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.t'Notary
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Sep
23,2015
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CI.AUDIA V CUBILLUS
Nofa,y P';bi!C - State of Florida
My ExVas Sep 23,
Commission # EE 128810
Bonded Thruugh National-Notary Assn.
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Miami Shores Village
Building Department
x '0'2
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
FBC `0
BUILDING Permit No.
PERMIT APPLICATION Master Permit No.
Permit Type: UIL IN DFING
JOB ADDRESS: 9969 NE 4 AV RD
City: Miami Shores County: Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO x Flood
OWNER: Name(Fee Simple Titleholder):Andrea Minski a#:305-244-7973
Address:9969 NE 4 AV RD da
Zip: 33138
City: Miami Shores S
Tenant/Lessee Name: Phone#:
Email:
T.
CONTRACTOR:Company Name: DiS COnstr Phone#: 786-256-1316
Address:
3029 NE 183 LN
tp 33160
venura
City: Atate: FL ,';,'� Zi
Qualifier Name: Diego Phone#:
State Certification or Re # C1505716 Certificate of Competency#:
Contact Phone#: Em ail Address: diego@disaalconstructlon.com
DESIGNE tect/E er: ` Phone#:
Value of k for this .$500 Square/Linear Footage of Work: 40 If
Type of ❑Addi ❑Al tion XNew ❑Repair/Replace ❑Demolition
Description r ew 5'wood ce with self close/self latch gate.
Arl
Color thru tile:
***** *********** *********************Fees**************�
Submittal Fee$ Permit Fee$ 1119e CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ 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 copy of the recorded not- e of co encement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit i issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
1,
Signature Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this ALJ The fo ing instrument was ackno dged before t isd-3
day of 201by .��.' iJO-S IL-1 , day of 20)�,by
who is personally known to me or who has produced
and who did take an oath.
NOTARY PUBLIC: NO ARYU LIC: .
Sign: Sign: Stn
r
Print: 1� tint: Sep 23,
•• .SML � Nhl ;�
My Commissi� Expires: :+ MY COMMISSION N EE1626t!'- Y Commis on x it Gomm ssren
,{ National Notary
EXPIRES Febmiary 11,201e
308-0153 FWWeNoUryiwvk*.ewn _
APPROVED BY !/GPlans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)