REV-17-2106BUILDING
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 UNE PHONE NUMBER: (305) 762-4949
❑BUILDING D ELECTRIC ❑ ROOFING
❑PLUMBING ECHANICAL El PUBLIC WORKS
JOB ADDRESS:
Master Permit No.
Sub Permit No.
RPCFINTeD
AUG8201
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FBC 2019"
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REVISION ❑ EXTENSION El RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
90 Nall
City: s Miami Shores
County: • • r • + Miami Dade Zip:
;Folio/Parcel#: • a Is the,Building Historically Designated: Yes . NO
'Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): EictL4 cLA
Address: c90• ,O % `V9r-4.61 t3Oy 5�u^ le \61 ,
City: kb" G(AAi(' S (�` (' i� 3 L State: ({� Zip:
Tenant/Lessee Name: Phone#:
Email:
Phone#: '6lZ-3 91
CONTRACTOR: Company Name: 44 tterects Az .a.._ Phone#: G= I68 - 7336
Address: f VVL 1 54) /o 242sd C7Q
City: t'( nom State: �L Zip: L
(� ( O1 .b
Qualifier Name: T1 C( k Ci v-esrO\ Phone#: r
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
0 Demolition
Zip:
Type of Work: ❑ Addition 0 Alteration ❑ New ❑ Repair/Replace
Description of Work: ,443 e . c u/Vfl (.6
Specify c
Submittal F
r03.r A: I+I3R3
7 :':f'•'r ylt ;nt1 a /.
Trc° ,c9IQ t)ru,tIIe:.' .
Scanning Fee $ •
4r
i011a+3 !^ +}51?, Cdr! rC rcrnk r. %(
tAtr,EO as r.Drzz,rr •no0
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Permit Fee $. �S
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ • CO/CC $ ri
DBPR $
Notary $
Double Fee $
Bond $
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
I £
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 alt
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 issu-d. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
SignatureCSk- /1—CA)
OWNER or AGENT
Signature
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
bb ��day of A (X705 r-, 20 a, by C % day of vI ,.›.3� 1 , 20 1 by
taC:- C LQA-c ✓ `
f , who is personally known to . e TL)3 6,,2i' --i— , who is personally known to
me or who has produce
me or who has produced cN'61 l t\C. 4—tea _
identification and who did take
NOTA
Sig
P
Prin
Seal:
Notary Public - State of Florile
.
Commission * GG 033187
''',, ;; My Comm. Expires Jan 19, 2021
t
identification
NOT PUBLIC:
Sign:
Print:
Seal:
dam, G icor
did to
oath. am
, It
I
: Notary Public - State o1 Florida
Commission • GG 033187
-1,#,;(iti-igv My Comm. Expires Jan 19, 2021
****************************************** ************************************************** **
APPROVED BY v Pens Examiner
(Revised02/24/2014)
***********
Zoning
Structural Review Clerk