REV-18-472BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Village RECEIVED
Building Department FEB 23 7018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 L-J�
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
I( l
Master Permit No.
Sub Permit No.
❑ ROOFING [?(REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
?vt)o /J. eg/1-y 5
City: Miami Shores County: Miami Dade Zip:
33128
Folio/Parcel#: // _ 3,20-5- — C' O/ /n Is the Building Historically Designated: Yes NO ^
Occupancy Type:s Load: Construction Type: C CJ Flood Zone: BFE: FIFE:-r'
OWNER: Name (Fee Simple Titlleh�older): /U f � V 13 U Phone#: 305 zo
Address::) / O UV t/ e ( l J �� 7
City: / �L t A 4-1 ' /J i=4,C t"4 State: f Zip: 33
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address:
23 7 /U ,i
City: M. -('41.t �� S �d
Qualifier Name: (34 p
�r
0 dvi S—r(Z UC /7Phone#: Q70 3 7c� ^Q i3v
!ip: 3:5 t/ 3 C�
976 -3 2-'7,7?0
State Certification or Regist tion #: L. / LC_ (� �(/ CS �n" ,Certificate of Competency #:
DESIGNER: Architect/Engineer: r /--� �✓/ Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ / 2- 00 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: L-�:, c— Fu /2-44L Af ✓/ 5 r U -5 745-1
Specify color of co thru'tile:
Submittal Fee $ :r Permitfee�sel d", Oz�, CCF $ t.w.._.... v CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ co Bond $
TOTAL FEE NOW DUE $ ) • vy
(Revised02/24/2014)
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 t be approved and a reinspection fee will be charged.
Signature Signature -"4
OWNER or AGENT CONTRACTOR
;Thefor oing instrument was acknowledged before me this
day of 20 by
who is a onall w�
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
CLARISSA A. RODRIGUEZ
Seal: Z ;R' MY COMMISSION # GG 041376
'o= EXPIRES: December A 2020
Bonded Thru Notary Public Underwriters
The foregoing instrument was acknowledged before me this
5— day of20 ( by
p s�i ally_ knot'
me or aQVrod rae> as
identification and who did take an oath.
NOTARY PUBLIC:
Print: LA --
Seal: fie
., .""' CLARISSA A. RODRIGUEZ
,�:�.,�
; MY COMMISSION # GG 041376
?' %r' • EXPIRES: December 30, 2020
• 9/ PAP' Bonded Thru Notary Public Underwriters
APPROVED BY Plans Examiner
Y Structural Review
Zoning
Clerk
(Revised02/24/2014)