RC-06-1555 64 /51c�)Co -
Miami Shores Village �
Building Department 't 2-15 '�
G 10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fag:(305)756.8972
BUILDING Permit Ivo �
PERMIT APPLICATION Master Permit No.
FBC 2004 JUN 0 7 2006 Jl
B .-- -4-5_�,,L
Permit Type(circle): Vr&ilding Electrica Plumbi Mechanical Roofing
Owner's Name(Fee Simple Titleholder) °r-u Phone# 72
1 �19 Z'
Owner's Address q_ q
City &k�lag ) - t9W 5 State _� �.. Zip
Tenant/Lessee Name Phone#
Job Address(where the work.is being done) 92AA
City Miami Shores Villate County . Miami-Dade Zip
FOLIO/PARCEL#
Is Building Historically Designated YES NO-
Contractor's Company Name /�� -� Phone#
Contractor's Address ►
City State Zip
Qualifier Name = Phone#
State Certificate or Registration No. ficate of Competency No.
AaL
Architect/Engineer's Name(if applicable) ,fes_j Phone#
Value of Work For this Permit$ Square/Linear Footage Of Work:
Type of Work: A'�dd`fition //+Alte��r±±ation nNew ( Repair/Replace ❑Demolition
Describe Work: `l�l� 1� �`T�l �°4'' 9P1� 61L�l Qm� D® Oy)t—
Submittal Fee$ Permit Fee$ �v �� CCF$ - CO/CC
Notary$ 6•00 Training/Education Fee$ Technology Fee$ ?,- °
Scanning$ Radon$ DPBR$ Zoning$
Bond$ Code Enforcement$ Double Fee$
Structural Review.$ Total Fee Now Due$ tm l
See Reverse side-�
�� ��
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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Owner or Agent Contractor
The for ing instrument was acknowledged before me this. The foregoing instrument was acknowledged before me this
day of ,20010 by day of .20___,by
who is ersonally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oathas identification.and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
NOTARY PM"r-STM of FLORIDA
Sign: aceres si
conwassion#DDS387,
Print: s , 1( 18, 2
�' s.
My Commission Expires: _t -�3!a$on d Thr+ 'e Bente Commission Expires:
APPLICATION APPROVED BY: Plans Examiner
Engineer
Zoning
(Revised 02/08/06