REV-16-959MC
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
JOB ADDRESS:
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
❑ ROOFING
ED
AP i i2O
BY•
FBC 20 10
Master Permit No. 2C t I IS se).
Sub Permit No.?Ev - S
s/REVISION ❑ EXTENSION
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
qua
RENEWAL
❑ SHOP
DRAWINGS
City: Miami Shores County:
Folio/Parcel#: ') 3200'4-? 60,
Occupancy Type: Load:
Miami Dade
Zip: 3 3 f 3r
NO
Is the Building Historically Designated: Yes
Construction Type: Flood Zone: BFE:
OWNER: Name (Fee Simple Titleholder): Oci+t7t4
Address: To s t4e- 9 -1- S7
Phone#:
FFE:
901 3 Orf
City: ( cS VC -1 State:
Zip: 3 31-2, b
Tenant/Lessee Name: Phone#: ( .90 1 . 34R -1 -
Email: `) J -firm 0 1/10.1 f). Cp✓►
1 Eyv-A Phone#:,X ' l o b— 2C3-'199)
A C s9t lam PTV C
CONTRACTOR: Company Name:
(512 Sw
Address:
City: QbV-? cl' IN7 State: Zip: 34 .95 -3
Qualifier Name: A
State Certification or Registration #:
DESIGNER: Architect/Engineer: -re10. J
7c-( of S fit ,Sv)le 22o
Phone#:
Certificate of Competency #:
` Phone#: S 910 OS 5i .
Cityt " �-)
� State: Zip: ��) O -
Address:
Oa
Value of Work for this Permit: $
Type of Work: ❑ Addition [t Alteration
Square/Linear Footage of Work:
n New
❑ Repair/Replace ❑ Demolition
Description of Work: C--1 P% i? W *n Pte' NCN/ S l D6 •
i_ Duc G1 S 'rte -o' -- S1
Specify color of color; thru tile:
Submittal Fee'$ Ff Permit Fee $ 3 - CCF $ CO/CC $
Scanning Fee $ 03 Radon Fee $ DBPR $ Notary $ g -
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 9
J
Bonding Company's Name (if applicable)
Bonding Company's Address r
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 /r `" ` Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of t\312( L— , 20 (6 by /6 day of
'Nat€.0.tl-.)--- 1,, 15 personally known to ft. p2 Li cer4 , who is personally known to
Cme or who has produced k3 (.1'4 E N N -A ND)?lM me or who has produced
identification and who did take an oath"C' Z( M
CONTRACTOR
The foregoing instrument was acknowledged before me this
, 20 ie , by
NOTARY PUBLIC:
Sign:
Print:
Seal:
S( Ii \L J✓\ 1::
**************
APPROVED BY
(Revised02/24/2014)
°Of Pok, Notary Public State of Florida
Sindia Alvarez
< My Commission FF 156750
* * * .*i*kes 09/03/2018
c
Pc6r te-e. t ?/ M
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
NOWA AGUILAR
MY COMMISSION t FF236412
EXPIRES: June Z 2019
9orobd TMu Notry Pubs eskers
as
*************************************************************
Plans Examiner
Zoning
Structural Review Clerk