REV-16-1324 �l
Miami Shores Village
Building DepartmentMAY I
10050 N.E.
Tel: 305)79 - 04 :(IV5) -89
E E 30 9 !1
FBC 20 lei
BUILDING Master Permit No.
:BUILDING
MIT APPLICATION Sub Permit No. �/l ® 13� i
❑ ELECTRIC ❑ ROOFING 24REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: �"- /p) `�1la"��
City Miami Shores County Miami Dade Zip: 3.39-B b
Folio/Parcel#:Z1- 3 zo S'_ 0 10 - 41)1,10 Is the Building Hlstorically Designated:Yes NO V
Occupancy Type: _Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name
�(Fee Simple Titlpholder): A9,W PtTA-loo-)11-1�&OWone#: 3v;-
Address: J`��-
City: i A9&e State: Zip: 3,�!)1 as
Tenant/Lessee Name: Phone#: �'
Email: a� j
CONTRACTOR:Company Name: PhonetQ& )7/�K,361'®9
Address: 9W
City: 1-114-af'I State: Zip: �®
Qualifier Name: %*'Ri() A,)Nlw 0 Phone# 76 " z11 7 - 1Z)
State Certification or Registration#: L6<' CST `"� Certificate of Competency#: 7
DESIGNER:Architect/Engineer: 9,41&b Phone#:
��//
Address: "T® 6LPZ-3 i City: 1-11 ;1 Stater Zip: /3
Value of Work for this Permit:$ g 6ZZ19. Square/Linear Footage of Work:
Type of Work: ❑ Addition EJ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: ✓�� 44u 6 v l S Io
106f.Uj 'rJ� , �c✓ kf-1G�' �; �1 r � r' f�rZ` / .1
Specify colo`of color thru tfle•_ "q
Submittal Fej '. 'Pft'Fag CCF$ .`C
Scanning Fee$ 12 - Radon Fee$ DBPR$ Notary$
Technology Fee$ 4' W Training/Education Fee$ SO Double Fee$
Structural Reviews$ 20` Bond$
TOTAL FEE NOW DUE$ ' 570
(Rev1sed02/24/2014)
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
whoseproperty-is subject-to ottacirment:Also,-a-certified-copy of the recorded 7ro IMof CommerrcemetX-must4Yepv3teV-a-ufh-elo�e
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appfoved and a reinspection fee will charged.
Signature Signature
.-d
OWNER or AGENT
Z� v
R- -_._The foregoing instrument was acknowledged before me this The fore& g-msitiledged before me this
� day of 1 20 by k%� day of20 by
_,who is personally known to �? Cv�J10 ,who is personally known to
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:
Sign: _ Sign
Print: Print:
PC
s,•,
Seal: �' ° Notary Public-State of Florida Seal: }',� "S Notary Public-State of F]527
'sN My Comm.Expires Jul 15,2017 1� My Comm.Expires Jul 15,Commis #FF 195 ':; °� ww Commission#FF 19
APPROVED BY fell Plans Examiner Zoning
- ' � �// Structural Review
Clerk
(Rev1sed02/24/2014) I