WS-15-1603 (2) C��S i5 Miami Shores Village
Building Department
JAN s o75
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 10
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 358 16 I®I .
City: Miami Shores County: Miami Dade Zip: 331�,8
Folio/Parcel#: 11 -32 —C>13 f2So Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): !SCx::ti Phone#:
Address:-358 ILL 101 '5+.
City: m\ami �Jhc�c�x� State: 1 Zip: 3313E
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#:
Address: �5ctx� N-X. 11;®1
City: State: V-1 Zip:33 kq
woF
Qualifier Name: r:E�;h a c C, Phone#:
State Certification or Registration M G I2 Certificate of Competency#:
DESIGNER:Architect/Engineer: iPhone#:
Address:_1(gcD 'Sr� IZ /A-Vc-- "' la'o city: State:-]�-hzip:
Value of Work for this Permit:$ ;�U (B 9-7 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: QCAX-'
i
Specify color of color thru We:
Submittal Fee$ `w� Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ 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 posted at the job site
for the}list Inspection which occurs seven (7) days after the building permit is Issued. In the absence of such posted notice, the
Inspection will not be ap ved and a reinspe n fee will be charged. 7
Signature Signature
OWNER or AGENT CT
The foregoing instrument was acknowledged before me this The foregoin as acknowledged before me this
-�/ day of �� _______,20)5 ,by 964 Sc� .20 IS ,by
�t
jcntt" 1-•S1Y1 i-rjrt ,who is personally known to Sc�vc.� 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: Kic , 9 N- 1
�� J-- Print � s ImLL
Seal: °` '*c MY COMMISSION#EE177745
e MY COMMISSION#EE177745 Seal: EXPIRES March 11.201
EXPIRES March 11.2018 ,+�•
Pp� �n3.4"*3 FWWaNuWrVSwmj.mw
•p71398-��`.r3
Fla7ideWOtarYS ®•rom ---
APPROVED BY (/� �7 1 t I Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)