WS-14-1322Miami Shores Village
2 0 2 1
Building Department JUN
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING Master Permit No. 0-4 " 1322 -
PERMIT APPLICATION Sub Permit No.
UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS:
City: Miami Shores County Miami Dade Zio• -3-' /3, a"
Folio/Parcel#: //— 32c?t;, c> rc,� `i�C9 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): rf�y _I ' � ��.� Phone#:
Address: J'V/ ILIcr5 '
4
City: 'X` Staw
Tenant/Lessee Name:
Email
p: 3313?
CONTRACTOR: Company Name: _ �2z:.o r -e— Phone#: - 0,15')_573 -< 0 70.
a
Address:
City: State: Zip: 331(-(,
Qualifier Name: v'e �'J �`�%va Phone#:
State Certification or Registration #: Certificate of Competency #: 0_3 '` c) o32, �
DESIGNER: Architect/Engineer: _ � r � G> Phone#: &��
Address: City: State: Zip:
Value of Work for this Permit: $ =���� : C.:' Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑"Repair/Replace ❑ Demolition
Description of Work:
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 $
Ah Ak
Bond $
TOTAL FEE NOW DUE
,BeiW4 Company's Name (if applicable)
Banding Company's Address
City
State Zip
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 AFF'iDAViT: 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
CONBIENCEMENT MAV RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITO 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 absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signature
o _
The fore ing insttume ire s `�
day of 20 � , by C L� � �-�
who is personally known to me or who has produced
NOTARY
sign:
Print:
My Commission
APPROVED BY
(Revised02J24/2014)
As identification and who did take an oath.
lE
1111 ROY AWL
Signature
Contractor
The fore g 'ng instrument was mej,
day of f y
who is personal to me or who has produced
as identification and who did take an oath.
t 4 - I
Plans Examiner
`
Structural Review
NOTARY PUBLIC:
s -
Zoning
Clerk
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CANCELLED
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