CC-12-497 Miami Shores Village R
_ I Building Department
veLL-)f, (Nr-10A 10050 N.E.2nd Avenue,Miami Shores,Florida 33138
r`2�tQlY1� g a Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PRONE NUMBER: (305)762.4949
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21,- �Lls� ��
BULD G Permit No.
PERMIT APPLICATION Master Permit No.
FBc 20 2)u I nd
Permit Type: f„o,jl 0(;�p�q j oq
OWNER:Name(Fees Simple Titleholder):;kS Wyn cy, LLL Phone#: WDS-;M
Address: 11gO { 1 ``� Roo r
City: rv+ �IL,'1f gu r—r--(s d i State:
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: �S ��S Cum
City: Miami Shores County: Miami D gip:
Folio/Parcel#: 0 I -3
Is the Building Historically Designated:Yes NO Flood Zone:
0
CONTRACTOR: Company Name: Phone#: c7 S"100 B'g
Address: I(Vgg9 uff ` &=&he # ZUo
City: K10 H,� O.M% bC-��&6 State: Zip: 33uo'Z
Qualifier Name: �(t a a=ly.\ln a�� Phone#:
State Certification or Registration#: Ct-rC.aS S Certificate of Competency#:
Contact Phone#:? �Do�s gd) g 7 Email Address:
DESIGNER:Architect/Engineer:yf Rfl� sem+ Phone#:60 5 fall . FN (.0 S Ir
Ve S%3A
Value of Work for this Permit:$ 5 t3b•®l�l Square/Linear Footage of Work:
Type of Work: ❑Address @Alteration C1New ORepair/Replace ODemolition
Description of Work:Q �-AeAl- Q.S -1�1�Y1
x:x:x:x:x:x:&:k:kx:x:x:skx:mx=�:kx::kx•:kx::kx:x:���x:x:mskx:=+�x;�x:x:Fees��::��'fix:x:x::x:�skxx:&x::kx:x=x=:kx==xx=:x:u:kx=x<=kx<#:k.:xx=x:x:x:x:x:x;skx:x:x=
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$
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
s
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 PROPER IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YO ER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF C CEMENT."
Notice to Applicant. As a condition to the`Wudnc a uilding permit with an estimated value exceeding2500 the
$ applicant must
promise in good faith that a copy Of notice., 'commencement and construction lien law brochure will be delivered to the person
whose property is su ect to anachmen. Also, a certffied copy of the recorded notice of commencement must be posted at the job site
for the first inspecti n which occurs e en (7) days after the building permit is issued. In absence of such posted notice, the
inspection will not appy ved a i ection fee will be charged
Signature Signature Q4
V_ V,
Owner orent Contractor
The foregoing instrument was acknowledge efore me this �� The forego g' strument was acknowledged beft re me this
day of NA 20 d a. by =c ..rs �����►� day of ,20 N,1 by
whos personally known to inor who has produced wh is perso own tom r who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: "",,,,, Martin Rubin
a ? oultnlss Print:
X07M MDW:5TATE OF ME=
My Commission Expires: &pjres: JAN.03,2013 My Commission Expires-.••""''•o,
''a'�n••` CBONDINGCO,INC. Mardn Rubin
B001ibTHRUAT MTT �' Cormr,' dot l§-DD843967
Expires: ,iAN.G3,2013
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
A00% dM� A0111
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