DS-13-388Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS
JOB ADDRESS: / O ' " CD i 1 t jT
Cit:
RECFIVE0
FE" g 20
FBC 20N
Master Permit No2D S
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF Q-e'ACELLATION ❑ SHOP
DRAWINGS
CONTRACTOR
Count
Miami Dade Zi.: i O
NO
FFE:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type:
Load:
OWNER: Name (Fee Simple Titleholde
Address:
City:
Construction Ty
Flood Zone:
State:
BFE:
Phone#: s- ri5 i -gV
Zip: 33/2
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: pp Phone#:
Address: Cp
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $
Type of Work: ❑ A 'tion El Alte
Description of Work: ante 2V___
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Permit Fee $ CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $
a•
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWN :G or AGENT
g�"'iatuF
CONTRACTOR
The foregoing instrument was acknowledged befor me this The foregoing instrument was acknowledged before me this
day of .�Z._ , 20 C7 , by day of , 20 , by
%"1 h12t Co0(4 i is p sonal y no to , who is personally known to
me or who has pl° 'duced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
11111111/00
' \ON EXp'••,,
Sign:
Print:
Seal:
APPROVED BY
(Revised02/24/2014)
i —
y C
��4'0)�p.v.\z9IYImatllia•
Sign:
Print:
Seal:
Plans Examiner
Zoning
Structural Review Clerk
February 28, 2017
Miami Shores Village
10050 NE 2nd AVE
Miami Shores, FL 33138
ATTN: Building Dept.
RE: 130 NW 111th ST
Miami Shores, FI. 33168
Dear Arlene;
At this time I would like to
Permit... #DS13-388.
The application is/was for
never commenced.
erely
RECEIVED
g pati
cancel my building application
a driveway repair/replace that
Beverly Gurn