MC-14-2103 h t
Miami Shores Village
Building Department fi
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC20 ( tJ
BUILDING Master Permit No .--' [
PERMIT APPLICATION sub Permit No. hA 1�4
T
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
//�'� ( s� /� CONTRACTOR DRAWINGS
JOB ADDRESS: I I®(Q '1 k.(A) G._T►JS
City: Miami Shores County: Miami Dade Zip: L��
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: / Flood Zone: BFE: E FFE:
OWNER: Name
ff(Fee Simple Titleholder):�,JP (� ;�. Phone#: 3� S X76 y--
Address: l �
City: it 'irw I ] ► ',S State: Zip: 3-7Ize?
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#: � . �6
Address:
City: State: �^ Zip: 33 l r
Qualifier Name: �sY�$ '�`t '✓`'� � - Phone#:3a�'
State Certification or Registration#: A G d .5V� %kS?9/�__ C rtificAF ��
e of Competency#: i
DESIGNER:Architect/Engineer:I � n Wt�1 �1 • Phone#: �J cz,70/
�
Address: AA) efa( a I k City: I "J State:R- Zip:-�
Value of Work for this Permit:$ 3cb o- 0% Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace El Demolition
Description of Work: 'mow e.� 1- `° v2�v. u'� `-
Specify color of color thru tile:
Submittal Fee$Ji:�a -00 Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ 0A �?
TOTAL FEE NOW DUE$ I
(Revised02/24/2014)
■
i
t
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 approved and a reinspection fee will be charged.
_.1
I `
r
Signature �,K-✓? .� ....._____....... _
t G
i\ OWNER r AGENT CTOR
The foregoing instru nt wa acknowledged before
)me his The Ing instrument a_so no-ledged before a this
�_day of C/� 20 / by dqy 20 by
who!s personally known to '�.� �% is r Wally known t
y� 10145 33fa 41G1J
,me or who as produced - Cas me or who has produEed ` �YXhSrP as
identification and who did take an oath, identification and who 041a�Q n oath.
NOTARY NOTARY PUBLIC:
Si 4t: i
Print: S
Seal:a°t'A%:,�•� STEPHENMAACUor1vum L7
* MY COMMISSION t FF 053131 Se LINDA yp�
• `¢= Notary Public.State of Florida
EXPIRES:September 10,2017
-'*()F rtoa`O Bonded Thru Budget Notary Seryi e ': My COMM.Expires Apt 16,2018
�** *********** ********* * �**�CgIR111}1lNb�i'�11�`Itt�`��** ****************
••,canna•
f�� 1 BMWAkflow NOINY.Assn.
APPROVED BY J \ ` Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)