WS-14-2717� Jai 1u /
BUILDW 0"V1,0
PERMIT APPLICATION
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: (305) 762-4949
EABUILDING ❑ ELECTRIC ❑ ROOFING
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS
JOB ADDRESS: 13 RW On S1
Master Permit Nojk, s ) � - ; -7 l
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores Countv: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
OWNER: Name (Fee Simple Titlehc
e1% 1% 1J
Construction Type: Flood Zone:
C.gVt-, to?0�v— G'6iZr_
Address: W _t I )-1
City: �-' tct.ml <reOk-p> State:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
71^e k1,1A
Uc'
FFE:
C1116j 51Z.0(2 -S-
p: 33150
hone#:��
Address: Z I L I Sw
City: "'"4 vt state: �L Zip: 3317--1
Qualifier Name: Phone#:
State Certification or Registration #: SCC C- I51`(o `[ 0
of Competency #:
2Z� ( 8r? -6:
DESIGNER: Architect/Engineer: 0ua�" C_ - t:pr,\11'� Phone#: (36J) 2-3r 4-1 4'�
Address: � �' �� CO r O'l U)C4,1A City: �AtOWA State.- Zip: 3J 14T
Value of Work for this Permit: $ 3 •000 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 46NM G lab1' s do --i f2zrt-4\r® i�-w 00 V�cM -toy -FieV1CLn d -or _
ar�1 IIALevuoa 111wj0InIa 1,I"CL u r—�r---ate 5 '<cn v —
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
DBPR $
Notary $
Double Fee $
Bond $
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 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."
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 recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. in the obs en such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
OWNER or AGENT
The foregoing instrument was acknowledged before me this
��L-- day of 20 `� by
Cited E.1Z rhb"is personally known to
me or who has prq�t(;e��' V!C--'Q LA O--C-tJs-e as
identification and who did take an oath.
NOTARY PUBLI
Sign:
Print:
Notary Public State of FlorMa
Seal: Sirrdia Alva
My CommissFF 188750
?pfgd" Expires 09/03127018
Signature \\�".I'/
The foregoing instrument was acknowledged before me this
G �-4 day of ��`�I �-�' ; 20 f , by
- U1 S 1P
me or who has produces
identification\\\\t
NOTARY PUBLI
Sign:
is personally known to
as
an oath.
Print:
Notary Public State of FWkia
Seal: Sindia Alvarez
Qc
� My Commission FF 158790
W Expires 09M3f2018
APPROVED BY Plans Examiner
Structural Review
(Revised02/24/2014)
Zoning
Clerk