DGT-13-832 4
Miami Shores Village
Building Department p 2 a Zo�3
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 201
BUILDING Permit No. P(MI—T ( 3 �
PERMIT APPLICATION Master Permit No. fzC-- I
Permit Type: BUILDING ROOFING
JOB ADDRESS: 23 90 I�IE 2- s"IcZf�-f
City: Miami Shores County: Miami Dade Zip: C�(88
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): i44Llt4I A T- AVLTL0 )__r Phone#:
Address: 2�p GES yyC K'AF_
City: 1 lyl (i 6FAC_�A State: EL Zip: X31+0
Tenant/Lessee Name: Phone#:
Email: C+42<<✓i c�.- d2F2 cam✓_-6E 6'\no C�2
CONTRACTOR:Company Name: ='� �^ .�2 A N C E L L E D hone#: '18-6 s G 57 � SO
P y
Address:
City: State: ( Zip:
Qualifier Name: r"c.r i1 c c: r i N iy Q L Phone#:
State Certification or Registration#: Ca L-O �q 7' u Certificate of Competency#: C_ U j ti-7,4
Contact Phone#: 1 VL 5 8 b '5 -1 Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit:$ 1 OZ00 square/Linear Footage of Work: 300 s' F
Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: UJOCA
Color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$ `
TOTAL FEE NOW DUE$ - t
r �
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 a construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified co �j corded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days in permit is issued. In he absence of such posted notice, the
inspection will not be approved and a reinspec ' l ed. _
Signature "(� Signature
Owner or Agent r� Contractor
The'foregoing instrument was acknowledged before me this The foreg/ngstrument was acknowledged before me thisA-�-
day of ZZ- 120 a,by moi.-�k Ar T A261D17E day of L
12-A-'Ll e
who is personally known to me or who has produced who is personally known tq produced FC-O
As identification and w12p\t alll�,��P�f th. � ( aside tion and who did take an oath.
NOTARY PUBLIC: Expo.cfj,%� NOTARY PUBLIC•
CD
Sign: _ = Sign: z �C
Print: :" J�4s�� C'' Print:
My Commission Expires: ''�i� OR I D P ��`�`\ My C Ex iAmi"On EEC 17426
APPROVED BY (�Plans Examiner Zoning
3
113 Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)