FW-12-1761Miami 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
)61312, _W(LIA1
BUI DING
PERMIT APPLICATION
Permit Type: BUILDING
SEP ?
FBC 20
Permit No.1q0 lot✓ I-I(V
Master Permit No.
ROOFING
JOB ADDRESS: _? —2— AAe- `�
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple
AddrPcc• '32— A✓y'q�
City:
Tenant/Lessee Name:
Email: C-1Al/
CONTRACTOR: Company Name:
Address:
City:
NO Flood Zone:
,'�e4 Phone#I �j,,// 31-® - f -tq
ed State:
Qualifier Name: Phone#:
State Certification or Registration #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer:
Certificate of Competency #:
Value of Work for this Permit: $ f Square/Linear Footage of Work: ZO�
Type of Work: DAddition OAlteration
Description of Work:
Color thru tile:
Submittal Fee $ Permit Fee
ONe �I W
��tepair/Replace ODemolition
Scanning Fee $ Radon Fee $
Notary $ 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
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 record Qtice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the buildinga issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be char '
�Y
Signature Signature
Owner or Agent Contractor
The fore" instrument was ac owled eddyfore me s � The foregoing instrument was acknowledged before me this
day of , 20 by y�W ay of , 20 _, by ,
who is p rsonally known to me or who has produced who is personally known to me or who has produced
' entification and who did take an oath. as identification and who did take an oath.
NOT Y PUBLIC: .. ^ a NOTARY PUBLIC:
Sign:
Print:
My Commission
FA9-W41011VJ.3 013:311
V. CUBILLdS
�y comm. Expires Sep 23.2015
Commission,# EE 12BB10'
Bonded Through National Notary Assn.
Sign:
Print:
My Commission Expires:
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I�Plans Examiner Zoning
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk