BP-2004-151Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circl
t,
FE3
ii ED
004
Permit NOBP2 i 1S
Master Permit No.
Electrical Plumbing Mechanical Roofing
Owner's Name (Fee Simp e it eholder) f r l Z ij & r a 131 r4 el Phone #_.,C6.) 7c54k3 to 3
Owner's Address `% T N LA -7
City l yq State
Tenant/Lessee Name
ne-: 'Thrr'
/ _L 1(4
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip
Is Building Historically Designated YES NO
Phone #
Contractor's Compan ame Phone #
Contractor's Address
City
Qualifier
State
Zip r%.!!)
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit ag/o E3 Ata /lb PJ cr' S Square Footage Of Work:
Type of Work: ❑Addition
Describe Work: ("4,9 ti
❑Alteration
❑New
Q(Repair/Replace ❑ Demolition
L%Lpr'S `—
c-Zubl hetj
La Si)
****************************Fees******************************
Submittal Fee $ Permit Fee $ 1 CCF $ ,t r 0 CO/CC
Notary $ Training/Education Fee $ ti, Technology Fee $ 3� / 3
Scanning $ 6 Radon $ � Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $
(Continued on opposite side)
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 prop'ertyis 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 building permit is issued. In the absence of such posted notice, the
inspection will not be'agav; d and a reinspection fee will be charged.
Signature -raZ < - _ � Signature
Owner or Agent
The foregping instrument was acknowledged before me this
day of
Contractor
The foregoing instrument was acknowledged before me this
20 09, by , day of , 20 , by
who is personally known to me or who has producediX % I_ who is personally known to me or who has produced
lb -3
ti-V;y e an oath as identification and who did take an oath.
NOTARY
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
************************************************************************************************************
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
*********************************************************************.*********************************
MAR - 9 ZOOkPlans Examiner
Engineer
Zoning
APPLICATION APPROVED BY:
Chc 12/15/03