CT-15-260 .I
�a Miami Shores Village
FES ® r
Building Department 5 X01'
g
� ®(t 10050 N.E.2nd Avenue,Miami Shores,Florida 33138
t/" Tel:(305)795.2204 Fax:(305)756.8972
V� INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING Permit No.
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: BUILDING
�j pry P�.� y_
OWNER:Name(Fee Simple Titleholder):
C i� • �.� ty Phone#: L 0,5 ze
Address: Du /11.J Jt7 'tc`
City.&.4 yl1 State:
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS. Y 1
City: Miami Shores County: Miami Dade Zip:J, t?
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zorn:
CONTRACTOR:Company Name: /s L e Phone#: � DOC
Address: �7
Ci Iju
Je S Zip:
33
Qualifier Name: A A Phone#:
State Certification or Registration#:efA0C1 0<"2/37-5 Certificate of Competency#:
Contact Phone#: 3�� 2 7Z `�_.:1mail Address: ,�r��ILG'.y�'c'7GL�.a:( „
DESIGNER Architect/Engineer: Phone#:
Value of Work for this Permit:$ Z0 Sqe/Linear Footage of Work:
Type of Work: UAddress DAlteration ®'NeURepair/Replace ❑Demolition
Description of Work: Ta— l �
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by.
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Doable Fee$ Structural Review$
TOTAL FEE NOW DUE$
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.
"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 0 COMMENCEMENT."
Notice to Applicant: As a condition to the issuanc i ermit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of comm t nstruction lien law brochure will be delivered to the person
whose properly is subject to attachment. Also, a cernfled cop h ded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the but ermit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature � Signature
Owner or AgentI Contractor �f1
The oforego' g^ t was ack ow,ledged before me this The foregoing' ent was acknowledged before me this 01
,9
�U y C (tL,JnU,CSP day ofno �� zo by a�tA 9,.A Al
pi
who is personally known to me or who has produced who ise
nally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOT&W PUBLIC: NOTARY PUBLIC:
Sign: Sign: a_
Print: 1' Print: 1��,5 de /� l><Urr^-
My Commission E it UUANA CUEVAS My Commission Expires:
Notary pdft-State of Florida
• My con.Expired Apr 20,2017 • °•y, LOURDES DE LA NUERTA
Ceomforl i EE 862175 F r'dag
APPROVED BY Plans Examiner WW commumn 0 142W 11oning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09xrev6/4/10)