix
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): E&YV 1 1--j U C& bp Phone#: ,? 05 7S 1- J 7/ 2
City: _
Tenani
Email:
C
i
t
Statdl-'.
® CONTRACTOR: Company Name:l.(� ri Q - Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: ((W"" of Competency M
DESIGNER: Architect/Engineer: %FpfV I ® r�JtPhone#:
Value of Work for this Permit: $ �1 7
Type of Work: ❑ aA`ddittion [:1 Alteration
Description of Work: V L DVA TI
City: _1q9 V State Zip:
K Square/Linear Footage of Work: 10-x /0
New ❑ Repair/Repla e El Demolition
a 4 11 L .aI Ai..,.
I w."-
Specify color of color thru tile: °YOU
Submittal Fee $ o Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ uble Fee $
Structural Reviews $ Bo
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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." ,rte
Notice to Applicant: As a condition to the issuance of a building permit , ' imated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and coon lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the ed notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the bu ' permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be cho; .
Signature Signatu
OWNER or AGENT
The foregoing instrument was acknowledged before me this
dayof . 20 , , by
�T "ice U Orc �B6 , who is personally known to
me or who has produced F7V--'D12ASM]&,1LAC)P"S-'--as
identification and who did take an oath.
' * NOTARY PUBLIC:
Sign:
Print:
Notary Public
Seal: Sindie Alvarez
g, My Commission FF 156750
1f;oj Expirm 09/0312018
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of , 20 . by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
as
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014) 0