PAINTPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 2/Z. 7 Job Address /6 6 /U. / Z Tax Folio // 30 /" giA✓'V
Legal Description `Y 7 zi/
Owner / Lessee / Tenant Master Permit 1 ✓7 /
Owner's Address /G‘ /b-- / 2__ v s Phone 9- 5 f Y
Contracting Co. (- e4 /C_7 / C /Pi1i Address 27OS / L 527
Qualifier /'/ 4 / - ��,-.,.0 to SS# / Phone C1 ?�
State # Pt Municipal # Ao eC Competency # 0/W- 7 ns.Co.
Architect /Engineer
Bonding Company
Mortgagor
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
Square Ft. Estimated Cost(value) X4
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.
atu /of owner and
Y •
Condo President
1Q` E CHURCH
': • p fititCoPrOguittfArd 30.1
,„ No. CC197545
..s
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ary as to Owner
Commission Expir
Address
I Address
Address
Signatur f Contractor or
Date : 37 //ff
tart' as to C v�; iRCd�ihHl[1cflBt
Commission : •' W Ole 0n,msS
JOSEPHINE CHURCH
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FEES: PERMIT g7/.0 RADON C.C.F. f t (96 NOTARY J dD TOTAL DUE 0/50
APPROVED:
Zoning
Mechanical
Plumbing_
Other
Electrical
Engineering
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