REV-16-3444v:40
1)00\e'
BUILDING
PERMIT APPLICATION
Miami 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 6
FBC 2011
Master Permit No. P5- 8 -/!o - d 3 80
Sub Permit No. 9--X. - 3444
Cf REVISICJN ❑ EXTENSION ❑ RENEWAL
( CEIVED
DEC .2 2016
BY: I,
t2f1.3tilEDING ❑ ELECTRIC ❑ ROOFING
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: / 5
/./Cc/
❑ CANCELLATION
❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: , ' 3 10 000 0 a a 0 Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type: Flood Zone: BFE:
OWNER: Name (Fee Simple Titleholder): kt Ven coq c.1
Address: / 5 5.
,v4, 9/ 5 /i c., /
33/50
NO v"
FFE:
Phone#: (605) yob - y7S2
City: jam, Am / CA "-CI State: FG Zip: 331 So
Tenant/Lessee Name: Phone#: (3 o5) yo, - V f g 3
Email: john OP/kits/ . Gort
CONTRACTOR: Company Name:
Address: 7'/!o ? 9 sw
f ssecia �ctii
Can
/oy s-/(4.47 1 y98
Phone#:
(3o5) S02 -Y
City: rniAin I
;;�� State: FG Zip: 33/ 86.
Qualifier Name: ?? 6e_tiI /72'Ye^ o Phone#: (86) 3 yl - 3 f o 3
State Certification or Registration #: CG G ! SSS 0 9 5Y/ Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: ` Zip:
Value of Work for this Permit: $ .1( 6-00 Square/Linear Footage of Work: P• 1 vg
Type of Work: ❑ Addition ❑ Alteration A ❑ New %Repair/Replace / ❑ Demolition 1
Description of Work: �c o S v� o elf i C- c w �/ p /cc r /�Y L10 / M cn 7
Q7F cva-/i_u.,Ay _ (6_ X",/.� l6 /2/4._,7.)
Specify color of color thru tile: k
'S
Submittal Fee $ • Permit Fee $J CCF $ CO/CC $
Scanning Fee $ — (. W Radon Fee $ DBPR $ Notary $
Technology Fee $ • Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 4 • CO
(Revised02/24/2014)
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 ncLconstruction lien law hrach jre w/lLbp deliiiececi_tatbe_peuon_
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 postal notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
L___OWIER or AGENT
The foregoing instrument was acknowledged before me this
�1' day of -' ✓ ,20 140 ,by
06.1 1—Y I , who is personally����""known to
6 me or who has produced tlt .V i %IQY VLIXvu, as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
•
ko'ytY l�•• ariso uintana
• `:Commission# FF172378
Expires: OCT 28, 2018
BONDED THRU
'• •`' 1ST FLORIDA NOTARY, LLC
*****************************4t******s****************
111 IC4
APPROVED BY
(Revised02/24/2014)
CONTR CTORI
The foregoing instrument was acknowledged before me this
9-I day of uic , 20 i(12 , by
306 34- 0 t-e-✓i3O , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUB
Sign:
Print:
Seal:
Plans Examiner
t
hil.C'F`&b( Nikt_.Atyla
44.?l, Marisol Quintana
ca,�'=Commission#FF172378
� ` Expires: OCT 28, 2018
•'' •• BONDED THEO
•,,,,,a` 1ST FLORIDA NOTARY, LLC
v I Zr****
oning
Structural Review Clerk
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