REV-16-280Miami Shores Village
ng Department
BUILDING
PERMIT APPLICATION
Avenue, Miami Shores, Florida 33138
5) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
Master Permit No2C`, 15-g
.-E` V
Sub Permit No ) b - ZGY
❑ BUILDING ELECTRIC ❑ ROOFING 9(fREVISION ❑ EXTENSION ❑ RENEWAL
El PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I�C/O t J 1
City: Miami Shores n County: Miami Dade Zip: 3"3 g
Folio/Parcel#: 1 --32O \
" 01 `T - 31 fp 0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
OWNER: Name (Fee Simple Titleholder):'v'
Address: 9 b O g c S'7
J f�Pr't `N1
Flood Zone:
BFE: FFE:
Phone#: S-61 d ` -3'491
City: F.t‘A` $V
State: -- Zip: '�J3 l 3
63
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: E 7 N
Address: 21,9 E3 S LJ 13 s- C -
Phone#: 6 21
City: 1-1-QMlz- lir '0 State: Zip:pn -2,--2DJ 3 2
Qualifier Name: 1'`1 v 4 & — C.,'C,' A Phone#: i 3c G di D--‘ 8
State Certification or Registration #: CAL lT 14 6 G Certificate of Competency #: flie-0 00 .(1
DESIGNER: Architect/Engineer: 'Tose3 1 L.N . Phone#:
Address: City: State: Zip:
ov
Value of Work for this Permit: $ (0 SquareeLinear Footage of Work:
Type of Work: ❑ Addition ITr Alteration
❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: C �L-e\- 1. (491- 56si `'T k5 T tx�TS
Specify color of color thru tile: T
�
Submittal Fee'$ Permit Fee $ �.1 /�U CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ - Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 9 8 . 03
(Revised02/24/2014)
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 b= • pproved a d a reinspection ee will be charged.
Signature
OWNER or AGENT
The foregoing instrume was acknowledged before me this
e29
7 day of , 20 / 'b , by
ho is personally known to
9&A14 l h
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
IO�µv,P� HEINRICH C. HUECK
o`�...w�
Signature
"At,
CONTRACTOR
The foregoing instrument was acknowledged before me this
D 2, day of fg(n) PFILLI 20 1 % by
' 4p ) ( C $ 1 , who is personally known to
me or who has produced �r — as
identification and who did take an oath.
NOTARY PU/r`'ALS it
geworwAitiew
' Ant IIA ...V11111weriau
Sign:
Prin
S:.I:
*****************************************************************
APPROVED BY
(Revised02/24/2014)
ABRERA
Notary Public - State of Florida
c My Comm. Expires Aug 31, 2016
,• 1r •.c
,r? Commission # EE 200665
Bonded Through National Notary Assn.
***************** *s **
CO. Plans Examiner Zoning
Structural Review
Clerk