EL-13-619 Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. AL 43'—
❑BUILDING )(ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING F--] MECHANICAL ❑PUBLIC WORKSHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: L2
;f, IN S4
City: Miami Shores County: Miami Dade Zip: 37-1
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
////((\\ ,. __ 30 �- tic) - 3 +10
OWNER: Name(Fee Simple Titleholder): � iUv, C' �U S �tis.+5` Phone#:
Address:
City: � � �o-n State: Zip: 3 3
Tenant/Lessee Name: l Ph/o'ne#: ►`�
Email:
CONTRACTOR:Company Name: A04 e ^ t,. c D C ' l t Phone#: -q, * '4 t o 63 6 y
Address: s u-) ( -L.
City: S�`I State: E!L- Zip:
Qualifier Name: 'e Phone#:
State Certification or Registration#:4-2 • � � Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Riepiace ❑ Demolition
Description of Work: U
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ YS >mU CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ cc,,__
TOTAL FEE NOW DUE$�V
(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
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, t applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be d ver d to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must�b ed at the job site
for the first inspection which occurs seven (7) days after the building permit is issu the absence Isu� posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signat Signa
OWNER or AGENT / CONTRAC R
The foregoing instr, ment was acknowledged beforeme this a foregoing instrument was acknowledged before me this
�2 _day of 1 20 t by �Z7 —day ofl%,JA 20 by
C
ril who is personally known toi1�'��C�t`^E 1.j� who is personally known to
me or who has produced � _ as me or who has produce DD as
identification and who did identification and who oa
NOTARY PUBLIC: NOTARY PUBLIC:
p" ORS ROSSEAU
'COMMISION#FF119045
i EXPIRES MAY 4,2018
s JORGE ROSSEAU
oFlorid aotaryServicecom MY COMMISION#FF11
9045
Sign: (4 7) tss Sign:
0 Florid =1,7Service com
Print: Print: (407)398-0153
Seal: Seal:
APPROVED BY 7 Yp` Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)