RC-11-1330it taricatc...
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Miami Shores Village S
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 JUL 2 2 X011
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit No.
Master Permit No.
Permit Type: BUILDING
OWNER: Name (Fee Simple Titleholder): 0.56AQ,.. Phone#:7 S/ — 543 -4516
Address: (2.5 iU e, clef 7`7
City: /4IArt4 State: • 124 Da
Tenant/Lessee Name: 11 A
° Email:
Zip: 33 /.3
Phone #:S '--° 793 "60?
JOB ADDRESS: /2-5 Lim. 61124 AZT 7-
City: Miami Shores County: Miami
= Folio/Parcel #: I I -32d; ° c /3=° % i eo /LOTS 10, (1.1 j7-, sac 22--
NO i0
Is the Building Historically Designated: Yes
Zip: 3 3/3S
rAA-r' dZl arEi S#r26 S 52r.
F1ood.ZoneFA 70
J
CONTRACTOR: Company Name: L/ASZaTO # DI WA. CnN5?JLJI,�[ Phone#: 7g6--2 3 ‘ S2-0 2
Address: 3 7 5 l(1= td, i 2 ,405-Ave �-� w
City: �li l ( State: .1CO%,.12A Zip: 3 /Q 2
Qualifier Name: 12-A FAel- pAP /(LA
State Certification or Registration - G °- / 5-'0 92 0 ei Certificate of Competency #:
Contact Phone #: 786 -2:34 ` Email Address: e LkcTk(o f4 pi i-GA ® coil
DESIGNER Architect/Engineer:
� � i rtrG7°S Phone #: 7 6° Z3 �z-01-'
<_v
Value of Work for this Permit $ 4-5-0 i O0.Q ..a Square/Linear Footage of Work: 4/7 4S . rT
Type of Work: OAddress OAlteration ` xr y Tew ORepair/Replace OUDemolition
Phone #: 786 233 S o 2
Description of Work: Ova' SZ ®2 f
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
***************************************F �� *, *** ******* *, *** ** ** *** **�r, *** * * ******** * **
Submittal Fee ,, , I , Permit Fee $ 1352X5 CCF $ CO /CC $
--- A� l
Scanning Fee $ Radon Fee $ DBPR $ Bond $
• a.
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ 4,0
TOTAL FEE NOW DUE $ 5 y & ?O ° 00
Bonding Company's Name (if applicable)
Bonding Company's Address
id/A,
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip ..i
® Zip
a
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or i :lation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all la regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMB11 's, 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 compliE ce 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 valu
promise in good faith that a copy of the not ; c %r_�i ncement and construction lien law
whose property is subject to attachment.
j. r the first inspection which occurs s
inspection � not be approved and
Signatur
Al
hrecorded notice of co
it ,is issued
00, the applicant must
e delivered to the person
be posted at the job site
such posted notice, the
f).1.1111
Owner or Oi" �l
�rit etW*&s ' W1
The fo egoin a ac o
Signature
Contractor
' beTore me this 1e) The foregoing instrument was acknowledged before me this /3
day of \My , 201 J , by , day of
who is persons knom
a
NOTARY PU
Sign.
P
or who has produced
r
o did take an oath.
o�J
201.1 , by r � I4-O/ 9,
who is personally known to m or who has produced
entification and who did take an oath.
Sign:
Print:
My Commissio
c449-0a-0
APPROVED BY
* * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * ** a**
�d�
/I-1 I/1(phi
(Revised 07110 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6/4/10)
Plans Examiner
Structural Review
Clerk