MC-10-1934Miami 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: MECHANICAL
Owner's Name (Fee Simple Titleholder
Owner's Address D4j 5Q 1 rck en 0A Su4'
City \a n,'\ State
Tenant/Lessee Name \j(C(ky -'
Email V,l- tc`ClV'Q6 4 A" G 1� ro 41 C 8 fr‘
Job Address (where the work is being done)
City Miami Shores Villa • e County
FOLIO / PARCEL # a- a n l' DOS
Is Building Historically Designated YES NO
5..-1,s-71.7 IT
NOV 02Z010
BY: .................... . ..
Permit No.I Vry 10 0Y1-
Master Permit No.
Phone # ? -11 QOgU
Zip 34[c'
Miami -Dade
Phone #j- -19^ gO
c101 ZAxAy,JE � JL
Zip
Contractor's Company Name QUA 1-1 ant. (
Contractor's Address 1' Z. q SOU 1 O 4T ►
Flood Zone
hone # 36,C -2.SS
City P-41 AIM 1 t' . • Zip 33 )e76
State Certificate or Registration No.
Certificate of Competency No.
Qualifier Name G>2. A
Phone # 3o�- 910 — 1 6139
Contact Phone "O,r- 6/35
E -mail &CSi9G 0A40t, , (Al'
Architect/Engineer's Name (if applicable) -52 r, -,p� Phone #Q5y - S1),- S5gV
Value of Work For this Permit $
Type of Work: ❑Additioo�n��
Describe Work: .,.wrterko2
!
n� __❑Alteration
Square / Linear Footage Of Work:
❑New ❑ Repair/Replace ❑ Demolition
*** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $
Notary $
Scanning $ Radon $
Double Fee $
* ** * * * * * * * * * * * **
CCF $ CO /CC $
Training /Education Fee $
DPBR $
Violation date:
Total Fee Now Due $
Structural Review. $
Technology Fee $
Bond $
See Reverse
\\
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 estim
promise in good faith th a copy of the notice of commencement and construction
whose property is subj et to a # chment. Also, a certified copy of the recorded ice
for the first inspecti . is occurs seven (7) days after the building peat i
inspection will not b ap F' v and ' reinspection fee will be charged.
Signature
e exceeding $2500, the applicant must
ochure will be delivered to the person
mencement mus be posted at the job site
In the absence such posted notice, the
er or Agent
Contractor
The foregoing instrumen was acknowledged before me The fore of i strument was ackn ledged before me this'
day of , 20 1 , byTOYhC*, j C�t'°tj re y i Zt) , day of , 20/0 , by 66e, G!J° j7 ,j.) ,
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
as identification and who did take an oath.
LIC:
My Commission Expires:
APPROVED BY
Sign:
Print: 80402. 1
1414415
M Commission Expir
Oij
11!
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/Vans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
46,....7€ tglY v
. Al! AU RODRIGUEZ
't , r * MY COMMISSION *Do 770751
EXPIRES: April1, 2012 -- -
o s , ' ) F o F 0 0 , 9 Bonded Thm Budget Notary S kt
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Zoning
Clerk checked