WS-08-1757 11MILYA, wl. Miami Shores Village
Building Department
artment
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax• 5)756.$972
itl� '�� W BUILDING Permit No.
PERMIT APPLICATIO sSEP �11_ Master Permit No.
FBC 2004 ---�Q08- -
Permit Type (circle): Building Roofing
Owner's Name(Fee Simple Titleholder) ZFA+kC-5 SM-5S Phone# 3 oS- Ito 2— 6 1 Z 2
Owner's Address q 4 k NE ck�ST TC—(Z
City kkkk1k ?0CA(M State Zip 33 28
TenandUssee Name N A Phone#
Job Address(where the work is being done) CILJ t NE 9 1 5T TT-_2
City Miami Shores Village County Miami-Dade Zip L 3 g
FOLIO/PARCEL#
Is Building Historically Designated YES NO
Contractor's Company Nameq0l4C_d L(J -76 Z (o t 2 2
Contractor's Address
VWCity State Zip
Qualifier Name Phone#
State Certificate or Registration No. Certificate of Competency No.
Architect/Engineer's Name(if applicable) N k(Lk rAJA P R E LL Phone# . 3 0S -- S - z3 t 8
Value of Work For this Permit$ Square/Linear Footage Of Work:
Type of Work: ❑Addition ❑Alteration NdNew ❑ Repair/Replace ❑Demolition
Describe Work: IV
10
�t f
Submittal Fee$ Permit Fee$ CCF$ ICO/CC
Notary$ Training/Education Fee Technology Fee$
Scanning$ Radon$ DPBR$ Zoning$
Bond$ Code Enforcement$ Double Fee$
Structural Review.$ 60,` f 6 0 •~ 46 0 ,Oe 4 8 i at Total Fee Now Due$ 4
See Reverse side-�
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 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.
1-2
Signature Signature
Owner or Agent Q Contractor
The f re oing instrument was ac owledg brie is The foregoing instrument was acknowledged before me this
day o� 20 ,by vv day of ,20_,by ,
who is personally own to me or w duced who is personally known to me or who has produced
CQ As identifi d who did an oath. as identification and who did take an oath.
NOTAR UBLIC: . �e �;�ti NOTARY PUBLIC•
Who ( 1) ) I a
Sign: AC;mss''o�S�'4 Sign:
Print: �4 �'� �c�s� Print:
My Commission Expires: 0= My Commission Expires:
******************************asw r ***********************************************************************
APPLICATION APPROVED BY: 4�(��!C� /!�r✓ -Al glfh e -t LJ C 4. Plans Examiner
Engineer
Zoning
(Revised 07/10/07)