REV-16-2736BUILDING
PERMIT APPLICATION %REVISION
❑ BUILDING ,ELECTRIC ❑ ROOFING
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
RECEIVED
OCT 112016
ts_.esy
FBC201u
Master Permit No.d�GG �t (?15 307
Sub Permit No._ -RG `1 1(0- Z130 '
❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: .39 /"' C% IDl
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade
Zip: `JI
Folio/Parcel#: 11 .Lae, – Is the Building Historically Designated: Yes NO
Occupancy Type:
Load:
Construction Type: Flood Zone:
OWNER: Name (Fee Simple Titleholder): ISUL bOA,
Address:
City:
33c1 ti E 1 6,0 s�
BFE: FFE:
Phone#:
9hice5--077)!
,"— vu ( (1*o (CS State: ?I- .
Zip: 33/3
Tenant/Lessee Name: Phone#:
Email: 1 'CONTRACTORR:Company Name: '\\)sC&&CA NQ Vi CQ Phone# : /187-9110—
Address: I Vb 11 Q1)3 87. C's
City: 1gc'I(
State: 4�
jO (5
Qualifier Name: 4k U 0 k.) Phone#:
State Certification or Registration #: E C- /3 DO 5b 0q Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Add' ' n ❑ AlterationA �, ❑ New ❑ Repair/Replaceac+❑ Demolition /
Description of Work: 1 /Q�V '�5 Te'/l-. / -�,J . 1 utl4 10 cols -1-1 oD
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ _% /dam CCF $
Scanning Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CO/CC $
Radon Fee $ DBPR $ Notary $
(Revised02/24/2014)
Double Fee $
Bond $
TOTAL 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
OWNER or AGENT
The ff'oregoing instrument was acknowledged before me this
kD `dayof 0(�-?J$� ,20 ,by
al—:a•11•1 V't F , who is personally known to
me or who has produced \Ice L1VE0
identification and who did take an oath.
NOTARY PUBLI
Sign:
Print:
Seal:
LlsiffalcDq.
A1n•`2.o J. '""i• ;tarp nr ctorida
Sa750
************************************************************************ski****s** ***************************
Signature
ClON
The foregoing instrument was acknowledged1before me this
day of(%b , 20J by
Wt'c O O1 .who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY LIC:
LIC:
Sign:
Print:
Seal:
My omm. Exp.res May 4, 2017
3 N i7t. .e
c Commission # EE 873648
°;;� "'' Bonded Through National Notary Assn.
APPROVED BY //‚7i Plans Examiner
Structural Review
(Revised02/24/2014)
Zoning
Clerk