1075 NE 96 StPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 6" Job Address / -' JvCE ci, •Cr Tax Folio
Legal Description
Master Permit # /(//'
Owner's Address I0�S GE e i r b Phone C� �'`.3 0
Owner / Lessee / Tenant O =1y h t /
Contracting Co. rE1 ble 1vwni Address (.p 6 in ' (,O 14.
Qualifier 11); 1, 1 YU):51 SS4 & Phone 3on g(135
State # Municipal # Competency #
Square Ft.
Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one• BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION 14.E 111/
Estimated Cost(value)$ t (g) 'OD
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
author ab• --na ractor to do the work stated.
Signa
Dat
\ '-'",:/%7.....42,1 . �4 ! ///' a / - 9/
Notary as to Owner and /or Condo President
My Commission Expires:
4 Y P& OFFICIAL NOTARY SEAL
O <., SANDRA RI MONTIEL i ',
** * N * � MMISSIRN NUMBER N * * * *
y Q CC401261
Tel" o
-71 `. Q' MY COMMISSION .EXP.
FEES: P 11° 114DON j
APPROVED:
C.C.F.
Fire
Buildin
Mechanical Plumbing
Zoning
Signature of Contract or Owner- Builder
Date:
Not
My
�� 6 NOTARY
ractor or Owner- Builder
* **
• OTAL DUE C 4
Other
Electrical
Engineering