1292 NE 95 St (9)Date (O - S - t Job Address \ ° (d ClE 9S-'-V‘ S Tax Folio / AT & /lyo y0 b
PERMIT APPLICATION FOE MIAMI SHORES VILLAGE
Legal P^,icri Lion 4/ 75
/ Lessee / Tenant ea_ Master Permit # gi// ,,9
Owner's Address ■_W ct SAP S4
Contracting Co. Address
Qualifier ail 4" R,
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION \96‘ \C\ -C--Q\-)C4? N r c g tcd \ c& ct c
odov c‘[6-e$ C L,UVSZ° .. mayimuw. V�-lg �
ud- cdlved . J } 1j
Square Ft. 1 , 11'eam- 1000001,10 I ie //s E „timated Cost(value) A 000
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
autho ze the abo - - work stated.
At /
INE C41lNIGi
Mk. Stalest Ronda
Sig ature of owne
Date: 1A -*jrjkg
• ` 'mawr stamp name of Notary Pub 'c
N1 4 ary g as to OwneT ► i4r;n;�!4 9If Fgg n
My Commission Expires: .2 ')L...
❑ DID take an oath, or
p l,DID NOT take an oath.
** * * * * * * *
FEES: PERMIT g ,iPn RADON C.C.F. / OP NOTARY SOD TOTAL DUE J (D' o
APPROVED:
Zoning
Mechanical
es
Phone - 2 S 7 - (cr-D
ss# - S/?
Signature of Contract
Date:
Notary as to Contractor or Owner- Builder
My Commission Expires:
* * * * * * * * **
Fire 1 Other
Building ) /�/ Q g/ Electrical
lumbing Engineering
or Owner- Builder