REV-16-3004 F
RECEIVED
Miami Shores Village NOV 10 2016
Building Department
10050 N.E.2nd Avenue, lorida 33138
,Riarnil 6-8972
INS I 05)762-4949
�1%jFBC 20 N
BUILDINGRMaster Permit No. VA%IS[�,� ��a�
PERMIT APMLICATION Sub Permit No.ZEV (G- 309 T-
OBUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 17 NE 109 STREET
Cir: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-2136-004-0610 Is the Building Historically Designated:Yes NO X
Occupancy Type: SFH Load: Construction Type: CBS Flood Zone: NO BFE: FFE:
OWNER:Name(Fee Simple Titleholder):MATT ANDERSON/BETH BARTELETTI Phone#:3052735706
Address: 17 NE 109 STREET
City: MIAMI SHORES State: FL Zip: 33161
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: CHAMPION CONCRETE Phone#: 3052528055
Address: 11001 NW 83 STREET, UNIT 103
City: DORAL State: FL Zip: 33178
Qualifier Name: JAIME BASILIO Phone#: 3052528055
State Certification or Registration M Certificate of Competency#:
DESIGNER:Architect/Engineer: SAME Phone#:
Address: f - City: State: Zip:
Value of Work for this Permit:$ 0:960 Square/Linear Footage of Work: 4 40'(
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: FRONT- BRICK PAVER DRIVEWAY/REAR- CONCRETE DRIVEWAY
Specify color of color thru tile:
Submittal Fee$ �.,n Permit Fee$ �Z15 - W CCF s_2. �Q CO/CC$
Scanning Fee$ • lJ�] Radon Fee$ �• Q7 DBPR$ Notary$�•
Technology Fee$ 3. 2� Training/Education Fee$ L'Z.eo Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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 commencement must be po ed at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the abs ce of such osted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature !� : Signature
e�
OWNE 'r AGENT CONTRACTOR
The foregoing i strum/ent was acknowledged before me this The foregoing instrument was acknowledged before me this
f� day of 20 04 by day of 9J--)'J 20 by
049"64 who is personally known to ��c 13ASI"vbt�'o is per onall o
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:
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Sign: Sign: ��•%�'
Print:
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Seal: � �n'••. MIRIAMDURAN Seal: -co
MY
.` MY COWSSION 9 FF 18070 `� ° S3H1a
EXPIRES:March 31,2019 %,�'9!�� °"•••••° v�o\®�
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APPROVED BY Plans Examiner l�lG QI-1-h Zoning
Structural Review Clerk
(Revised02/24/2014)
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c�COMPLIANCE WITH ALL FEDERAL
RECERTIFIED, FIEI,II -
REVISED. TefrzQ