REV-17-2187BUILDING
PERMIT APPLICATION
❑ BUILDING 74 ELECTRIC
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
Master Permit No.
❑ ROOFING REVISION
prn
AU 2 9'2017
BY. i a_r:.
TR-
FBC 20 (Li
_ FOS
Sub Permit No. V 9-' Zia R
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
// CONTRACTOR
JOB ADDRESS: c9. j 6-Dern\Lb coal Ca
City: Miami Shores
County: Miami Dade
❑ EXTENSION El RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load:
Construction Type: Flood Zone:
BFE: FFE:
OWNER: Name (FeeppSimple Titleholder):14 E' £ifzi� (ter Phone#: 7Ol, J� 5 i5 c .
Address: Cfc (F�C-1-0c1T0) 7✓ Cq, +eNA-S ,
City: I,1 J j"f? I ' / 1' S' State: �. Zip: 33 3g.
Tenant/Lessee Name:
Email: c-d-j P. (-••2-00 ED ''L'+'‘O-zrt )
CONTRACTOR: Company Name: 4•C •..
Address:
City:
Qualifier Name:;
State Certification or Registrati
Phone#:
Phone#(...3otl.89-a68
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
State: Zip: pQ�
Phone#0e5 ( 9-207
Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration(( ❑ New ❑ Repair/Replace n Demolition
Description of Work: EL c ti c `lam- -= LA, AJ \eo 1V),,,,
•
Specify color of color tliru tile: ".
Submittal Fee"$""' '
Scanning Fee $ y •
Permit Fee $ 73CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $ -5 •
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ e3 - G�
( Revi sed 02/24/2014)
' r
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."
a
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 ed at e job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence such posted tice, the
inspection ill not be approved qnd a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
me or who has produced
, 20 -R' , by
ho is personally known to
kC as
identification and who did take an oath.
NOTARY PUBLIC:
• •.: MAHARAI K. GONZALE
o;' •
EXPIRES: • , GG 044602
t ;°T-Bonded T► ru Notary Public Underwriters
***********************
APPROVED BY
Signature
The foregoing instrument was acknowledged before me this
22 day of -CJ �V ,20 " ,by
DOT) Wet/ 'U � �
, who is personally known to
me or who has produced .j'" ' 11LQ.n as
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
Seal:
RAI K. GONZALEZ
i* •', ?r: MY COMMISSION # GG 044602
0
114 . ``P,,; EXPIRES: November
?, oi. .. Bonded Thru Nosy, PublicUnderwrriters
*******************************************************************************
' ',4 i 4- 7 } Plans Examiner
Structural Review
Zoning
Clerk
*
(Revised02/24/2014)