RC-15-129BUILDING
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
❑BUILDING ❑ ELECTRIC ❑ ROOFING
Master Permit No.?)C 15 �
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 17 In N VV 0 O ( S+
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): _b/l/1 1) T N V e S 1 0 ,eja TS Phone#:
Address: 1(10 7 619 1.111. ( A f -I l 9+.
City: 'Dck V\, State: f-(- Zip: M336
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: APC. &h 5 o "r -e f 1 n 4 Ey Phone#:3ta S ---7.f
Address: -2( S'® L.J. D " eaw
City: A t a( e A h , rState: Zip: 330 ( 0
Qualifier Name- q V 4tP1 t FIJI. Qi i t Phone#: '� 0<--2,1i-'�Z G %
State Certification or Registration #: Ic &-e, I Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Ad
City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New // Repair/Replace
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Description of Work: _yt '2"'d f -e iP l a c -e b 4 4 h s Uvel q in d
PU /_arM+ine.
rI Yr4 . Aeavh/'
❑ Demolition
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v e1 4v�S•
Specify color of color thru tile: n,
Submittal Fee $ � -( `� Permit Fee $ A2w
G . CCF $ CO/CC $
Scanning Fee $
Technology Fee
Structural Reviews $,
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
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
A
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 on 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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
�
I day of 1 r 20 19 ' by
r
JW T Aoki ' &t -t , who is ersonall n to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
•JX_'Notary Public - State of Florida
Seal My Comm. Expires Jul 26, 2015
Commission # EE 116040
APPROVED BY
r
Signature
CONTRA OR
The foregoing instrument was acknowledged before me this
I— day of 1 �" , 20 (5 . by
I �Gt (J4 ) (Pigg I to . who ' ersonall kno to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
Plans Examiner
Structural Review
f- 494(
(Revised02/24/2014)
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SANDY RO �
otary public _State R0
y Comm. Expires Jul pFlorida
Commission # �n 2015
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as
Zoning
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972 e.
1-zt--15
Permit No: C 15 -1Z-q
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Page 1 of 1
STOPPED REVIEW
Plan review Is not complete, when all Items above are corrected, we will do a complete plan review.
If any sheets are voided, remove them from the plans and replace with new revised sheets and Include one
set of voided sheets in the re -submittal drawings.
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