ALARM PERMITPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 4;6 4;6 Job Address 2 J 2 C ! / 6r Tax Folio
Legal Description Historically Designated: Yes No
�hvge?/Lessee / Tenant /Bg/ /1)6F1 6.4) :OrV E5 Master Permit # 96/0 qV
Owner's Address ,J a N•
C o n t r a c t i n g Co. 1 ' ' 1 7 ,1A57,2
Qualifier RD ti Q c /-1 r4v✓l S
State # s e2(29
gnature ofI
Notary as to Owner an ∎ F or ondo President Date
My Commission Expires: g -' 3
OFFICIAL NOTARY SEAL
SCARLETT MOUNA- URREGO
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC767318
MY COMMISSION EXP. AUG. 132002
FEES: PERMIT 5 RADON
APPROVED:
Zoning
Mechanical
C.C.F.
Address
Phone
Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION / /4'c_4
l Go,,/1 0%,_ 4Z Ze0,7S
Square Ft. Estimated Cost (value) 1 7 / 9
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN YOUP
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. F , I authorize the above -named contractor to do the work stated.
4i'
gnattut o Contractor or 4,06
Builder
My Commission Expires:
/
)16
p ?"-- ``.SUON N IMBER
CC797277
EXPRES
75S 774‘.
Date
Plumbing Structural Engineer