CC-10-1182 -7• qvo ` ` Miami Shores Villa 0394
� Village a
Building Department JUN 2 4
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fag:(305)756.8972 BY. "
INSPECTION'S PHONE NUMBER: (305)762.4949
BUILDING - Permit No.(� 0
PERMIT APPLICATION Master Permit No.
FBC 20
Permit a �3UIDYNG R OFING
Owner's Name( ee S ple Titleholder) ow CaN 1.u v Phone# ✓w
Owner's Address
City State Zip
Tenan ssee Name # to
r
Email Gl( Z 4
Job Addressbein where the work isdone)
( g i
City Miami Shores Village County Miami-Dade Zip ,c t
FOLIO/PARCEL#
Is Building Historically Designated YES NO X Flood Zone
Contractor's Company Name Phone#
Contractor's Addreps .0 �'pO
City `' State Zip
Qualifier Name .4,Wv- 1�— Phone# .741 0Yy-/
State Certificate or Registration *i ;f 6 a Certificate of Competency No.
Contact Phone E-mail ,l //
Architect/Engineer's Name(if applicable) %7id0 � .h , / Phone#
Value of Wbrk F is ermit- _ ✓l,t� `® Sc�uarElLinkar-Trootage ffi b�k�, J 9 5v
A Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair/Replace 'Demolition
Describe Work: -`
1 °
3 v
Submittal'Fee$ Permit Fee$ CCF$ CO/CC$
Notary$ Training/Education Fee$ Technology Fee$• \..
Scanning$ Radon$ DPBR$ Bond$
Double Fee$ Violation date:
Structural Review.$ Total Fee Now Due$
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.
66WARNIING TO OWNER: YOUR . FAILURE. TO ' RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING , TWICE FOR
IMPROVEMENTS TO YOUR PROPERT* IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR Li�NDER. OR AN ATTORNEY BEFORE
RECORDIN91 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 proved a inspection fee will be charged.
Signature Signatur
Owner or ent _ T \Contractor
The foreg ing instrument was ac owledged before this The foregoing instrumefli was acknowledged before me this
day of M ,20 t ObyV-15 day of ,20�.�by��1 N4�i�°'� Su rn e�ifr, s
who is �ersonall kno//w��ln tome or who has producedjE� who is =- or who has produced
AVt,�dentific&;,on aced who did take an oadi. <� ation and who did take an oath.
NOTA. PUBLIC: NOTARY PUBLIC:
EF.
Sign: .E <; ;� �," ,'�� Sign: r�e►i� u�iii�
Print: �'r Print: ���� ���' ,r
�i
My Commission Expires: a ti��' 4 Q�e�� My Commission Expires: 03106/2012
NOTARY PUBLIC .
�° = Commission #
APPROVED BY Plans Examiner 1,'7,1i0f„F,0;®, ning
Engineer Clerk checked
(Revised 07/10/07)(Revised 06/10/2009)
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