RC-15-1844 (2) i �
Miami Shores Village C -,TN,FD
Building Department NOV 17 2015
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY,
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(30S)762-4949
FBC 2010
BUILDING Master Permit No. fCe t r2 — t8�4 .
XBUILDING
PEERMIT APPLICATION Sub Permit No.
❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION `SHOP
CONTRACTOR T� DRAWINGS
JOB ADDRESS: r�" O /YL�" zo7fC -5./-
City:
fCity: Miami Shores Countv:Af Miami Dade Zip: 3� �
Folio/Parcel#: It— ?.2,9;1 4-1(V-00*0 • Is the Building Historically Designated:Yes NO
Occupancy Type: Ar-A Load: Construction Type: y-1%v Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): Phone#:. !o-.x" 0
Address: 23 U /YE t D7fy, Sf
City: tW ia,w i S h ou es State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: h'1�.N CF�t-�So'C4'4�G�lwP.� Phone#: fs•Zr'�fo *IS;
Address: tw:!pb 5W bv err
City: State: '" Zip: '3 3i(oVr
Qualifier Name: ��"�L,O 1-ttl•N•�'"�G�� Phone#:
State Certification or Registration#: G OlP2 It yq' Certificate of Competency#:
DESIGNER:Architect/Engineer: ifS t s• V-A• 9O Phone#: 700%rr 940 *t241
Address: 4400 GO•f.0 S b C-Pq' City: G•GN+4K0S State:Zip: 0:1
Value of Work for this Permit:$ X11100.a Square/Linear Footage of Work:
Type of Work: K Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 'tV-090CV *44,0*1 b .�!►-�Cn S
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews WL, c0i Bond$
TOTAL FEE NOW DUE$
(Revisedo2/24/2014)
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES,BOILERS,HEATERS,TANKS,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 YOCJR 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 th abse of such posted notice, the
inspection will not be approved an coon fee will be charged.
Signature s _ ' Signature
r .
OWNER or AGENT NTRACTOR
The foregoing instrument was acknowledged before me this The foregoin instrume was acknowledged before me this
day of Nhy ep"bke ,20 /:,by lam_" ay of* ,20 IVPI ,by
j � $.iInW,who is personate known to 4r*-tKA .Srt.tFOf.]A-#."# +iSL6-oersonally known to_
me or who has produced as me or who has produced . as
identification and who did take an oath. a identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign•
pmoff-q Print:
Seal: Seal:
•****��s�•�*�a�xs�es�***e�a�s�s�s�s�ws*���+�**�w*ws���sa��s*w•�xss���x�xsa��a�**ss�s*a�s�s�**�sa��xs�xs�x�x�����x�x�a�w***s�s���xs�x��+s�x
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)