FW-12-1255 Miami Shores Village
Building Department
f.
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
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B I DING Permit No. `t'W L �
PERMIT APPLICATION master Permit No.
Permit Type: BUILDING ROOFING
N£
JOB ADDRESS: Ida Y3 AP (o AVS
City: Miami.Shores County: Miami Dade Zip: 33/3 5
Folio/Parcel#://-'L2 3 101 2 0 2.10
Is the Building Historically Designated:Yes NO 1z Flood Zone:
OWNER:Name(Fee Simple Titleholder): 8j" M-D AL 1AN9YLA 1-- a0NA i fZ Phone#: `R6-ZOO '/9
Address: 108q? Nf- & -AV Z
City: rn-3.A mM SA0&.£S State:_ F • Zip: 3313$
Tenant/Lessee Name: SAme AS A&M Phone#:
Email: LT � 1T2 ,G'rJ
CONTRACTOR:Company Name: MODULOe_f_W0jLk9 SNG Phone#:od 80q-1S51
Address: _ _ _ _ 9 W ow 2.5 ST 10`4
City: ("_SANXI. State: F L. Zip: X33112
Qualifier Name: � 4 P. �oA� Phone#: �) $0g-n s l
State Certification or Registration#: Certificate of Competency#: 1-19 OD 14q
Contact Phone#: ,l `1951 Email Address: SD @ i tIVEI-N FcNCEUX-W, COM
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ (1001).00 Square/Linear Footage of Work: `i L0•k.
Type of Work: ❑Addition DAlteration ❑NewRepair/Replace ❑Demolition
Descrip n o or
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1111
tile:
Fee
s
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning
Sca g Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
Uj 1ZHf7W M-0 S-79
Bonding Company's Name(if applicable) r11A
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 notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after,the birijding permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
f
Signature -' ��` Signature
wn or gent Contractor
The foregoing instrument was acknowledged before me this �pi r� The foregoing instrument was acknowledged before me this uto
day ofJ Q 1 12012-,by brgj30 Ll rCJt?Q L#t day of JLdq 20 1 z,by Vi-O-k -DLACXr-ir ,
who is personally known to me or who has produced 1'L.DhVf?1'+7 who is personally known to me or who has produced FL Dill—VieYS
0630 3(6 3 41 dentification and who did taaLicense-. D(P3G W 3(0 j �� i- Gtr 1 Ste'
�}. s i � �s identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: /�Xg Sign:
Print: 6 1 Print: -U14 J
\I\ Y P ,'� 1\1111111,
\11111111
My Commission Expir jp�"" .� 4 HEATHER BELL My Co ,"pires: HEATHER BELL
n"
I\ �- Notary Public-State of F7WW a _. Notary Public-State of Florida
My Comm.Expires Nov 13,2015 o My Comm.Expires Nov 13,2015
'•O OF F' \� Commission!EE 145710 "'.;ROF F� Commission#EE 145710
*a:�* * x*
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)