PAINTDate y
APPROVED:
• PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Legal Description /6 / W:a /X / >(/ )2
Owner / Lessee / Tenant ?•s� ;�1, r - r� �G,�2
Owner's Address _��.� �' ` q
** * * *
'Job Address
Notary as to Owner and /or Condo President
My Commission Expires:
FEES: PERMITS/ RADON
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Via/
Tax Folio // J'
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Master Permit #L_%l.� -1 7�
Phone �� C' / 0
Contracting Co. (���f/•!�iP/1� /�i Address
Qualifier SS# - - Phone
State i 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 /_;: > l ��
(
Square Ft. /t / / • - / (.� �' ( Estimated Cost(value) _- 41/ 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 contr_etor to do the work state • � '
Signature of owner and /or Condo Pre dent Signature o -B i etor r=Owner- Builder
Date: Date: 0/?
xx �;� f '
e? ,! t ; :u s,ian Etip.
N a. 37545
1 IitSt1
tar as to C
y Commission
NOTARY ✓ ` TOTAL DUE 0' �J
**
Other
Zoning Building f Electrical
Mechanical Plumbing Engineering
4