1125 NE 91 Terr (6)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Dateo2- Job Address 1 OS' N. E Gas4J vie Tax Folio
Legal Description , 1
Owner / Lessee / TenantC kr CS Master Permit #
Owner's Address Ni. C• _l Ls+ Tyr v-ce C._.
Contracting Co. A Q,'e A; r Necf AddressSI V +A S"f /
Qualifier ?) In r=va ? „V'V) SS# Phone I k -' O 7 : 7
State # Municipal # Competency #Ci7CO / ? /)/ Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING (FECHANIC ROOFING PAVING PENCE SIGN
WORK DESCRIPTION I r1q ,� �v Le- in cal Kt /C. 14 in
Square Ft. g S �tY:rE Estimated Cost(value) ( Q
i
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.
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APPROVED:
* *
FEES: PERMIT 1
Signature of owner and
Date: alR 194
Notary as to Owner and or Condo President
My Commission Expire;:
do President
Phone - 7S — ) ^ O S.3
Notary as �o ntra tor' or Owner= Btiirdier
My Commiss 40xpires:
* * * * * * * .- **
RADON C.C.F. )A NOTARY TOTAL DUE 7
Fire Other
Zonin: Building Electrical
Mechanical � 'ii�/i/ ` Plumbing Engineering,