DGT-14-2646 Iq
Miami Shores Village
�� � DEC 0 6 201
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 13Y`
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(30S)762-4949
FBC 2010 II //
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BUILDING Master Permit No-�-'T )`r ,— Z�`�yy
PERMIT APPLICATION Sub Permit No.
UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
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,� CONTRACTOR DRAWINGS
JOB ADDRESS: 160 NY 4" 1 1"l '514l�
City: Miami Shores County: Miami Dade Zip: `3-5(50
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): Al be&10 (m 11l" 0 P. Phone#:
t Address: g ow �06 rtA
f' City: illi f KA dies State: : Zip: SS.� So
Tenant/Lessee Name: .rrr �t. Phone#:
Email*
CONTRACTOR:Company Name: 'a(A ._I)f:Phone#: SQ_� gj! �2�
ress• D O3 A)
City: ` 1 state zip: 1 7
Qualifier Name: Phone#: O JP ID
State Certification or Registration#: �,�t G 1,5-l/&Oaj Certs irate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 0i LinearFootage of Work: S-Igo .
Type of Work: ❑ Addition ❑ Alteration New s❑i Repair/Replace ❑ Demolition
Description of Work: f \�J`�V j1A: %1DN &01;7 7rff,
Specify color oof�f//color
'thru tile:
Submittal Fee$ .JV Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
-a
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 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, onstruction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of rded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will b
Signature i red : gt'grt ire
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me'this '' The foregoing instrument was aclinowledged before me this
da01 9'ay of
nn Pr 20 by day of ! 20--R��by
who is personally known to ,who is personally known to
me or who has produced as... me or who has produced as
identification and who did take an oath.
identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUB -
XA
Sign: O
Print 'c Print: Ct
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Seal: NWGALYFOnistc.p�ern seal:
coN#EF -< N m
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MMUM:APR 2. : �$0
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WWWAARONNOTARY.:-r?Q&
APPROVED BY Plans Examiner 1 / Zoning
Structural Review Clerk
(Revised02/24/2014)