DEMO-11-1916OCT 1920.11
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?t1rn�, 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
Permit No.
1-101
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 20 be rko
Permit Type: ffl
OWNER: Name (Fee Simple Titleholder): -'1 ed al," t A4; --7--/-0c-
Address: /
/. /�! �*� ' _�,
City: ' � 444. o rr State:
Tenant/Lessee Name: Ore Mil 7' ® "/f/ ( Email: n°'c, c ti-,,, ,-`j ? c i �i ��' r'- e I c* er,9 a
3 cP �3 -72 i
Tip r � h Phone #:
Zip: 3 3
Phone #: 3 _ dre- ectf" '
JOB ADDRESS: /a-` 27o
City: Miami Shores
County:
Folio/Parcel #: 0/1 00 / - or?)
Miami Dade Zip: � ' 3 ) 3
Is the Building Historically Designated: Yes NO -y Flood Zone:
CONTRACTOR: Company Name: -9 . ' ' " ____, Phone #: - 3 3 -7 >a
Address: /a :01V? Lee. ✓ / t
/--
City: / !�.%��- -% � 1' S-ta�te -:� �`�
Qualifier Name: . A //. / iA Phone #: 3 " j e %'7 -a_-
State Certification or Registration #: — Certificate of Competency #: 6-- . _' ""' i®,tf'O
Contact Phone #: -3 7 .5`7; -2.._
Email Address: f / "�' ,°
DESIGNER: Architect/Engineer: Phone #:
Zip: 3
Value of Work for this Permit: $ WS2", �'� Type of Work: ❑Addition' ❑Alteration
"1 eScription of Work 4' ,/7 7--
0L,;:,%
Square/Linear Footage of Work:
New ❑Repair/Replace
° a �: ,^. : a •' . ti%
demolition
******i* *Ii * ** x***a:****+x*+x+x *x:+x**x *** * * ** Fees **** **** * **+x**** * * ** * * ******* ******** * *****
Submittal Fee $ Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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.
Signature
AtL
The foregoing in
■
day of . Y,
who is personally
Owner or Agent
ment was acknowledged be -fore the this
duced
o did take an oath.
ConttPor
The foregoing ins ment was acknowledged before me this
day of 0 20 //',` by / .041
who is personally known to me or who has produced /71. -
>)-4) 07 OAP as, identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Sign:
Print:
My Commission
CLAUDIA V. CUBILLOS
R,,,Q•,,; Public a e . .
s`•
Notary 23.2015
+` � • • = My Comm. Expires Sep
Commission # EE 128810
Rnnded Through National Notary Assn.
***** ******> k*************** * * **** **** x********* a: *** ****** x*********x:+x**** ****
APPROVED BY Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
* * * * ** *** ****** **
Zoning
Clerk