RC-15-821 (5) Miami Shores Village
RFS": _�
'tea Building Department MAY lt32016 .
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No. /tel
PERMIT APPLICATION Sub Permit No.. �1/
UILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
j CONTRACTOR DRAWINGS
JOB ADDRESS: �P�J� D / -7,.z
City: llMiami Shores County; Miami Dade Zip:
Folio/Parcel#: / oy -04-3-0516 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFEE:i
OWNER:Name(Fee Simple Titleholder): /�S.�u�j Phone#- /
, , 7 • �' �
Address: � p� c��' � 7T�J�wip
City 4� �e �>K State: /��- Zip•c � �
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#:�� -' '�LG ��= 1 �'I"-4e- •�-
Address:gja2 6 v?6
City: Sta Zips,
Qualifier Name: U �" -- �-S Phone#:
State Certification or Registration#: C 1'� ` dag I Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: -,•, City: State: Zip:
�e� v
Value of Work for this Permit-$ Square/Unear Footage of Work.j j� f�°r
['
Type of Work: ❑ Addition ❑ AlterationL❑ New ❑ Re h�r/QRepplace ❑ Demolition
Description of Work- � r 1SQ �-�� 11`'OS G'.✓vZ
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ =r�. ' CCF$ CO/CC$
Scanning Fee$ s-,4 C'S Radon Fee$ DBPR$ Notary$
Technology Fee$ TmIning/Education Fee$ Double Fee$
Structural Reviews$ 4 2-0"w Bond$
TOTAL FEE NOW DUE$ �-ld
(RevbWO2/24/2014)
i
• 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 commencementust be posted at the job site
O
for the first inspection which occurs seven (7) days after the building permit is issued. In the abse c of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNE AGENT C NTRACTOR
The foregoing instrum was acknowledged before me this The foregoing instrumen, as acknowledged before me this
/0710'dav of 20 /e�7 by ° day - 20 /4-7 ,by
r
who' sonally known tom, ' ' ��' who is iso �� y known t
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 PUBLIC:
7
Sign• Sign•
Print• Print:
Seal: a�`; .` � KELYA Rg5R60 Seal: �`;�%�:e� KELYA AODRK�ttEZ
NY COIBIISSO 4 FF 040067
* * EXPIRES:,bly 25,2017 * * MY CO�411SSItbV 3 FF 040087
EXPIRES:J*25,2017
'Fovvt�' '���.e�`OF B�edThroBN�Yg
IN I
APPROVED BY SA6I l 4 Plans Examiner Zoning
Structural Review Clerk
(ReVMW2/24/2014) 7