REV-16-263BUILDING
PERMIT APPLICATION
❑BUILDING D ELECTRIC
❑ PLUMBING
ECHANICAL
JOB ADDRESS: i' 0
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 20 0
Master Permit No. e C I g - 1589'
Sub Permit No. r)6-2 6 S
❑ ROOFING D REVISION ❑ EXTENSION ❑RENEWAL
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
rJE 9 c S -r
CONTRACTOR DRAWINGS
City: Miami Shores re
Folio/Parcel#: 1 - 72-06 ' 1 — 31 6 0 Is the Building Historically Designated: Yes
Occupancy Type: Load: Construction Type: Flood Zone:
County: Miami Dade Zip:
OWNER: Name (Fee Simple Titleholder): V
Address: l
City: RkA S (fig
U T-1 M
3"3 (38
NO r
BFE: FFE:
Phone#:
al -e101 -3`f-1
State: Zip: 3 3 1
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: frk"1" 14h
2 So i,,,J 1) 0+Ni
Address: [( 01 oe (9 1 0 2
Phone#: : b Z b 8- 1D 2
City: I SMA
State: `j. L
Qualifier Name: `X, 2 6/ 0 C.5 -7M 6.4/7gF2-
State Certification or Registration #: 99C /J/J'7/J Certificate of Competency #:
DESIGNER: Architect/Engineer: 'o 9eS 1 �� Phone#:
S� 1 [� ZZ c�
Address: 1 r)--1 G 0 C b w )' S .P l City: j4 O ) S,-<-1 State: Zip: 37160
Value of Work for this Permit: $ t(3 Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Zip: 3 3 1 .
Phone#: (i-
Description
of Work:
co1(Oil) aN S.
rle tkfi'e-N 1 C}lrl. 20 c7uJ (le -1"0 rt Gl _Y�
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $ 3.o 0
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Permit Fee $ V 5 ✓" VCCF $
Radon Fee $ DBPR $
Training/Education Fee $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ '0 0
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 •e approv• • and • in pection f : will be charged.
Signature
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrum- t was acknowledged before me this The foregoing instrument was acknowledged before me this
C�
�� day of
L/ 1 20 /—b , by '2(Q day of 3c4bel earvl , 20 `to , by
whhho is personally known to S�c.+rc� i o So,v1c�2.Z ,who is personally known to
me or who has produced F L — as me or who has produced r)1....-4+- on -c-;I<_ as
identification and who did take an oath.
NOTARY PUBLIC:
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
APPROVED BY
(Revised02/24/2014)
2J
Sign:
Print:
Seal:
12) Plans Examiner
Suyapa T. Vasquez
Commission ;i FF942611
Expires: December 9, 2019
Bonded thru Aaron Notary
Zoning
Structural Review Clerk