478 NE 92 St (6)Date 4- /i Job Address 4 7 ' (o?
Owner
Owner's Address
Contracting Co.
Qualifier
Signatur
Date:
Nota
T APPLICATION FOR MIAMI SHORES VILLAGE
Lessee / Tenant K —Q\ /Z C
Legal Description GAT 3
State #
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION .&A4 -1.,
Square Ft. Estimated Cost(value)
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
auth• ize the above -named contractor to do the wo./ stated.
1
s
owner
r. Q. l�
GCECIL B •UE
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. 47.C29172
MY COMMISSION EXP. ULY 7,1997
0
and
My ommission Expires:
** *
�7 nJE
�IA� T.f �illC :J() f L )2 Address
SS4
Municipal # Competency #
or Condo President
FEES: PERMIT 3/ RADON C.C.F. ' NOTARY
Fire
Zoning Buildin
Mechanical Plumbing
Tax Folio /f ��o�° ' gig-- c/OO
• )1-lea-she-EA. - 2
Master Permit #
Phone 7 . S i " 3 O 1
i - - Phone
Ins.Co.
Signature of Contractor or Owner-Builder
Date:
Notary as to Contractor or Owner- Builder
My Commission Expires:
* * * * * * * **
Y TOTAL DUE
Other
Electrical
Engineering