REV-17-101Miami Shores Village �~PIVED
Building Department JAN 13 2017
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201
BUILDING Master Permit No.��
PERMIT APPLICATION Sub Permit No. �)'-y
❑BUILDING WELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: Q! ANC{ Ce> a)rO 0 A S e
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Occupancy Type: Ri 5 Load
OWNER: Name (Fee Simple Titleh
Address
Is the Building Historically Designated: Yes NO_
Construction Type: Flood Zone: BFE: FFE:
City: � & k a ru- � S �a2Es State:
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name:
Address: '42-6 19 3 2
City: t14fdI« k,,
Qualifier Name: Lyl
State Certification or Registration #:
te:
hone#: V 3
-Zip: 3 3 / 3
Phone#: Y
--&�:rr34 ,vV Phone#: 9X6 -q/ ?
Zip: 3, 3 D /3
Phone#: � FG - b S 3 - 1-1 1 �
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ X �) Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
//
Description of Work: A L E c"f a., t c- r> t^ F 12 C t..` o a
f-,C iLA nLa 1dT Gross �00�s
Specify color of color thru tile: 4
Submittal Fee $ Permit Fee $ �' ; 4 o CCF $ �' ,.,, - , CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 RLCORDING
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 approved and a reinspection fee will be charged.
ignatur
_
The foregoing instrument was acknowledged before me this
a- day of 20) by
kh)t-� who i ersonally know to
me or who has produced
Signature /4
CONTRACTOR
The foregoing instrumsakwledged before me this
q//day 20 �� by
Lr \
.C1(S I`E 612(I n who is personally known to
as me or who has produced
identification and who did take an oath. identification and who did take an oath.
as
NOTARY PUBLIC: NOTARY PU IC:
: :J
Sign: - W4% ALSign:
Print: GR Print: ���/j�f' .✓nah®-
11111
Seal: Seal: �51k R ue<,� LUIS FERNANDEZ
� V Notary Public State of Florida * * MY COMMISSION I« EE 838180
Marc Goldberg
LNOF
MyCommission GG 015050 EXPIRES: November 7, 2016
d� Expires 07125/2020 1)�roF F%-oPOP Bonded Thru Budget Notary Services
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APPROVED BY /� v'/}/'� ! `l Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)