RF-14-1615Miami Shores Village
Building Department
90050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 200
BUILDING Permit No.
PERMIT APPLICATION Master Permit No. ffly
Permit Type: BUILDING ROOFING
JOB ADDRESS: l03 o5 N. E° 2 Ave gl"or.; f(. 33i3g
City: Miami Shores County: Miami Dade Zip: 3313 lb
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): LO N 2 r h uyv (vr d Phone#:
Address: /03 ® G N • E , 9, Ave
City:vv'. k a o\,\ C'a\'0Ye S State: &c,— Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:: Company Name: ?a'rnGY lwf TeA int Phone#: 30-S Sg 3 g' 7 6
Address: WV_ mom
City: Ill. l G rn a, 7 Zip: 3.3 is?
Qualifier Name:y y Q AA. ?C(1Phone#: ,3G6 5 ® Q 9.2 4 �
State Certification or Registration #: 'RIC a9 0 a 7// S Certificate of Competency #:
Contact Phone#: Email Address: -?at VKC P V OOP kck @ 5shco• C44
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 3/ 5 00 Square/Linear Footage of Work: Yeo S y'vcLYeS
Type of Work: OAddition OAlteration ON$"' """ """`QRepairlReplace ' - ODemolition
Description of Work: '"Aa RAF e1nA-+ r e W ; A,, o v)e' #30 }'e L f .144 pr d SE
A c� r� nrg ++ le ttytrie rCrA�c.ynev�4. (i Np-j� aoncwafe S _t-ArG4// -gfiaa <
YY C0)L) fiC_+uvei SpeeF� c�. -iyn7, C ffAA,� rw S}PaniA Red,"Y Cltzt�hwue -We
Color thru tile:
Submittal Fee $ %0?3 Permit Fee $
Scanning Fee $
Notary $
Radon Fee $
Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO/CC $
DBPR $ Bond $ , cy3
Technology Fee $
TOTAL FEE NOW DUE $ D --)O °
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 la*s regulating`gonstruetimand zon'ltgs n ti e
"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 i$ with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commenceme construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified cop- g%recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after ding permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee willcaged.
Signatu' re 1 Signature
e
Owner or Age t a' Codfractor,
The foregoing instrument was acknowledged before me this ` The foregoinstrument was acknowledged before me this I
day of ` J 20 �, by M.w? , I.dc�1- "k day of �v lY _,20"'t, by ���0/%%c� "
who is personally known to me or who has produced who is personally known to me or who has produced]—
�.----------------
_i,:. '...'. a 'i ..., •. of Yt
As identification and who did take an oath. 790-5 0D4') as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: h
My ColLssion Expires:
APPROVED BY
SUYAPAP&MER
EXPIRES: October 4, 2016
BMW Tim NotmyPublic undemitets
Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
NOTARY PUBLIC:
Sign:
Print:
My
040 pG Notary Public State of Florida
_ Joanna M Feliciano
. My Commission FF 082753
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