RF 2001 50 NE 109 StPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
d 1
Dat 20 - Job Address fib - rV � / [ 41- •) Tax Folio l I - 1 3 6 0 1 / " 0 3 6 O
Legal Description 4 O T y - 8 4,)-- a 1 S - F6 5-g- .?� istorically Designated:
No I/
Owner/Lessee / Tenant SA W d r A A Q ti& 4 Ii All Master Permit #
Owner's Address I Vr e 1 0 /n "V- Phone ,3 D 5 <y
Contracting Co. 6/ v 1 7-d tip / L o z / L_ /c3 Address i /2/ D A
A
Qualifier lf D a r-T °� . �� c a �, C� SS# : �( �) Phone I f 0 D -9 -7 ? S
State # 8 S 3 Municipal #
Architect/Engineer
Bonding Company
Mortgagor
Competency #(1 Ins'. Co. J I it
Address
Address
Permit Type (circle one): BUILDING ELECTRICAL P MBINIG MECHANICAL- ROO IN AVING FENCE SIGN
WORK DESCRH'TION'""L"S l `9 'L L Q t2 D.00 r r V1 T"
Square Ft (value) / s 6
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.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
cons ction and/zoning. Furthermore, I authorize the /above -named contractor to do the work stated. a, J
giinature of own and/or ondo President Date Signature of Contractor or Owner -Builder D e t
p1�RY PyPn ' Y�{.Pv aGPC
I RIP IF PINK
Notary as to O Fr Con q� t � f 00 012023 ate Notary as to o apr �, Date
My commis R _ eaMedTho��N ry My Commis P es: ecna a PING% Aag4,2oo5 3
apa k",, �
FEES: PERMITS RADON C.C.F. �r NOTARY BOND
APPROVED: TOTAL DUE Sol. LO
Zoning Building
Mechanical Plumbing Structural Engineer,