DS-14-1270BUILDING
Miami Shores Village CEIVED
Building Department 17 2014
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972 B
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 201 U
Permit No.
PERMIT APPLICATION
Master Permit No. D5 z L-/ ^
Permit Type: BUILDING ROOFING
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: % ®S .
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO i/ Flood Zone:
OWNER: Name (Fee Simple Titleholder): CM [ ` 1,0bda 6Ff). Phone#: () 01 -41{ -[
Address: -9 ®1 14-1 '5'?'4 ✓o () L-A A Vic -A& to 0-1 °
City: Pf>Qtc_.�!�4ig State: Zip: -4 1�
Tenant/Lessee Name: W'.It a
Email:
CONTRACTOR: Company Name:
Address: (.-G 4N �J tJ
City: a 4,041 State: 'L - Zip: 3 -:3((e(
Qualifier Name: "e%. -To C—t o Phone#:
State Certification or Registration #: Certificate of Competency #4 0
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Value of Work for this Permit: $ 'JL —S e/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration Mew ❑f Repair/Replace ❑Demolition
Description of Work: C -405 -Toy^ S4QQ& :a.)1 c-gth6S T��� s X0®0 PSI
&DPti.-d� f® if 14.0 t o'0'^o r r
Submittal Fee
Scanning Fee $
Notary
Color thru tyle:
Permit Fee $
Radon Fee $
Training/Education Fee $
Double Fee $ Structural Review $
CCF
CO/CC $
DBPR $ Bond $
Technology Fee $
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
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
promise in good faith that a copy of the notice of commenceme�
whose property is subject to attachment. Also, a certified co
for the first inspection which occurs s n (7) days aft
inspection will not be approved and a 07 nspection fee ;ar
Signature
an estimated value exceeding $2500, the applicant must
c ruction lien law brochure will be delivered to the person
corded notice of commencement must be posted at the job site
ng permit is issued. the absence of such posted notice, the
SignSture
�/ caner oVAgent Contractor
The fore Ling trument wasacknowledged before me this The foregoing instrument was acknowledge before me this
15
day of Urn p , 20 L(by day of , 20 i! L J by r ,
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.
NOTARY PUBLIC:
Sign: Vfl L
Print:
My Commission MARIA DE BRLM
P r ; MY COMMISSION # R 0
EXPIRES: August 20, 9017
' set • ° Banded Thy Nfty POD U iMP W,
APPROVED BY
as identification and who did take an oath.
NOTARY PUBLIC:
Sign: L If Z<'=>
Print:_
My .: n ExPWADEBR--tn
:'� MYCOAIAIISSION#�'O44D99
Pgs EXPIRES; August 20, 2017
tlf�gc ` Bonded Thy Notetp Pu6� Undenvrnens
Plans Examiner Zoning
Structural Review Clerk
(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
APR 2 3 2015
-fp UJ/UsM 1�4- IMOu.�
J
rialto 4-D,- I q - o--4�
a3,
�� 6y) Wo ,
VvI
4 D51 12--7
- han L yam,