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Building Department 13Yem®moom
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10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949 s�
BUILDING Permit No. CC!°L
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: BUILDING ROOFING _ e ,
OWNER:Name(Fee Simple Titleholder):_ \ Phone#: c�J 7 S4 �S'`f
Address:_ .4(02 /q(5 T(.e -sr'
City: IA1nAA( ^S�_ O � State: V(_ Zip: ) 79
Tenant/Lessee fN-ame: k 9 I ��t di7C � e t°g �I 311• Phone#: !'- 7
Email: &A Al(-N---%-:�tl C . A)e 'r
JOB ADDRESS: of 4o Polz-r— (DuyC
City: Miami Shoresii County: Miami Dade Zip: 340
Folio/Parcel#:�- 320.,s()j 4 o 1/0
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR:Company Name: wak-%on:1� 1.���i��K�1� l � Phone#:
Address:
City: State: " Zip:
Qualifier Name: > A one#:
State Certification or Registration#: Ia ompetency#:
rr
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: Phone#:
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Value of Work for this Permit:$ 19i�o Square/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration ONew *epair/Replace ODemolition
Di.scriptiod of-Work.. S�n `� , 51 �L L.A 91`-ML y�"I 0 k
eo
Submittal Fee$ Permit Fee$ Au 0 CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double 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 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 broth re will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of comment ent must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In he a sence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Ja
-;er
Owner or Agent R „i Contractor
The foregoing instrument was acknowledged before methis
ay i The fore oin 'nstrument wja ac o led ed orVmefihis ,l
�J`) lP d lilC�e� da of 201 b
day of ,20 foZ_,by D y >
ho is ersonall known to me r who has produced o is personally known to in or who has produced
As identification and who did take an oath. as I entification and who did take an oath.
NOTARY PUBLIC: NOT7"A
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Sign: �' �%'� Sign:
Print: V I�- a �f£ Print: V.CUBILLOS
Fida
NOTARY PUBLIC-STATE OF FLORIDA QIP e,•. Notary uD is-State of Fl
My Commission Expires: �a�"""• Sylvia Halter My Commissio -= r • Us My Comm.Expires Sep 23.2015
Commission#EE098053 �, 'o:: Commission#EE
128810
Expires: JUNE O8,2015 �111i,�p�` Bonded Through National Notary Assn.
BONDED THRU ATLANTIC BONDING CO.1NC,
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APPROVED BY Plans Examiner `' Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)