REV-16-2416BUILDING
PERMIT APPLICATION
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
BUILDING ELECTRIC
PLUMBING MECHANICAL
JOB ADDRESS:
City:
Folio/Parcel#:
Occupancy Type:
10025 NE
ROOFING
RECF,T\7ED
AUG 3 0 2016
BY- 9--(i�J
Master Permit No.
FBC 20
BPP s- I to -111(o
Sub Permit No. PO - g " U -o- zoo
°
EVISION ❑ EXTENSION El RENEWAL
PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
prv6
Miami Shores
I1-3Zo10-
County:
011- 1200
Miami Dade
Zip: 3313B
Is the Building Historically Designated: Yes NO
Load: Construction Type: Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): -50SGVIA1 (pei a. et -To Phone#:
00ZS NE 5' RVe
Address:
City: 111% Itifti S It R6S State: Zip: 3 3
Tenant/Lessee Name: Phone#: 3 (o) 3 I G ZS
Email:
GpM O , 9 Prou . frt
l O N a-- p)(-- t-5 1 (s'13
Z11,23 S.,) I 4 A-4.0- 4+ 2,1Z
City: t l State: Zip: 33) S
CONTRACTOR: Company Name:
Address:
Phone#:
to Za
Qualifier Name:
lhul:P-G O1ZcO9--x T\J 67_
State Certification or Registration #: CPC I t S1$y S Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
b W
Phone#: 3-s$ /0 ?22
Value of Work for this Permit: $
Type of Work: ❑ Addition ❑ Alteration
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace
Description of Work: I NC-RC—MeD •?i4v6la_ 51-2-e
2,025
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ I •
Scanning Fee $
Technology Fee $ 2 •
Structural Reviews $
(Revised02/24/2014)
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Radon Fee $ DBPR $ 2 2 Notary $
CO/CC $
Training/Education Fee $ • (00 Double Fee $ fa'
Bond $
TOTAL FEE NOW DUE $ f G •
Bofiding 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 . ' pproved and a reinspection fee will be charged.
Signature
R or AGENT
The foregoing i 'ument was acknowledged before me this
II da of t' U)'1J 5 r, 20 t� , by
--sos p'\ 1 e 0 , who is personally known to
me or who h.... uced PL-- as
identification and who did take an oath.
NOTARY PUBLIC:
MARIA THERESA PINO
Notary Public - State of Florida
Commissl . .
,,„,;.' My Comm. Expires May 7, 2017
*******************************
APPROVED BY
(Revised02/24/2014)
Signature
The foregoing instrument was acknowledged before me this
t) day of ''v051” ,20 t(0 by
P;1 -9"o QodQ Z, who is perso y kno n to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
14,, l4
I J0
tel �°�1; MARIA THERESA PINO
Not: Ida
.���c Commission # FF 15368
1111 •' aY , 2017
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Plans Examiner
Zoning
Structural Review Clerk