REV-16-2285eKs 1 !Cy10(17A
BUILDING
PER IT APPLICATION
BUILDING ❑ ELECTRIC
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
FBC 201q
Master Permit No. -110 t " 449 2 -
Sub Permit No.P€V 1,6- 22 '
❑ ROOFING ErREVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS
JOB ADDRESS:
City: Miami Shores County:
Folio/Parcel#:
Occupancy Type: Load: Construction Type: Flood Zone:
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
I 14 6 90+4 .re_—
Miami Dade Zip: 3ea 13Q
Is the Building Historically Designated: Yes NO L
BFE: " FFE:
OWNER: Name (Fee Simple Titleholder): M 1 Kr,- (- S
Address: t24 <) a crpNc-d-
Phone#:
City: 01111 �, Stare: Zip: �j�j 1312
Tenant/Lessee Name: Phone#: 0 S 336 3 i 03
Email:
CONTRACTOR: Company Name: '4'([.D CADy) St 0-061,0c.( ( L(7 .
1 20( ct 0,-X;1 0.4kS-� �1
Address pp
City: V�
Phone#:
3x:529?-6So?
State: 4
--1,_ Zip: 25"--v 4
Qualifier Name: L6.5 -in 3 GNS,P Phone#: (3(0,c') szqL-6-5;07
State Certification or Registration #� 2'i-( \ ¶7G 1 6Certificate of Competency #:
DESIGNE rchite Engineer: Y' 1 A174(- A- C/ 'W( 1,6 LL- Phone#: la S 7S'' Z3) e
'Address: -----"--
1 3 tJ i2 51 c City: M/A'► I S ift r �' State: (Z Zip: T i 3 €
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration
❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: t 4 J/sl (1j2»o& F 66-4A.) AJ r t -,etQ frt-rAcz,primvil
Specify color of color thru tile:
Submittal Fee $ Y� Permit Fee $ 'c>c=.
Scanning Fee $ 1 • UV
Radon Fee $
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
b� .420TOTAL FEE NOW DUE $ `
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.
Signa
OWNER or AGENT
The foregoing instrument was acknowledged before me this
/'' `�l, ^ . The foregoing instrum Ut was acknowledged before me this
11 day of MC (I , 20 I IR , by 11 day of USL( S t , 20 J , by
ho is personally known to (J StCQ - l� I v, who is personally known to
me or who has produced as me or who has produced as
Wvrui Pt(
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
SLALO e w�
GLORi ALDF.EA CUER:'J
' - •
MY COMMISSION #FFO`„ i,: u
:
EXPIRES: JUN 21, 20'1/
Ii062edthhrG: 1'.s! tsInlimr:'9t
************************************************************************************************************
identification and who did take an oath.
NOTARY PUBLIC:
Sign: '\ l
Print: SV✓w/` 0 . CUCr r '^^ v
•LC:1IA I,'... EA CIll t14
}'` fti LY COMMISSIO>`.:
Nr-�r EXPIRES: JUN 21, 201Y
1,00,A
Seal:
APPROVED BY
(Revised02/24/2014)
cb)/7-11i
Plans Examiner
Zoning
Structural Review Clerk