BPP-12-1158 (3) Mi mi Shores Village
Building Department ir s i'l ' 2u-,
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING Permit No. m C-("a
PERMIT APPLICATION Master Permit No.pjpp - 1 15
FBC 2010
Permit Type: MECHANICAL
OWNER:Name(Fee Simple Titleholder): ply / ����►N Phone#: 7��-�7f�-8��l
Address: ��5@7 ls�v'*?
e
City: �s-�is� State Zip: �����
Tenant/Lessee Name: Phone#:
od
Email: e('..' AoOr7 C1J a®/• C
JOB ADDRESS: (?3 Ad 4E ` fie_"
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR:Company Name:ll?Oc)`1-t cC1 1 C�-r ni IC ✓11� 1( Phoneti� � � l
Address: q 00 �T-
City: � I r*Y__A fi State:� Zip:
Qualifier Name�ncl n C'I C )�� c1C::l,t,V'r- Phone �,(pt �� 0
State Certification or Registration#: Certificate of Competency#:CI,) �-
Contact Phone#: Email Address:-ECIC(����� c _C t 1 l� f( yy� , •�[r(1/�
DESIGNER:Architect/Engineer: Phone#:
J
Value of Work for this Per too Square/Linear Footage of Work:
Type of Work: OAddress DAlteration ONew ORepair/Replace ODemolition
Description of Work: 416- -_XUAV491V ®r— &60L
xx���x���xxxx�x��nxu�xx�xx�x�xxxx�x����Feesx+xx�I��x�xax��x�x�ax�x��xxxx�xx���x�+�x�xxx��xx
Submittal Fee$ Permit Fee$_ �. �/ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training(Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ in
V 0 1�
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 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 occurfs seven (7) days after the building permit is issued. In the ab ence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Sign it re
Owner or Agent Contractor
The fo oing instrument was ackn ledged be or is (D The foregoing instrument was acknowledged beforemethis 2C
day o 20 y day of ,20 L2,by�n0y l�0��Q�Irl
w o is ersonally known to me)r who has produced who' ersonally known o me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARMP BLIC: ' ' NOTARY PUBLIC:
ZAPATA
Sign: a\ 215 Sign: .•'o is•state of Florida
s , , comm.Expires ep ,
Print: m. E Nssn.
Print: 14. Z C QMSA ssion A FF 25341
Commis hNa\`0��a %f °`°��•• Bonded Through National Nota Assn
My Commission Expires: i;sr .Q g0�dedtb�ou9 My Comm sioiY rr
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APPROVED BY ✓,1,-R�ns Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)