ACPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date /0543 Job Address ue 10 � 4/6 9.3 S Tax Folio // .1cI /--/ -�,,0 . /
Legal Description4-l4 '° -- -- ,,z 7 , //
Owner / Lessee / Tenant e-o t_ Master Permit # 5.50
Owner's Address I4I a 93 Phone 7
Contracting Co. //4 eoraz?/vv Address 232-Z 1-0' 7g 37
Qualifier 'Q /lUL
c ' OCENCIO JOSE GONZALEZ
a ir C3! xis tJPmwiden
4 Bonded Thm Notay Public Urderetters
of owner and or Cond
Signa / •
Date
No ary as to Own
My Commission Ex
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APPROVED:
Zonin
President. :;
ss # -
* * *
N. ary as to
My Commission
Phone 55&_78 4
State 4te#605 (0zgo Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING (FiCHANIC ROOFING PAVING PENCE SIGN
WORK DESCRIPTION 1- of 5 CE,t4,4A - 4/cl /1ar bitctS
Square Ft. Estimated Cost(value) 1Y' a a00
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 i, : pliance w all applicable laws regulating cons -•c ion and z%ning. Furthermore, I
author' abov: n /e. o nor to do the work stated.
Signature of Contractor or Owner- Builder
Date:
Jbvwanis_ •
INOCENCIO JOSE pONZALEZ
tc
,:or 6>�IROWriE38rii Lder
T ` d mm Notary Roc L'omo ; .
PEES: PERMIT / /4�� RADON C.C.F. /&iiIO NOTARY TOTAL DUE 72 7
Fire Other
Building Electrical
/ 1?' � i✓ Plumbing Engineering Mechanical4/
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