REV-16-2516pv-w
US
cog loo
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
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS:
39 /Y7 roo c
Master Permit No.
FBC 201
o_IS-3(%
Sub Permit No. (k-)-25
REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
City: Miami Shores
County: Miami Dade
Zip
Folio/Parcel#: / 1 -- 12ca. -- elf)G3 - $ $60 Is the Building Historically Designated: Yes
Occupancy Type: t2- 0, Load: Construction Type: VI, Flood Zone: BFE:
OWNER: Name (Fee Simple Titleholder):(' <- //)✓ ' �+�i 4209
Address: ../4541? -/OVA
City: 1-7/4.4/1-1 State: 71t52---
Tenant/Lessee Name: Phone#:
NO X
FFE:
Zips/(57
Email:
CONTRACTOR: Company Name: ( fV,S ) r,-,-, V1C& Phone#: "78& --740d
Address: 3 q1 - �J
City: lV t (,l t4,1 ( State: i—L
Qualifier Name: ‘I- re/L4.lehu e--7
State Certification or Registration #: (76c / Q % 6-9,
DESIGNER: Architect/Engineer: � - t-4 . C464-10 Phone#:
Phone#:
Zip: 35 t 4�
—0
Certificate of Competency #:
Address: 41 06 C.6•104r0 G,0./.9O Cr' -
Value of Work for this Permit: $ a-1) , (i
Type of Work: ❑ Addition rg Alteration ❑ New
or, 44o 7121
City: C.G.PotieS State: L Zip: '9? lel.Cp -
Square/Linear Footage of Work:
❑ Repair/Replace - ri Demolition
Description of Work:t?.U1C-,tOI.- "TO IFC,�S ^ -001 COL IJ l�QCL / - a
b•-5(. L)rec .-�'1�4=� "Vre.0110k5. Lav ►- ? tSco D .
Specify color of color thru tile:
Submittal Fee $
Permit Fee $ G . W CCF $ ` ED()
Scanning Fee $ / 9 • O
Technology Fee $ '7 " U
Structural Reviews $
(Rpvispci ni 04/2(11 41
Radon Fee $ DBPR $ pZ'
Training/Education Fee $ ( ' ZG
CO/CC $
Notary $cg.
Double Fee $ .05
Bond $
0
TOTAL FEE NOW DUE $ 1 e. C/p
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 t - _ S Signature
0 R or AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of FTEMEe— , 20 Ifo , by�'j X day of e,4/ex6Pt` , 20 /6 , by
[J4e/ ,v41g,1 ez , who ' personally know to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
ULT! N \I1 DMY , who is personally known to
me or who has produced EL D(2.1 VE -2 UQNSk-.as
identification and who did take an oath.
NOTARY PUBLI
Sign:
Sign.
Print: Si Nip & . f\ . Print:
Seal: pa! Poe Notary Pubic State of Florida
° `' Sindia Alvarez
Zr My Commission FF 156750
flag Expires 09/0312018
APPROVED BY
*
(407) 398-0153
i�BEI `E F p),N
MY COMMISSION #FF1
EXPIRES June 1, 2018
FloridallotaryService.com
d'ez
as
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Plans Examiner
Zoning
Structural Review Clerk