PAINT•
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 5 0 Job Address V )c) (G q lC . C ( . Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant ∎)"\ \ c \ 1 c l t �� ,� I) ) AxIICL..1) • Master Permit # � �O 73
Owner's Address ' Phone L i fc't
Contracting Co. y eE4 kV E Address
Qualifier
State #
Architect/Engineer
Bonding Company
Mortgagor Address
FEES: PERMIT
RADON
Municipal #
Signature of owner and/or Condo President Date
Notary as to Owner and/or Condo President Date Notary as to Contract or Owner- Builder
My Commission Expires:
SS#
Competency #
Address
Address
Phone
Ins. Co.
My Commission Expit a r,ciiii - R EA
' a�1 P t2 °T GAF.11ALION11EL
E ` ' Vi ., ,� Cl co : SSON NUMBER
; :. ':;;, v (C797277
X, ' c? Liv c ;'- t:^xssoPl EXPIRES
`� 4 <' 0 :: r■O S; -; :. 1 7,2002
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C.C.F. /.)— NOTARY 3 BOND
Permit Type (circle one BUILD i ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK (
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Square Ft. Estimated Cost (value
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WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO 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.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I certify that all work
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
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. Furthermore, I authorize the above -named contractor to do the work stated
/ . I
: of Con : • or Owner - Builder D. to
Date
APPROVED:
�j� Zoning Building ' / Electrical
Mechanical Plumbing Structural Engineer