FW-13-322 Miami Shores village u i__"3
Building Department
I S I I y 10050 N.E.2nd Avenue,Miami Shores,Florida 33138B Y;____________
Tel: (305)795.2204 Fax:(305)756.8972 N-__--
I y ' INSPECTION'S PHONE NUMBER: (305)762.4949
S .� FB 2�0
B IL ING Permit Now
PERMIT APPLICATION Master Permit No.
Permit Type: BUILDING ROOFING
p�
JOB ADDRESS:\1 Nc Pto7_ Lcj aj `N Oq `U3� *)A & '6 dy� _,
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: -3 f�--
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): -T44NZ {Z\V1yM Phone#:
Address: 1.02657 1St M F tI3L\10,
City: State: 'L Zip: 3?11IaA
Tenant/Lessee Name: Phone#:
Email:
�a C�
CONTRACTOR:Company Name: %SIV Phone#: 305-30!.-$S-Sb
Address: 6S39 GOLu m S Me- J� .if
City: w k f ka l -IkAg A State: F:L Zip: 33141
Qualifier Name: EV-P-'EM Phone#: SS1.1-30?-2-09'Z
State Certification or Registration#: GC_nC, 1 SI 5'Q-,Lk Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: 1MT 1A,1 Me"Q Phone#:
a %NG•6! c. 7 An of Work for this Permit:$ ' Square/Linear Footage of Work:�S.J
Type of Work: ❑Addition WAIera on OF ❑New YRepair/Replace ❑ molition
Description of Work: rJA01 wL "q
all
Color thru tile:
Submittal Fee$ Permit Fee$ tNCCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
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 ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 i ted copy of the recorded notice of commencement ust be posted at the job site
for the first inspection which occurs seven (7) er the building permit is issued. In the abs ce of suckposted notice, the
inspection will not be approved and a reinspection feel-,V charged.
Signature Signature
Owner or Agent 4� ctor
The foregoing instrument was acknowledged before me this 2.2— The foregoZtrument was acknowledged me this-9—
day
his1.day of -3-AA 20-tL by �_ ���� day of '011+.1 2012- ,by >� ,
who i ersonally known me or who has produced who is rsonally kno to me or who h s produced
1111UIt//
As identification and who did take an oath. as iJapgt ( yvho did take an oath.
IN rte•....... �ii9V
NOTARY PUBLIC:. NOTARY PS`ON EYo,••;
AP
Sign: Sign:
Print: J Print:
My Comm ssion Exp res My Commission "�`f`"�VBLIC,9
MATILDEMSSRAFN !!►ItIN111N►�`'
MY COMMISSION A OD 983274
EXPIRES:August 19,2014
Bonded Thu Notary Pubk Underretters
APPROVED BY / //F"f� Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)