WS-12-903 Miami Shores Village RECEIVED
Building Department MAY 21 ZOV
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 fi
�1 41u d Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING Permit No.1
PERMIT APPLICATION Master Permit No.
FBC 20 J()�
Permit Type: BUILDING /ROOFING
OWNER:Name(Fee Simple Titleholder): C1,4X(_0 DHCA 4CA Phone#:
Address: q,306 AJ02rH 8,4f✓rSHO&f Z)/2-
City:
)/Z.City: 1'11,4141 S/-104,E5 State: F zip: 331a:z
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: '7300 /1117629'" &,4 PJHat2E 0,v--
City: Miami Shores County: Miami Dade zip: 2)--3 2
Folio/Parcel#: 11 3 20.50 27 0/3 O
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR:Company Name: PERJAA)S 0 C.A P6 UV16146 .J53 C phone#: C3 a
Address: 20(o S u) 2:2 4 D.
City: H 6Ax44 State: F zip: 3 aJ 12
Qualifier Name: r2QNC6 SCO G t1w1 6_2 Phone#:aOS 625-4933
State Certification or Registration#: CG ' / 2 t Certificate of Competency#:
Contact Phone#: r�ss
DESIGNER:Architect/Engineer: C11 Phone#:
Value of Work for this Permit:$ /2j 000 Square/Linear Footage of Work:
Type of Work: ❑Addition DAlteration ONew *epair/Replace ODemolition
Description of Work: -X#4 A017 tJ 1AJ D-0CV,-)
x�xx�x�������x������xx�xxxxxx�xx�:xxx��xFees�xx��x�x��x�xxxx�x���xxx�xx��xx���x�xxxx�:x�x
�^ C.74
Submittal Fee Permit Fee$ Q CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
�tJ�
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 incompliance 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 ch posted notice, the
inspection will not approved and a refpspection fee will be charged.
r✓
Signature Signature
Owner or Agent P yactor
The foregoing instrument was acknowledged before me t s The foregoing instrument as knowledged before me this—Lk
i f7A do
day of _ �,20 by 2AN!<{ �C-4&e 5q . ,: day of 20�°' ,by 15i4AJC15G0 l/siaLE�
who is personally known to me or who has produced who is personally kno to me or who has produced F
As identification and who did take ail.oath. as identification and who did take an oath.
NOTARY, BLIC: NOT BLIC:
Sign: yy)��AA Sign:
Print: lilS Print:
�p`PpYPGO LIS ���1fg'PhA.i
My Commission Expires: M.,A Ccmmisv!.-,+ DD964672 My Com issio Expires: r: :COMMISSION#DD964672
EXPIRE- MAY30,2014 ��- �� �� 3� p��EXPIRES: MAY 30,2014
��� '••inoF;;°,`'WWW.AARONNOTARI'ca[I •••�dm►:`` www.AARONNoTARI'com
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APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)