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MC-16-2158Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 79S-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20JO BUILDING Master Permit No. t- r- k I G PERMIT APPLICATION Sub Permit No. A-1 & 2 -ISP',, BUILDING ELECTRIC ROOFING REVISION EXTENSION Z*NEWAL PLUMBING [4MECHANICAL [:]PUBLICWORKS CHANGE OF CANCELLATION SHOP City: ,t.-//ll17/ Tenant/Lessee Name: _ Email State: -z GGm Phone#: i CONTRACTOR: Company Name: ad IL Phone#: Address: S10 -/,F City: /t -//Ccs -ii — State: Zip:3% Qualifier Name: ";Q12,-. e f'211 z Phone#: bzo State Certification or Registration #: Certificate of Competency #: C'qC DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $1 Square/Linear Footage of Work:, a' -w•' 3 S Ccs• 'C% Type of Work: DI Addition [K Alteration New Repair/Replace Demolition Specify color of color thru tile: Submittal Fee $ GO • C-0 Permit Fee $ Scanning Fee $ 3 a Technology Fee $_ 3 . ZO Structural Reviews $ Revised02/24/2014) Radon Fee $ 2. 10 Training/Education Fee $ It,/ -Z ' (' CCF $ 0CO/CC $ DBPR $ 2 , (U Notary $ Double Fee $ Bond $ 0 TOTAL FEE NOW DUE $ :Z6 ' CONTRACTOR DRAWINGS JOB ADDRESS: A/1 C(U"VS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 2.200-012 - 021P Is the Building Historically Designated: Yes NO C Occupancy Type: Load: Cons i Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 9 L r C" '7 /I Phone#. 2 Address: a 9fawe a5zlryi City: ,t.-//ll17/ Tenant/Lessee Name: _ Email State: -z GGm Phone#: i CONTRACTOR: Company Name: ad IL Phone#: Address: S10 -/,F City: /t -//Ccs -ii — State: Zip:3% Qualifier Name: ";Q12,-. e f'211 z Phone#: bzo State Certification or Registration #: Certificate of Competency #: C'qC DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $1 Square/Linear Footage of Work:, a' -w•' 3 S Ccs• 'C% Type of Work: DI Addition [K Alteration New Repair/Replace Demolition Specify color of color thru tile: Submittal Fee $ GO • C-0 Permit Fee $ Scanning Fee $ 3 a Technology Fee $_ 3 . ZO Structural Reviews $ Revised02/24/2014) Radon Fee $ 2. 10 Training/Education Fee $ It,/ -Z ' (' CCF $ 0CO/CC $ DBPR $ 2 , (U Notary $ Double Fee $ Bond $ 0 TOTAL FEE NOW DUE $ :Z6 ' Banding Company's Name (if applicable) f 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 and a reinspection fee will be charged. c Signature Signature OWNER AGENT C TRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 !(w by / a day of 17d 20 /l! by 2 - 1 ' _, who i ersa I wn to ' f'/QZ who ' ersona e Wto me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: // Sign: Print: o' Vwe Ci Print: Seal: S®NIA OUERRA Seal: :: MY COMMISSION # FF971557 MY COMMISSION # FF971557 a, •r EXPIRES March 15, 2020 EXPIRES March 15, 2020 awyIN n un„ .tee :.,--- (107) 3p8 -0t53 JAAPPROVEDBYPlansExaminerZoning IVY Structural Review Clerk Revised02/24/2014)