DSM-1909 \Jr Miami Shores Village
VED
Building Department ��� 20%10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax: (305)756.8972 r
INSPECTION'S PHONE NUMBER• 1 —
. 30 762.4949
FBC 2010
BUILDING Permit No.
PERMIT APPLICATION Master Permit NODS" —a' lot 09
Permit Type: BUILDING ROOFING
JOB ADDRESS: 9 -1&to t� a (,
City: Miami Shores County: Miami Dade Zip: '3 313
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleho der):_ 4N, e%w `, 0 V5 ��1 e_ ® Phone#^'�
Address: o i A ol C
a
City: � ���.� ��1-��" '� State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 17 t � 1e-
p y a Xc , Phone#:
Address: Ci WC IJ%,oj 17--, - .OL -
City: e i State: Zip:
Qualifier Name: Phone#•
State Certification or Registration#: Certificate of Competency#: .e6 C'()00
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ QU Square/Linear Footage of Work:
Type of Work: DAddition DAlteration ONew ORepair/Replace DDemolition
Description of Work: "�7-1 dSV-,L L' 4:50--% 9t1A
Color thru tele:
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
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 firs inspection which occurs seven
( days after the buildingpermit is issued. In the absence o such posted notice the
P l
inspection 11 not be approved and a reinsp ti n fee will b charged.
Signature �°'�— Z 6`` Signature
Owner Agent Contractor
The for o' trument was acknowledged before e s.c� a foregoing ins ent was acknowledged efor e,thi
day of ,20 Lq,by �e y of 'l� ,20 by i aer
who is perso lly known to me or who has produced who is personaIly known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
F
Sign: Sign: r,
Print: T. Print:
MY COMMISSI
My C =' °2 Ems:Aum 20 2017 My Co ,.11„�u�l COMM1SSlOV t��oaa�9
Borated Tto Notary Puft Onderwfts :,&? r
EXPIRES:August 20.2D17
q Borded Tft Notary PUM undenuritera
APPROVED BY Plans Examiner
Structural Review Clerk
(Revised 5/2/2012)(Revised 3/12/2012))(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Miami Shores Village
�
las ® NINE Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF(FLORIDA)
COUNTY OF(DADE)
The undersigned Affiant, � 'e5e ) des he by attest that
(Property owner)
The attached survey,performed by ' ��a1-1
(Name of surveyor's company)
For address:
Performed on '4 �° ®3� (date of survey)is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures may affect final inspections as applicable to this or other permits.
rurftther, r�t say eth nau� �-er Signature Property Owner Print NameAND SUBSCRIBED before me this � day of personally known to me, produced as identification.
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Revised on 5/22/2009/Revised on 6112/09 ,;q `urbr COMMISSION#FF 044099
'* * EXPIRES:August 20,2017
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