MECHANICALPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date /MP Job Address f Z5#i Tax Folio
// 30706 oD 6 oo o
Legal Description Eke Historically Designated: Yes No
Owner/Lessee / Tenant Eke / ` / -s 0aeCC/ !, Master Permit #
6 --/ 6 17
Owner's Address 9,25 5 /V C 2 Phone 3®f 757 a gg, 7
Contracting Co. A /7/(/U' "'Aok /4 C2 �V C` Address i riZ5 O ° 2 - 5 / �i`n" 3
/ fle e ce /9 Qualifier QJ SL /9 SS# ___- 7PhonCo ) 752 ?'2
State # 0574W Municipal # Competency # Ins. Co. /ga
Architect/Engineer Address
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBIN
WORK DESCRIPTION
� ® V
Notary as to Owner an
My Commission Expires:
OFFICIAL NOTARY SEAL
ADA PALACIO
NOTARY PUBLIC STATE OF FLORIDA ,
COMMISSION NO. CC814167
MY COMMISSION E . MAR.
FEES: PERMIT � . ; 7 °� - RADON
APPROVED:
Zoning
Mechanical / /VD 6
Date
Address
Address
MECHANIC
ROOFING PAVING FENCE SIGN
ex4(// ige il(e0469, 27
fin:
Square Ft. Estimated Cost (value) / riJ t�I7
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YO UT' FAILURE TO DO SO MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENBER..
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 zoni g. Furthermore, I authorize the above -named contractor to do the work $tat
Signature of o
Notary as to ontractor or
My Commissi “ OFFICIAL NOTARY SEAL
ADA PALACIO
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC814167
MY COMMISSION EXP. MAR. 2,2003
C.C.F. ) . NOTARY ` BOND
uilding
Electrical
TOTAL DUE
Plumbing Structural Engineer
Tir