REV-16-3076Miami 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
5 BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
10:(10000:_
FBC2014 S
Master Permit No. -.C(
Sub Permit No
.41 REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
JOB ADDRESS: 12 �.
❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade
Folio/Parcel#:
Occupancy Type: Load: Construction Type: Flood Zone:
131c
Is the Building Historically Designated: Yes NO
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): t((-fi {tE L d 1 Q) R:Pe '> ?.)(.#t,l}f)Phone#:
Address: i2-6, P) i✓ q 6 5t 2
City: . 9,e -t O Zip: d; 1-51?
Tenant/Lessee Name: Phone#:
Email:
State:
(ea./7
CONTRACTOR: Company Name: , 4 Q LI) COO Stift Q 4
Address: t 2 q 614 VG- LO 4'41'`�
City: . 8' L/) State: L.
Qualifier Name: ��� /' 2 (iV 5EN
State Certification or Registration #: �� 1505-16 3
DESIGNER: Architect/Engineer: J jc fi(Z c7. PI> at9
Phone#:
Sob=$%2 -.‘So7
Zip: 3$
Phone#: W — 2-cu,C0.7
Certificate of Competency #:
Phone#: ' o-, 5C
Address: �7O Nt (', �9tfl
Value of Work for this Permit: $ 4O D 0�
Type of Work: ❑ Addition
Description of Work:
G -
Alteration
City: .geState: i L Zip: .377 (
Square/Linear Footage of Work:
❑ New
�z a?c or s
53Z, 41? - (ye—
❑ Repair/Replace n Demolition
Tam 1 -j-lA-Cf 72,a7tr0C r st f -P
6
Specify color cif toior`thrii tile'
Permit Fee $
Submittal Fee $
Scanning Fee $
IP: to ,'31Lrt1ti
Radon Fee $
rr �.
G•
CCF $ i3rOsi ::lA CO/CC $
DBPR $
Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
(Revised02/24/2014)
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signat
OWNER or AGENT
The foregoing instrument was acknowledged before me this
3rd day of Ncuennter , 20 11.E , by
Mi 0h0491 4. Rxr-04.4 Gt .. who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: ViGjOr�,
NOTARY PUBLIC
llP' STATE OF FLORIDA
Seal:
Evisstitkii
-71"t4.,-,e.:' Comm GG0242T$
Expires 8/24/2020
APPROVED BY
(Revised02/24/2014)
Signatur
ACTOR
The foregoing instrument was acknowledged before me this
3(d day of MOve,prjC( , 20 t 1.p , by
lSre L ` 9 , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Plans Examiner
Structural Review
•
Mobil Et lib ViCtiori6i • PIGI
NOTARY PUBLIC
STATE OF FLORIDA
Came 000242/1
Expires 8/2412020
Zoning
Clerk