MC-14-2001 Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 9PP I
Tel: (305)795-2204 Fax:(305)756-8972 1'
INSPECTION LINE PHONE NUMBER:(305)762-4949 - --- -- -
FBC 20 l
BUILDING Master Permit No. aC- 5-1
PERMIT APPLICATION Sub Permit No. vnC-)q
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL [—]PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores Countv: Miami Dade Zin:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
A0
OWNER: Name(Fee Simple Titleholder): / lJ //�'7/tPhone#:
Address: por !31 -
City: State: Zip:
Tenant/Lessee Name- Phone#:
Email 1 V /
I " IF" RLE U
CONTRACTOR:Company Name: Phone#: dS
Address: (00_"\
City: i State: Zip: 1 1
Qualifier Name: ecc �e, - -L G ' Phone#: 3aS`�7 Co
State Certification or Registration#: Q Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ •y() Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration New Repair/Replace ❑ Demolition
Description of Work: 7,n 6 '41-ku1k /`� �L Gezk 1 c 0 t IC,r , aKJ !fir l I II i X 4i 1
-xi 54,'n WCs
GL kqA ? 60riv> Qvti,dl,
Specify color�0 color thru tile:
.�
Submittal Fee$ Permit Fee$ t CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ 7
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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
p
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 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 Signature
rf OWNER or AGENT CO TRACTOR
The foreg`c ng instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
—L�
dayof b eY , 20 , by _1�day of 20 /� by
f�J A ,(/c( who is personally known to rK-Ode/b who is personally known to
me or who has produced ()111 Uf.(S OCCO C e as me or who has produced w'IjelrS as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign Sign:
Print: ® P�EREZ Print: �-� PEREZ
MY COMMISSION#EE843591 + ;'e MY CO
Seal: '~' EXPIRES October 15.2016 Seal: %,, EXPIRES October 116.2016
14071398-OIS3 RWW -CM 11011 -0161 FbIdONobrySwvrCO•oom
rf
APPROVED BY Ilans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)