815 NE 92 St (4)Date
Legal
Owner
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 6(6 tQa 5
fi; ,/
Description
/ Lessee / Tenant /J fro
Owner's Address V5 it/ & r - 9a
Contracting Co. P 8 4, 4 f c
Qualifier/e,,
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL 1)OFING PAVING FENCE SIGN
WORK DESCRIPTION � 1 2. J -70 /0 x /C
Square Ft. Estimated Cost(value) 0 —
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.
Signature of ow�►er
Date:
No ry
My Co
** * * *
ident
FEES: PERMIT .5773 RADON C.C.F. 4. 3 O NOTARY
APPROVED: Fire Other
Zoning Building /d a 7 r?
Plumbing
echanica
SS4t phone
Tax Folio 1/ l 'W �� e6 /7 /'
Ado 1h
Master Permit
Phone
Address 7 3 ; f &), ___ >
2 A 0 " Ce , 7
Signature of
Date:
tractor or Owner - Builder
Notdry as to Contractor or Owner -B der
My Commissio
Electrical
Engineering
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