WS-10-202 Miami Shores Village o
FEB 1 0 2010
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: .
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
BUILDING Permit No.
PERMIT APPLICATION Master Permit No. Li
FBC 20
Permit Type: BUILDING ROOFING
Owner's Name(Fee Simple Titleholder) —7NA 1a 1'(,9" 9415-5 Phone#
Owner's Address Ne Gq [ ST
City VA 1l States Zip �� [
Tenant/Lessee Name < Phone#
Email SI VA T-I l L-MA<
Job Address(where the work is being done) Y 7Gi .0/4/ IV� q/ ST TFIL
City Miami Shores Village County Miami-Dade Zip 331
FOLIO/PARCEL#
Is Building Historically Designated YES NO Y Flood Zone
Contractor's Company Name CU_AKJt't2 6J Phone#
Contractor's Address " .�►
City Stately
Qualifier Name Phone# .,
State Certificate or Registration No. Certificate of Competency No.
Contact Phone E-mail
Architect/Engineer's Name(if applicable) Phone#
�.900.90 Square/Linear Footage Of Work:
Type of Work: ❑Addition (Alteration DNew ❑ Repair/Replace
❑Demolition
Brum PwyntS
c7
aV
„i 00 Submittal Fee$5— D.CO— Permit Fee$ �(� CCF$ o
Notary$ Training/Education Fee$ D' Technology Fee$ LJy
Scanning$__Q1 Radon$ DPBR$ Bond$
Double Fee$ Violation date:
Structural Review.$ Total Fee Now Due$ 1 �,40
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. certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs sev days after the building permit is issued. In the absence of such posted notice, the
inspection will not b roved and a re' on fee will be charged.
Signatur Signature
Contractor
The foregoing instrument was a edged before me this The foregoing instrument was acknowledged before me this
da of 20 b da of 20 b
Y � _� Y � Y � _� Y
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
My Commission Expires: My Commission Expires:
APPROVED BY Plans Plans Examiner Zoning
Engineer Clerk checked
(Revised 07/10/0 7 X Revised 06/10/2009)