WS-13-1670 (2)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
;1 ,COED
AUG 2G2013
FBC 20
Permit No. - ! 3 `--15
MO/Waster Permit No. k.,o5 " 3 "/
Permit Type: B�JII;DING
JOB ADDRESS: ISS
City:
ROOFING
Miami Shores County: Miami Dade Zip: 3- 1
Folio/Parcel#: \ 1 10 1 D 0 C oZZ
Is the Building Historically Designated: Yes NO
OWNER: Name (Fee Simple Titleholder):
Address: I q
City: M ‘04.1^(14 State: Zip: "3--( S
oVNr yrO.s
Flood Zone:
Phone#:30S 40 1 `49K?
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 2 \ ' PrSSta t 13l,t S
Address:^ h (p Z 9' 5 L) 1 out,
City: t Gt,YY% t State:
Qualifier Name: 27 c2,.(7VD€/'+ 1,0`ce-it\ O
Phone#: � ��'�
Zip: 3-3 I VO
Phone#: 305 33S- %Oa
State Certification or Registration #: (,.61('. S 2. 0C((-(' 1 Certificate of Competency #:
Contact Phone#: 3 o5 -9-3i y ) 3g Email Address: XmotilNQ ()rTY\CIeSI 9W JI (CI • cefy) .
DESIGNER: Architect/Engineer: Phone#:
$ Square/Linear Footage of Work: 1 Op 1i(12ar
t) 5-06
Value of Work for this Permit:
Type of Work: ❑Addition ❑Alteration
Description of Work: (p.L-e-l'Yl e of
'(New ❑Repair/Replace ❑Demolition
5-0- g h I u) 000i -(n -e
s,7ant,tfoo linear-- k.
Color thru tile:
**************************************Fees********************************************
Submittal Fee $ t
Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
'TOTAL FEE NOW DUE $ 6A(./' ..0
1
r )r
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 rAtikvarlF Yr t 1 o as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and 'that all; *9rr' /il 'formed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must lie 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 exceedin 500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be vered to the person
whose property is subject to attachment. Also, a certified copy of the recorde• . ' e of commencement must be p ted at the job site
for the first inspection which occurs seven (7) days after the building permit is 'ssu • In the absence of such sted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this 1
day ofV 0 i,20la,by aOhr% Krt
who is personally known to me or
whhas produced T)' IV Qis
As identification and who did take an oath.
- NOTARY PUBLIC:
Sign:
Print:
�l ALI it- iJ10
My Commission Expires:
************************
APPROVED BY
MICHELLE MORENO
MY COMMISSION #DD92b779
EXPIRES: SEP 16, 2019
Signature
Contractor
The foregoing instrument was acknowledged before me this In
day of V , 20 13 , by \2^bert- Marta°,
who is personally known to me or who has produced brive►3
1 15L,eV IC.e as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
IA tM M0'fl.Mo
My Commission Expires:
*******************************
Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
MICHELLE MORENO
MY COMMISSION #09925779
EXPIRES: SEP 16, 2019
Bonded through 1st State InsurafCe
/4ning
Clerk