REV-16-2591Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
�� JN INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
SEP 2 0 2016
5th
FBC 2Oly
Master Permit No. «-lj' g 4
Sub Permit No. '1;?E N 1(.0-73-61
❑BUILDING ❑ ELECTRIC ❑ ROOFING iEVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: a 101 1UV44'Tj7d U`Q
City: Miami Shores County: Miami Dade Zip: 73 1�q,
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 0 VY) D"VV 05Y7 a I Phone#:
Address: q 0 "P ---9(
City: \t'41 'CjyAIe) State: TSL.
Tenant/Lessee Name: j3 /R
Email: L
Zip: 2 1
Phone#:
CONTRACTOR: Company Name: 7kiluB Go n4(ILO(i jOR) OzAtC Phone#:
Address: 12 i.DeS 104 ' 7r
City: • AkA,
State: Zip: j (
7
Qualifier Name: `.`77 _ Phone#: (30c)
2c0L-x.077
State Certification or Registration #: re"'" ( 5 O5) 03 Certificate of Competency #:
i
DESIGNER: Architect/Engineer: 6 AI�Lt (44 -iv 3> �� (P�i, Phone#: r Z3 -'Ye
Address: 785-0 AIN /40 st� ;.Ne le SOS City:11 - frijL ) State: a—Zig:Okj
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
4.
Description of Work: ��t :r; 01n -1-0 Plc 1,..b fri f 1 ,-`S
i
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 9- 5 CCF $ CO/CC $
G
Scanning Fee $ / Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ 12 0 Bond $ /
TOTAL FEE NOW DUE $ 2p�1
(Revised02/24/2014)
v #
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 approve , and a reinspection fee will be charged.
• • Signature
U ilk Signature
OW R or AGENT
The fore oing instrume was acknowledged before 1CJ this Th or going instru
l day of , 20 i , by I. • day of
01i -?AP 63 14 A w , who is personally known to affeii3
nt was acknowledged before me this
20 G ' , by
, who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
-
"""' CATHERINE A. DUFFIN
,,z;V Pie`', ,�11111�,
z »�. �= Notary Public - State of Florida ,.;Pa Pie, CATHERINE A. DUFFIN
°414,ha..41,11
. Notar Publi S Bonded Through National otar Assn.
identification and who did take an oath.
NOTARY PUBLIC:
Sign: toPrint: C64/411 ---e
Seal:
a a- a
• c My Comm. Expires Apr 15, 2017c -ttp{FI,�A######*** k### ##################t#####.##M�##�F'�F##############
�•.°�P;,. C�`�F8`rl�fi��i��"�`�`>#�`1'�`-_�'�,'eo�m.�x'Ires Apr 15, 2017
-��-�° Commission # FF 8417
APPROVED BY �17Oi/", Plans Examiner "'" Bonded Through National Notar assn. Zoning
Structural Review
(Revised02/24/2014)
Clerk
Invoice
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795-2204 Fax: (305)756-8972
For Inspections please call: (305)762-4949
!Return to:
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Bill To
OMAR OSMAN TANYA DE LA ROSA
9101 PARK DRIVE, LLC
9101 PARK DRIVE
MIAMI SHORES, FL 33138
Permit Number: REV -9-16-2591
Invoice Date: September 20, 2016
Invoice Number: REV -9-16-61403
Bond Number:
Comments:
Permit Type: Revision / Work Class'
cation: Building
Date
10/05/2016
09/20/2016
09/27/2016
Fee Name
Revision Fee
Scanning Fee
Plan Review Fee (Engineer)
Fee Type
Calculated
Calculated
Calculated
Fee Amount
$75.00
$9.00
$120.00
Total Fees Due:
$204.00
Payments
Date Pay Type
10/20/2016 Credit Card
Check Number Amount Paid
$204.00
Change
$0.00
Total Paid: $204.00
Total Due: $0.00
Thursday, October 20, 2016
MIAMI SHORES
VILLAGE HALL
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
(305) 795-2207
DATE: 10/20/2016
TIME: 11:26:22
REFit: 2649
TYPE: CREDIT SALE
CARD: AMEX
NAME:
ACCT: XXXXXXXXXXX1001
EXP: XX/XX
APP: 162788
AMOUNT: $204.00
X PRO) A ------
Signature
Cardholder agrees to
abide by the obligations
set forth by the
cardholder agreement
with the issuer.
CUSTOMER COPY