CC-08-532 (2) -b11x108 SIZAIM Ikeg '
xbr�k Miami Shores Village
Building Department
�7I j/S 10050 N.E.2nd Avenue,Miami Shores,.Florida 33138
A Tel:(305)795.2204 Fax:(305)756.8972
BUILDING ( :C,, �'� Permit.No.
PERMIT APPLICATIONZd®8 r Permit No.
FBC 2M
Permit Type(circle): (:B4� R �^ t
Owner's Name(Fee Simple Titleholder) eIb R°S �s��rL SC11yvl. Phone# �l�.l �T Z3�,
Owner's Address / �✓� �� �il.
City!2 i4 rd,I 5"t/- State AQ- zip
TenaaVL.essee Name Phone#
Job Address(where the work is being done) 1130/
City Miami Shores Village County Miami-Dade Zip y V
`k\^ n�
FOLIO/PARCEL# l.,
Is Building Historically Designated YES NO �
Contractor's Company Name &V,4 I V,4 Q S -c lS iYuchMane#
Contractor's Address 3 N3
City �,kL lkH-tl, S cAcolltiS State E( Zip S(3
Qualifier Name Phone# M�_--%M� —5-%C-s;>
State Certificate or Registration No. GOJ`,�CCertificate of Competency No.
Architect/Engineer's Name(if applicable) [ Phone#
Value of Work For this Permit$ 400 `' y Square/Linear Footage Of Work::
Type of Work: []Addition [gAlteration ❑New ❑ Repair/RepIace ❑Demolition.
Describe work: LNE sL) twaMMO 0 :?O&4-j-,
Feesxe� x * +
Submittal Fee$ Permit Fee$ !" CF$ CO/CC
Notary$ Training/Education Fee$ Technology Fee$
Scanning$ Radon$ DPBR$ Zoning$
Bond$ Code Enforcement$ Double Fee$
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 P
t
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 atthe 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
wner or Agent Contractor
The foregoing instrument was acknowledged before me this / The foregoing instrument was acknowledged before me this Z6
day o4dUa,200 by day of 4 Y 20 162,by 4Z AMrtt}
who is personally known to me or whoLem produced who is personally known to me or who has produced��d/�5
As identification and who did take an oath. UIC 5'P d as identification and who did take an oath.
NOTARY P LIC: � - --------
--- o NOTARY PUBLIC:
' W COMMISSION 6 DD 289343
';t EXPIFEB:Ap P 10,2008
Sign: Sign.
Print: Print:
ry
My Commission Expires. My Commissio
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APPLICATION APPROVED BY: Q Plans Examiner
Engineer
zoning
(Revised 07110107)