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-1 Miami 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
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING
OWNER: Name (Fee Simple Titleholder): )C hl m ( � " �� s v ) - -i:° Phone #: %(-,2 ' 217 q — e ( t
Addr s: i ! '(.; 3 & - - ' i r TI 4' I )-(5- C
City: I L( Ti r--) - 1 i 1/1(_ C' . State:
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Permit No. q� _2-
Master Permit No.
6 .
Zip: 3 ' 3'6
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS:
City:
Folio/Parcel #:
Miami Shores
Is the Building Historically Designated: es NO Flood Zone:
CONTRACTOR: Company Name: 3r1"E!) g-tr d Yi -.1 . Phone #:
Address: L & L C' L # .
City: 1O A IL
State: ,�
Qualifier Name:
State Certification or Registration #: �_t ' / ' i ..,:56 Certificate oCo .e
Contact Phone #: `'L 15 ' 6, y `_ C (I' Email, dr
DESIGNER: Architect/Engineer:
Zip: 3b
Value of Work for this Permit: $ 9) X10 • CO
Type of Work: Address OAlteration
Description of Work:
Square/Linear Footage of Work:
UNew OR air/Replace ODemolition
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ 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 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 first inspection which occurs seven (7) days after the '% Xa in_ permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be c
�- -.
Signature Signa : , i`
Owner or Agent per` ontractor
The foregoing instrument was acknowledged before me this The foregoing insti�um : ; , =edged before me this #1.:3
day of , 20 , by , day of / a,
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
as identification and who did take an oath.
NOTARY PUB
Sign:
Print:
1
My Commissio n 4 . CARMEN ARAN
MY CCAVISSION If DD b91862
EXPIRES: Junt 2G, 2613
s ' F g Tlao6tlSdNI Y t3
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APPROVED BY
(Revised 07 /10 /07XRevised 06 /10/2009)(Revised 3/15/09Xrev6/4/10)
Plans Examiner
ci Zoning
Structural Review Clerk