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PL-15-2506 (2) • - - Miami Shores Village Building Department OCT 01 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tei:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2004 BUILDING Master Permit No. d?C. LS°-2506 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL T LUMBING F-1MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP 1-y CONTRACTOR DRAWINGS C JOB ADDRESS: �I W I t City: Miami 1Shores 1 r` County: Miami Dade Zip: Folio/Parcel#: u A16 d�J 041 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): �i�ll l kl%i% Phone#: tl/ q(4? Address: t l y_h" [( City: OG,% State: . Zip: ?3(U Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Phone#: Address: ;d` �W ~ City: -i State: Zip: Qualifier Name: KQIe Phone#: State Certification or Registration Mcto of Competency#: DESIGNER:Architect/Engineer: Phone#: Address:' r ?rz "C' • City: State: Zip: g ° ,r Value of Work fQis this Pera»k� k • CS© Square/Linear Footage of Work: Type of Work:.. ❑ Addition Vl_ Alteration 1 -� ❑ New epair/Replace ElDemolition �Y-� cd - Description of Work: 1 I�Oi IA t e rArl� Specify color of color thru tile: ..GG►► Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ S((3 TOTAL FEE NOW DUE$ t C3 ° (Revised02/24/2014) 6( Q °< o 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 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 not be approved and a reinspection fee will be charged. Signature 0" knature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before me this day of L'"`jGr ,20 by �_day of�-ge ,20 JC ,by who is personally k wn to ✓' ,who is personally known to me or who has produced as me or who has as SHERYL A MENDES identification and who did take an oath. identification a kt@Cff&.Slide 01 Florida ' My Cot.Expires Oct 23,2018 NOTARY PUBLIC: NOTARY PUBLI CoBgmisslon#FF 138597 .,'� �� Ndary Assn. qAt Sign: Sign IJ Print: Print: KtMULE ETTRICK Seal: c2°+ s`� Notary Public-State of Florida Seal: •: ;•?My Comm.Expires Sep 19,J s Pic.` Commission#FF 055732 ,'i,F GF c��••`• Bolded Through National Notary AssrL IIIIIII• KIM APPROVED BY � L Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014)