FW-7-983 Miami Shores Village - '
Building Department L,. MY 1 1001
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 - � ^�
Tel: (305)795.2204 Fax:(305)756.8972 •-----------
BUILDING 1!61 +ld✓_ Permit No. +
PERMIT APPLICATION Master Permit No.
FBC 2004
Permit Type(circle)Celder)
Electrical �u�nbing Mechanical Roofing
Owner's Name(Fee Sim �4 Ar-A(ClD 411�-KL Phone# '716& 75:5 C
Owner's Address �,[�CC 3-(�" pZ L
_ N Vf/ P
City cAM f 6 y I��7 State 42-r— A— Zip -07 3 S C�
Tenant/Lessee Name Phone#
Job Address(where the work is being done) q f-f 3 O N W 0L
City Miami Shores Village County Miami-Dade Zip J 5
FOLIO/PARCEL# I 1 3 10 1 Q 1 5 o o e'
Is Building Historically Designated YES NO
�OML
Contractor's Company Name (SX>4 Phone# 76110 — 3 ® 7 S S
Contractor's Address 30 -/ l T L M-C4�'
Cityr S3 Zip J 3 . 1
Qualifier Name Phone# ( 3 1?0 — 7550
50
State Certificate or Registration No. ertificate of Competency No.
Architect/Engineer's Name(if applicable) Phone#
Value of Work For this Permit$
Square/Linear Footage Of Work:
Type of Work: ElAddition []Alteration E]New Repair/Replace ❑Demolition
Describe Work:
Submittal Fee$ Permit Fee$ 00 (d��" CCF$O- CO/CC
Notary$_6 Training/Education Fee$ Technology Fee$ �2 i1
Scanning$ Radon$ DPBR$ Zoning$
Bond$ Code Enforcement$ Double Fee$ 1 _
Structural Review.$ Total Fee Now Dues
See Reverse side a
onding Company's Name(if applicable)
riding Company's Address
ity State Zip
i
Mortgage $jer's l e,(if applicable)
7ior,gage
L�ader's Address';
ty State Zip
.?application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
Construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS.and AIR CONDITIONERS,ETC.....
I
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
plicable law$regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
AYING'TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
ONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
OMMENCEMENT."
otice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
romise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
hose 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
nspection will not be approved and a reinspection fee will be charged
{
ignature Signature
h
Owner or Agent 14
Contractor
The fore oing instrument was ac owledged before me this The; ore going instrument was acknowledged before me this
day of 2001 by dJ56A AklftZ day of .20_,by ,
who is personally known to me or who has produced IldiS who is personally known to me or who has produced
I^ic As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: `'`` NOTARY PUBLIC:
ao V\SS�N�\8 g95
Sign: �SOMM\SS\OOv Ol?.Zq�s .
•o, Sign:
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Print NtaN p .
Printrn : :
My Commission Expires: My Commission Expires:
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APPLICATION APPROVED BY: Plans Examiner
fi
Engineer
j <
Zoning
,(kteviwd OVOM)
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