RC-13-2168 (2) L
Miami Shores Village C
Building Department NOV 25 2013
/ 3 ' 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 c
Tel:(305)795.2204 Fax:(305)756.8972 BY:
1 INSPECTION'S PHONE NUMBER: (305)762.4949
FBC 20
BUILDING Permit No.
PERMIT APPL Master Permit No.k, I _x216 F
Y..
Permit Type: BUILDING ROOFING
JOB ADDRESS: //9 A)al //()()
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated.:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): 62, AC e Phone#: 796 37 305q
Address: Zj6ZO 2 7 /)' ✓1
City: 1- State:
Tenant/Lessee Name- Phone#: �-
Email:
CONTRACTOR:Company Name: a®�`T T oc_�(U/ls� V i CSS Phone#: -19(0
Address: qq%o &LO
City: V1 A-r ( State: `o Zip: 55 1'7 3
Qualifier Name: -�Oat) 1N• CZDPPhone#:�� 'Gi`l�a-5-7
State Certification or Registration#: C64 16 /J�'lO Certificate of Competency#:
Contact Phone#: 7!5- 5,D -Email Address: &oOl ll'w e WW /- 60A-7
DESIGNER:Architect/Bngineer: dL/ Phone#:
Value of Work for this Permit:$ Square/Linear Footage of Work: �<
Type of Work: ❑Addition dlAlteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: ��-��i n� �='� C(r1 r1 t t a((
Color thru tile:
Submittal Fee$ s r~ 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 conditio to the issuan of a uilding permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a co f the notice o co ncement and construction lien law brochure will be delivered to the person
whose property is sub' t to ac ment. Also, certi ed copy of the recorded notice of commencement must be posted at the job site
for the first inspect'on whi o curs seven 7 days after the building permit is issued. In the sence o such posted notice, the
inspection will no e ppr ved nd a rein cone will be charged.
Signature Signature
r or Ag nt rasacknowledged
ntractor
The forego' went was acknowledge ore me s The foregoing instrument before me this-:9x
day _ ✓ ,20 1' ,by s day of �1�� ,20,a>by
who is personally own me or who has produced wh is personally known tom or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLI NOTAR UBLIC:
Sign: Sign:
Print. � ' -2- Print. Pf4 6A;
MYLAI
My Commission Expires: `qti;J'y c, MYLAI HERNANDEZ My Commission Exp' MY COIIl1`AISSM#EE 221249
My COMMISSION#EE 221249 RuIU,
EXPIRES:December 1,2016
_ ;J(PIRES December 1,2016 Bch Thi N1►Pub
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
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