DEMO-10-1428tia?)},to Coar-
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING ROOFING
30 MY
AUG 1 0 2
csit:ct
Permit No, .t011010-1-rgS
Master Permit No.
O w n e r ' s �t':t c ,r' v krii-,r .-� Phone # : ?)C, -1 1Ct i3.`(2gt,
L
Owner's Address ` ) - ' > ( ' ; \ \ C \ \`), t". t '('C
City ': '? 1! C',_o -.) t State A- Zip ,S,') iL -1 L•
Tenant/Lessee Name\;(iAC I :cr-1 \-- Phone # 3C5 - -17• - S Q
Email i :-c.: E N 1 \-t:. - (AA-C-1, t v. -. %' i c f! . Cr1 t ). - 'S OS CI 70 06 6 r/
� 1
Job Address (where the work is being done) At.
writ `sC1l
City Miami Shores Village County
FOLIO / PARCEL # "i'� _ ' ; ; `
Is Building Historically Designated YES NO
Contractor's Company Name
L -Al 1166 it'ller
Miami Dade Zip
eI
ne #
Contractor's Address /E St72
City xlp : re' i- --r
Qualifier Name ✓V c 7 i t)(
State Certificate or Registration No. C c. rS y 4 0..1". Certificate of Competency No.
Flood Zone . .;
"CMG 4 Z -1/46.
Zip 3'13/ 6.2-
Phone# 6 -.4o4 -/ /4c.
Contact Phone c``t . - 4C2 -' /4C
E -mail
Architect/Engineer's Name (if applicable) ` �' rt�om, i ? � , )
Phone #
/0 30J
Value of Work For this Permit $ . $ �e0 Sq
Type of Work: []Addition ❑Alteration Die
DeescribgWork: _ _�.f te a.i� .. .,+ i i lr
L.0
e / Luaeai- Fodtage Of Work: / :">7 -p'
IJ Repair/Replace RI Demolition
* Ott*** *** * **** * *** * * * * * * * * * * * * * * * * **
Submittal Fee $ • °- Permit Fee $
Notary $
Scanning $ Radon $ DPBR $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $�?
******* ** * *** * * * ** * ** * ** * * **** * * ** * * **
Training/Education Fee $
CCF $ CO /CC $
Technology Fee $
Bond $
See Reverse side a
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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.
e ,
teo
Signature
‘0.0
Contractor
Owner or Agent
The foregoing instrument was acknowled l
day of k �Yt ; �.. , 20 ! - , by ,(-1 1 it ',b
r- .who is personally known to me br who has
As identification
NOTARY PUBLIC:
Sign
Print: . 4
My Commission Expires:` (t t �{
\■11\LN.i 1f::.•
The foregoing j
egoing instrument was acknowledged before me this `
i ' l Lc day of Nut (. �� , 20 , b � y ` tC
� iii � � O'C rJ i � &I ,
who is personally known to me or who has produced
an oath.
APPROVED BY
ded//-21/c)
Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Comm
•
•
otary .4 l J_ State of F
+4,
res Aug ?9, 2014
i
# EE 8916
gh National Notary Assn
Zoning
Clerk checked