DGT-13-318Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
UII, ING
PERMIT APPLICATION
Permit Type: .BUILDING,
JOB ADDRESS: J 5-SD (t•J [ 0 S
City:
Miami Shores
FBC 2010
Permit No.
Master Permit No. DGTI 3-3-1
ROOFING
County: Miami Dade
Folio/Parcel #:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple Titleholder):
Address: " e0 N {
City: HZ c. LA
Tenant/Lessee Name:
NO C
t
Flood Zones, -`
Email:g'.:�/�.�� -.,.
CONTRACTOR: Company Name:
Address:
City:
Qualifier Name:
State Certification or Registration #:
Contact Phone #:
DESIGNER: Arc i t/Eng
zeio yart
Zip:
Phone #:
Value
T
De
44
k for
Ce + Cate of Competency #:
Phone #:
Square/Linear Footage of Work: 13
3 r! Ali` . tion UNew ❑Repair/Replace ❑Demolition
ption of Wo 4 Lt_ '� -,' l (r s, 4, A 4 c qe< /���
Color thru tile:
******** * * * * * * * * * * * * * * * * ** * * * ** * * * * * * ** Fees************* * * * * * * * ** * * * * * * * * * * * * * * * * * *** **
Submittal Fee $ `( 0 Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 caztllr�rta
promise in good faith that a copy of the notice of comme
whose property is subject to attachment. Also, a certified co
for the first inspection which occurs seven (7) days after the
permit with an estimated value exceeding $2500, the applicant must
and construction lien law brochure will be delivered to the person
g recorded notice of commencement must be posted at the job site
permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charge
Signature Si
Owner or Agent Contractor
E Via, r
The foregoing instrument was acknowledged before me this The forego' s ,ument was acknowledged before me this
day of Pe'7 , 201), by RI P!r aradc. , day of � �* +x: , 20 , by
who is
me or who has produ niognos t,
As identification and a ,���s oath
� .
NOTARY PUBLIC:
\ `\
NOTARY PUBLIC:
Sign:
Print:
who is personally known to me or who has produced
as identification and who did take an oath.
My Commission Expires:
APPROVED BY
Plans Examiner
Structural Review
Sign:
Print:
My Commission Expires:
(Revised 5 /2/2012XRevised 3/12/2012) )(Revised 06 /10 /2009XRevised 3 /15 /09XRevised 7/10/2007)
Zoning
Clerk