DS-15-701 ` Miami Shores Village
Building Department
MAR 27 2015
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No. DSS 5
PERMIT APPLICATION Sub Permit No.
El'BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS [:] CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 12-,4 F� u' (V5, ��I
City: Miami Shores County: Miami Dade Zip: 3315r)
Folio/Parcel#: I I -•3»1 " Q�� - C LC)1-0 Is the Building Historically Designated:Yes NO
Occupancy Type: 5 E Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): 6A 1 5) —F�)- ie-e W-� Phone#: w J" J° 12-11(,,
Address: 12-L A
City: ' CiPy�� lose Zip: 3
Tenant/Lessee Name: Phone#:
Email: (-A(11 �
CONTRACTOR:Company Name: I 1 '( �-�LC �� � Phone#:
Address: 6 � �( S1 i �_� E �� kc
City: ���� -� State: Zip: )
Qualifier Name: J M77 M e-- �An!4t4 Phone#:16
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ ®t) Square/Linear Footage of work: 111 00 54t
Type of Work: ❑ Addition/❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$ �S] . Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$Svc✓•m
TOTAL FEE NOW DUE$ S :� 1
(Revised02/24/2014)
Bonding Company's Name(if applicable) •
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable) Uv left%
Mortgage Lender's Address 333 -
City 1 e,10 State IZ A® Zip 22-2— 1
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 i estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of com f q, on lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the k' tice of commencement must b osted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OW rAGENT CONTRACTOR
The foreggling instrumentwasacknowledged before me this The foregoing instrument was acknowledged before me this
day o�1f. i 'l ,20 / S, ,by day of �/'�� ,20 J by
�II Ste- •/ G�Y'��� who is personally known to wh ersonallv known t
me or who has produced t— as me or who has produced
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sig Si
Print: �1�f Print: Y Pv Notary Public Stag f Flo' e
Seal: X10 anna
CAUNIIRANARRIM Seal: ;o y ¢ fifio Commission FF 082753
,Q No1Ary Fub1(c.$tate Of Florida n of flo�� Expires 01 N 212018
Comm**n#EE 196163
My wmm.expires May 14.2016
l
APPROVED BY I Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)