RC-10-792Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: {305) 795.2204 Fax: (305) 756.8972
Permit No. I 0 712%
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle) Building_ ) Roofing
T003E17E11
MAY 0 7 74)10
Owner's Name (Fee Simple Titleholder) -12.1.‘0 f $ 734' Phone # 45-/ 5-5 9 " y30 6
Owner's Address 7 1.007P Q/t °A IV
Sf-Q Po ()
City ii r V{ "t- State 73c Zip
Tenant/Lessee Name N ( (11 Phone #
� SO 6.3
w /0-
Job Address (where the work is being done) a-10 A) 6 ®0a ,s"t (& am
City Miami Shores Village County i ; mi-
FOLIO / P A R C E L # /I-39-0 6 , 6 , 0 e / 4 2 6 0 /
Is Building Historically Designated YES NO L
Contractor's Company Name /l k 6O
Contractor's Address Li 301
City c CAA State ���4w. �t�� '� Zip 3Lett,,ty
Qualifier Name O - 1 Phone # 13
Phone # g 13-- 5 44 -7t.61)
State Certificate or Registration No. 'c /3
ertificate of Competency No.
++ r
Architect/Engineer's Name (if applicable) k.1 1 , 5 Phone # 3
Value of Work For this Permit $ / Ch 0 0
Type of Work: glAddition ['Alteration ONew -,A epair/Replace 0 Demolition / ,,
Describe Work: U'�dL ) P 0 3�(tvvL W- f x %� �, ;. p-Prowi. i I t4 d v 4 r 7'6
Pe+i�. ur�-pero KeJ vD1. tut A, ct aeetr�f S amt./ f Q 4o demo pd ®I/
n v�-e re 0 Lor si 1,11944,14 n(.4„) ,a
(419 0 * `elii T1 rooI
I Yua+&x*f.p.4*ii&**r' urvPti ***** itiir# ti. iifirf ].4xxA #Fees'i *4+44rirk.4ttwr' ****i** Teal+ Yii }vfvi.4ieirr.ii,pxaiif.*** *tk tk
Submittal Fee $ Permit Fee $ CCF $ CO /CC
Notary S Training/Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement 5 Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side ->