WS-15-275BUILDING
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
MBUILDING ❑ ELECTRIC ❑ ROOFING
Master Permit No. W S_15.
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
r-1 PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 166 10 100 I-errate,
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11—,5101 —0226 -02SO Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): l�QQI'PA 66NZ.41t6 - Phone#:
Address
City:
Tenant/Lessee [B,nName:
Email: 'IV 11�r'
100-rerrac&
State: r -L
one#:
P: 331M
CONTRACTOR: Company Name: JQE kXMIF dei t a-� %me NZWj0.-Phone#: L95H 3--,)(,
Address: 040 f;(,(h')IJQi(L nd h&W-au .f
City: lq'TLsW1* State: 64 zip: 3x7339
Qualifier Name: L/S[e CT %?Gii' dW Phone#: •,
State Certification or Registration M ��C at/1600sov Certificate of Competency #: A A
DESIGNER: Arc 'tect/Engineer: N Phone#:
Address' 1401 City: State: Zip:
Value of Work for this Permit: $ ! �/ S00. 00 Square/Linear Footage of Work:
Type of Work: ❑ Addition [M Altteration ❑ New/_ E]Repair/Replace El Demolition
Description of Work: t � 7 W 11V �1.11y- &PlatDr ed —
Specify color of color thru the:
Submittal Fee $ 570 -Q) Permit Fee $ 2-10 • C -JD CCF $_
Scanning Fee $ Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews
(Revised02/24/2014)
CO/CC $
Notary
Double Fee $
Bond $
TOTAL FEE NOW DUE $ ( 9 g • 50
Bonding Company's Name (if
Bonding Company's Address 1
City
A'may a
cable)1q 1A
State
Mortgage Lender's Name (if app, cable)
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 coh menceriignt 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 reins.7eill be charged.
Signature r Signature-
OWNER or A/NT CONTRACTOR
The foregoing instrument was acknowledged before me this
Z-& day of f A vLM 1,% , 20 1' . by
sa u 7-4 who is personally known to
me or who has produced rLot � % as
identification and who did take an oath.
NOTARY PUBLIC:
" �� LAWRENCE M BURNETT
Print: .b''�a
Seal: I ` n EXPIRES December 06, 2015
The foregoing instrument was acknowledged before me this
day of sVWAtA^J 20 15 by
e_ t• !Cl[ l o is personally know to
me or who has produced as
and who did take an oath.
NOTARY
Print: myw(Ql1'2,*,,]--. „e,;,
Seal:.a Oi:.i Arirli20lh
�, � i i �.,.� a rage'•. P�r,Pary ie^,rra,
APPROVED BY f! /� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Date.April,17'',2015
Cancellation of Permit Request
The customer listed below cancelled the contract with our company before any work was
done. Please cancel the following permit.
Permit # WS 215275—Miami Shores
Customer: Ms lleana Gonzales
166 NW 100 Terrace,
Our Job # 8023088
Please send any refund to:
THD At -Home Services
Attn: Peggy Payne
2690 Cumberland Parkway SE ,Suite 300,
Atlanta, GA 30339
Sincerely,
The Home Depot -At -Home Services
BOYSIE G RAMDIAL CRC046858
Qualifier
State Of Florida.County of
Sworn to and subscribed before me by ecl S a , ft who is personally known
to me or produced as identifi tion, and who did take an oath, this X day of APP L- ,
20 i5
Signature of Not
MARRISKA MORALES
Printed Name of Notaryjf'�'r+�a�s =�•`•��� y y puNIC - State of Flodda
s. Commismon # FF 220108
Commission No. / Expiration �%� I ';;� aass My Com�m�.Edx�p1reaApr13,u2019
u-WM,n�l
THD At -Home Services. Inc.