925 NE 95 St (4)PERMIT' AIFIFILII(CATII®N FOR MIIA `MII SHORES VILLAGE
Date ' Job Address 9 2 S (K& , 9S bTax Folio
Legal Description Historically Designated: Yes No
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��wn�/Lessee /Tenant Master Permit #
Owner's Address Phone 9 —1382.8 -- f 7.4
Contracting Co. (0 /n (l- Address
Qualifier SS# Phone
State # Municipal # Competency # Ins. Co.
Address
Architect/Engineer
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING IFIENCE SIIGN
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WORD DESCRIPTION
Square Ft. Estimated Cost (value) / (((, 00,
WARNING TO OWNER: YOU MUST RECORD A NOTIICIE OF COMMENCEMENT AND YOUR FAILURE URIE TO DO SO MAY
RJESU LT I(I`1 YOILIR PAYING TWIICIE IFO E'; IMPROVEMENTS TO YOUR PROPERTY (IF YOIIJ INTEND TO OBTAIN 1FIINANCIINO,
CONSULT WIITIIi[ YOU e'; LIEND E 0 I +; AN ATTORNEY BIEIFORIE RECORDING YOUR NOTIICIE OTF COMM1ENC1EM1ENT.)
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.
OWNERS 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.
, s 6 e 4
g nature of owner and/or Condo President Date
Notary as to Owner and/or Condo President
My Commission Expires:
Date
FEES: PERMIT 2 7 D RADON C.C.F.
LRAr
7
ature of Contractor or Owner - Builder
Notary as to Contractor or Owner- Builder
My Commission Expires:
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NOTARY S. BOND
TOTAL DUE
a
Date
x/7
APPROVED: q p�
7ng Building
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Mechanical Plumbing ?/71 Electrical
Engineering