1273 NE 92 St (4)Date Z Job Address /Z /�. �- ��5,: Tax Folio � f026,5 -- (17;79 �� 0.
Legs Description 2‘ /‘3 . � ,7 13 7,
Lessee / Tenant 7��?If'7 , al # Permit 37
Owner's Address .9S �i Zoe2 - e Phone 7L 7 '227 7
Contracting Co. � -C- Address -5'
Qualifier �iU /i° / / /�U / /�- "�v SS4� - 2-5 - 7
State # Municipal #069( Competency # 04K5J5 Ins.Co.',44 i'4/�CG/ '
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING
WORK DESCRIPTION
7 , J/.cJ �i-�',
Square Ft. 26.
/_I
ary :' to Owner and
My Commission Expires:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
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 nd z• g. Furthermore, I
authorize the above -named contractor to do the work stated—
79; ia•g 4' �
Signatur of owner and /or Condo President
Date: e4/V
•
"•:'% JOSEPHINE CHURCH
ciOrdMisdittito. A1Ng*0. lI
:;��.cr���•AF' No. CC197545
Estimated Cost(value) z/ 4'2
SEPHINE CHURCH
Signat r o ontractor •r Owner- Builder
Date: r�d'�
?:tar/ as to C
My Commission
FENCE SIGN
**
** * * * * * * * * * * * *
FEES: PERMIT 11 17 - 0 RADON C.C.F. / / 5 NOTARY S O TOTAL DU E i M
Other
Electrical
APPROVED:
Zonin
Mechanical Plumbing Engineering