RC-05-1104 (3) UjjA Miami Shores Village
Corlvq Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
BUILDING CCXR � Permit Ivo.
PERMIT APPLICATI NUG 2 8 271
Master Permit No.
FBC 2001 BY._KAC ' 4...
Permit Type(circle): Building Electrical Plumbing Mechanical Roofing
Owner's Name(Fee Simple Titleholder) TMM4 bey Phone# MS-762- 6122
Owner's Address q 4 j N t `t j SA_
City M�drni c4&&_3 State �L Zip �3 1 ��
Tenant/Lessee Name Phone#
Job Address(where the work is being done) q , ac&
City Miami Shores Villa e 1 _ Miami-Dade Zip
Is Building Historically Designated YES
Contractor's Company
P Y Name �J�XJI V� � Phone# JNJ 1Q%:s O4 19
Contractor's Address I404O �W .�� 1
lt�
City IC y< I State iF(i Zip 3?,1 FA
Qualifier _ ObbC�O
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name(if applicable) Phone#
$Value of Work For this Permit Square Footage Of Work-
Type of Work: ]Addition ❑Alteration []New
❑ Repair/Replace El Demolition
Describe Work: 1-}
1 h
UP 00#0 14MV 0000F
Submittal Fee$ Permit Fee$ ✓ CCF$ CO/CC.
Notary$ Training/Education Fee$ Technology Fee$
Scanning$ Radon$ Zoning Bond$
Code Enforcement$ Structural Plan Review.$
Total Fee Now Due$_ .4I
(Continued on opposite side)
I
Bonding Company's Name(if applicable)
Bonding 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 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 copl.,#f the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after they„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 Signature
Owner or Agent Contractor tt
The foregoing instrument was ackno me this The foregoing instrument was acknowledged beVAh�is�
day of ,20�by day of 6 cxT ,20M by
who is personally known to me or who has produced who is na y o o me o ced
As identification and who did take an oath. NOT pl .g
$9185 did take an oath.
NOTARY PUBLIC: NOTARY PUBLI Co n#DD535535
13 0
Sign: Sign. NIAY C 2D�
Print: Pmt:
My Commission Expires: My Commission Expires:
APPLICATION APPROVED BY: Plans Examiner
Engineer
chc 45/13/03 Zoning