REV-16-3445BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
•PLUMBING ❑ MECHANICAL
JOB ADDRESS: 652 NE 105 ST
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
❑ ROOFING
PUBLIC WORKS
RECEIVED
DEC 2V6,
BY•
5
�FBC 20,q
Master Permit No. iC• 1 5- Z : ic31. 0
Sub Permit No. "l5
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION • SHOP
CONTRACTOR DRAWINGS
City: Miami Shores
County:
Miami Dade Zip:
11-2231-012-0140 X
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Kiluan, Inc. Phone#:
Address:990 Biscayne Blvd.
Miami
State:
Florida
Zip: 33132
Tenant/Lessee Name: Phone#:
Email:
J & J Davis Plumbing (954) 680-6543
CONTRACTOR: Company Name: Phone#:
Address: 5101 SW 111th Terr.
City:
Davie
State: Florida
Zip: 33328
Qualifier Name:
John Davis
Phone#: (954) 680-6543
State Certification or Registration #: CFC 057602 Certificate of Competency #:
DESIGNER: Architect/Engineer: Victor Bruce Phone#: (305) 310-5030
370 NE 101 ST Miami Shores FL 33138
Address: City: State: Zip:
0 50 UFValue of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration 1] New ❑ Repair/Replace ❑ Demolition
Description of Work:
Drawing showing gas line for future generator as requested by Ron Levy
Specify color of color thru tile:
Submittal Fee $ /� Permit Fee $ 35 • CCF $ 1 CO/CC $
Scanning Fee $ t Radon Fee $ DBPR $ 1 Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 4-1 q
• S
(Revised02/24/2014)
Bonding Company's Name (if applicable) N/A
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) N/A
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
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this The fgoing instpa1nent was acknowledged before me this
tiVidlay of
John Davis
oil day of DCE./Y1 bey' 20 LCo , by
who i ersonally kno n to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Marco Bruzzi
Sign:
Print:
LUCIA G ISASI
MY COMMISSION #FF182628
..rte. ,g
* .1>u ** F 6slaeeeinbesr+40t€b4
(407) 39&0153 FloridallotaryService /
APPROVED BY
*ans Examiner
>
I*********p*******************************************4,4.4,4,*********4.4,4,4,
22.0-
, by
who is personally known
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
(Revised02/24/2014)
Nft-
MY IS aN #FF020236
aFo?:' EXPIRES May 21. 2017
(407) 398.0153 FloridallotaryService.com
Structural Review
Zoning
Clerk
LE /
jun 2cQ-S -"C~-
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0101
RECFr'
DEC 2 2 2016
BY:
PEV ice -U
Miami Shores Village
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
/P
11-1.14(0.
SUBJECT TO COMPUANCE ALL FEDERAL
STATE AND COUNTY RULES AND REGULATIONS
PL -/o- /G- a9/8
2" PVc
S/Eev.e