EL-17-212 (4)A..
Miami Shores Village #`'�
'
��AN2�2017
F'
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BYI
.
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 S T\
FBC 20 lC(
BUILDING Master Permit No. 61 /'4 — 2 l Z
PERMIT APPLICATION
Sub Permit No.
❑BUILDING X ELECTRIC ❑ ROOFING
❑ REVISION ❑ EXTENSION
❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
❑ CHANGE OF ❑ CANCELLATION
❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS: VC, .t, a CCn t,
C o v "t e
City: Miami Shores County:
Miami Dade Zip:
3
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO
Occupancy Type: 15E Load: Construction Type:
Flood Zone: BFE:
FFE:
OWNER: Name ���
(Fee Simple Titleholder): (fCt
Phone#:
Address: Si' ✓ck A L— 'L- o
vV S"
City: ( State:I
Zip:_
Tenant/Lessee Name:
Phone#:
Email:
CONTRACTOR: Company Name: LoAicilv, r/n/ �( c4, hC C Phone#: 3CS— ?.Sg P 1/
Address: q 5 N L ) % /'(v c.5� -'
City: /:'L" G?"%'1.- State: Zip: _33 ) 6. I;Zl
Qualifier Name: M 1 Cfhoz,, LL9, 6 /), C/l► Phone#: -k . 25,9-1, Z/
State Certification or Registration #: Eel 1300 37/ 3 Certificate of Competency #:
DESIGNER: Architect/Engineer:
hone#:
Address: ��-- City: State: Zip:
Value of Work for this Permit: $ �Tf}7� Square/Linear Footage of Work:(,
Type of Work: Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $ �Permit Fee $ _ �i �✓r®G CCF $ �I-1 . CO/CC $ _
Scanning Fee $ Radon Fee $ DBPR $ Notary $.
J Oa
Technology Fee $ 2 Training/Education Fee $ S Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ 5 ��
(Revised02/24/2014)
T A
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
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 approved an \ einspection fee will be charged.
v Signature" f Cam--. �t nature Si J
g
OWNER or AGENT
The foregoing instrument was acknowledged before me this
"2-4 day of � V\, 20 t by
u. -Who is personally known to
me or who has produced
identification and who did take an oath.
NOl
Sign
Prin-
as
CONTRACTOR
The foregoing instru—mee-nt was acknowledged before me this
Q 3 day of bt q !!"1 20 i by
M'bod �� ti/►;,y� , who i ersonally know o
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Seal: � Seal:
r>JIURAFARLE`f c`P" Notary Public State of Florida
MY COMMISSION 1 FF 1027 ? Michelle Perez
* etch 16� 2018 My Commission FF 000321
* EXpIF1E3; M %*F ` Expires 0408/2017
MINI
'ICON
APPROVED BY ��%Z L 1p %/�/� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)