REV-16-3093 � (.0
AeE
� Miami Shores Village E0
�� Building Department
O
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 �—
FBC201 �
BUILDING Master Permit No.-pS�4
3�
PERMIT APPLICATION Sub Permit No. _P_E V/b
❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION r-1 RENEWAL
❑PLUMBING ❑MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
/► CONTRACTOR DRAWINGS
JOB ADDRESS: Iq3 4? 0 �. .� B d o
ON: Miami Shores County Miami Dade Z)o: -
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):�' _fvly �y��'� Phone#:�'�d
Address:
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: e&yl V 4Q UC Phone#:
Address: SLU
City: Ck CA.4 State: �� 01 p:
�r 'Z— Phone#:
Qualifier Name:
State Certification or Registration#:��i��l� jQ2._'T4_ Certificate of Competency# —'
DESIGNER:Architect/Engineer. Phone#:
Address City: Statee: 1 Zip:
Value of Work for this Permit:$� Square/Linear Footage of Work: 1U
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work-1:61 (ON Chl lbi
Specify color of color thm We: ..1
Submittal Fee$� //W
Permit Fee$ " CCF$ CO/CC$ �—
Scanning Fee$ q Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(RevisedO2/24/2014)
}
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
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencemen ust be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the a en of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
-
0 ER or AGENT CONT CT R
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of (5�C! ,20 /frs by (9 _day of 20 by
C- (< tPP I Oi, who i personally known� is rsonally 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:
Sign: 4 Sign:
Print: Z Print:
�` MABEUS E FERNANDEZ
Seal: Seal: +ear! MABELIS E FERNANDEZ
,r ,�'`,.
} MY COMMISSION#FF127992 • MY COMMISSION#FF127992
aj._ ;Ovg O
', a; d�.•' EXPIRES June 1,2018 '��'gEXPIRES June 1, 2018
(407)398 0163 FlorldalloteryServlce.cam ( )ao7 398-0153 •n rr�xx�x��x�r+�
APPROVED BY Plans Examiner Z��Zonlng
Structural Review Clerk
Y
(Revised02/24/2014)