MC-12-926 p',T�cm
Miami Shores Village CBCT 0 2612,
Building Department B Y°
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fag:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING .
PERMIT APPLICATION Master Permit NiCl 2,—
FBC 20
Permit Type:MECHANICAL
OWNER:Name(Fee Simple Titleholder):_ eFFry y /`'1l3.Yer phot;
Address: /ass icl� 93 ST _
city:_ /Chit; O&C—OS —state: �'L zip: 33Map
Tenantflxwee Name: Phone#:
Email:
JOB ADDRESS: /off S S A16 q.3 5T
City: Miami shores County: Miami Dade Tip: 33 ep
Folio/Parcel#:
Is the Building Hlstarically Deftnateis Yes NO Flood Zone:
CONTRACTOR:Company Name:_Ar c o I lz_- , A-(_V, cophone#: C®_4_10_4m -
Address: (0 3 3 51 ( ��
City: _,AA l l State: , j �� T1P; a 3 l Er�
Qualifier Name: Phoma: -2 44 -x- -�
State certification or Registration# L�@ fe 6 4' Certificate of Campetency#:
Contact Phone*.3 0 —/5Z-U, Email Address:C, q 0 A/-"-
DESIGNER:Architect/Bngineer.t p}onetp;
Value of Work for this Permit: Square&hmr Footage of Work:
Type of Work: OAddmw cWtenition ONew Ultxpair&qlace UDemolition
Desc *&w of Work: A fA&W& i SA/tr 5%3*.m S= !t � Xe�io,�
!n �stretaior �/e�TFi4�h ��L Go de�Siyt l�issT
aee�ea�eewaseoae�esea+seeeee�*e+��og�se�weeeeao���sse�ss�s���wna�e e
Sbwlttd Fee$ PernI t Fee$� CCF$ MCC$
Scanning Fee$ Radon Fee$ DBPR$ Bow$
Notary$ Training/Edncsdon Fee$ Technology Fee$
Douhle Fee$ Struc hm-9 Review$
TOTAL FEE NOW DUE$
�� 13
Bonder 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 Et•ECTk7CAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOMERS,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
1IMPROVEN[ENTS 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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7)days after the building permit is issued In t absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charge4 ���III 1111j,
v- ; � p res•• ;
Signatiu�e Si 01
or Agent '1,�i Ractor
fy
The g.' t w ged me this The foregoing r°�E `"'166w`ledbed before me this f-
day o 20 by day of `
Who is y known to me or who ha produced �71 who is personally know I�who haspuced
3� i tification and who did take an oath. as identification and who did take an oath.
`1iV111111/1111)
NOT 'Y PUBLIC: NOTARY P 0 rti��
��� •':`�,PlfPs'•.Sid /li
Sign: ' ���tO�F oclda5 Sign: 21 6
• yb;i Sep —
Print: otacv t-
;ces a9�o print:F —
MyCommission Expires: '_; �.=MY�omm�sswNaicona�N°tatY n• MyCommissio� l t60096 X,
Shtou9h
............
O���F OF f'�p`` 8°°ded /�'•iT�0 F F\-
YJ `Y # �& ��&�� �08is0nk��8 >� ffi=�4sg��e1+6P8ai�8+@IE�N�BIffi���>s$ 6$nB�
APPROVED BY `—Plans Examiner Zoning
Structural Review Cleric
(Revised 07110W)ateviwd 06J10aW)(Revised 3p5/W)