PLC-14-2745 (3) Miami Shores Village
Building Department DEC 16 Z014
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.IC /4/ - 1�8�
PERMIT APPLICATION Sub Permit No.PJ(! Al--2. 979
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
MBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 'a
City: Miami Shores County: Miami
Dade zip:
Folio/Parcel#:_4/- -3,7-,D G --®I I Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: 115 Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): 7� 7 6'a.two-, I-L c. Phone#:_ 36 r 9 q9 -9m qy
Address: /5-9.J' A4/&.3 -5
City: State: Vic-- Zip: —3`3� d
Tenani/Les,see Name: Phone#:
Email:
CONTRACTOR:Company Name: �i q Phone#: 7
Address: S°��1 SW. 12-12
P �
City:9a/ / ( State: Fz. Zip:
Qualifier Name: 4r- i,7 Phone#
State Certii=idation or Registralio' #C` I,��6 I' Certificate of Competency#.: y
DESIGNER:Architect En sneer: 5�e t, lit, :
Address:, 1'_d�GJ�`4Ty:'I tP*�1 <a�� a®� City:?&Jt t, e� State: /eCp:
Zi 3 3/ 7
s arhal
Value of Work for this Permit:$ Square/Unear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Dgmolition
Description of Work: b: sF
Specify color ofcolor
a thru tile:
Submittal Fee$ Permit Fee$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$_
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 6100 -a
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appy ed and a r ' spection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing ins ment was acknowledged before me this The foregoing instrument was acknowledged before me this
1� day of — C.4W IX00' 20� ,by J�1. day of 20 N by
who is personally known to '1(lfy�( q1M
P Y who is personally known to
or who has produced as me or who has produced 1AVI Si !9 -q02-0 as
identification and who did take an oath. identification and who did take an oat
NOTARY PUBLIC: �ttt11111111/!�°°° NOTARY PUBLIC: o��`�` NEITTe
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Print: ti = : e• e Print: ;aOFF132633 ��:
Seal: %2o� y�i y����;'`�OQ` 'o •:"9h����te�:• Q�O`��
'°1°°�o��U$C•1STP �e�``000 Seal: 0°1°°°Gi/I�STATE
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APPROVED BY iZ"L �`� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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