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PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
1
Job Address d /t/!6, ?2'if�ax Folio %•Z Db O/�307d5 a
Legal Description4 97L 4"GlnJ f9,„,,. 0 �/o rp
Own / Lessee / Tenant 3 14;4=65_1,4/7w447 Master Permit # R,6 387
Owner's Address 7 b A.J 6 , 9 7 S.7 • Phone 7 5'/ f?3
Contracting Co. Address
Qualifier SS# - - Phone
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor A,4,414 Addres sP 0 , L 6,q 351Y LOV:v' /lr >)/.
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION
Square Ft q(0 Q A , Estimated Cost(value) 2, 7D'U.(7c
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 contractor to do the work stated.
Sig a of owner /o C o esident // Signature of Contractor or Owner- Builder
Da � ` � � fi Date:
FFICIAL NOTARY ]
Notary as to Owner an or Condo Pre tnt <� BARBARA ANINb l s to Contractor or Owner- Builder
My Commission Expires: 2 r , , i . coMMISSIONOmm ssion Expires:
Q CC36OY9
v tie my COMMISSION EXP.
FEES: PERMIT / ' j' RADON C.C.F. )66 NOTARY TOTAL DUE btior
APPROVED: Fire
Zoning Buildin
Mechanical Plumbing_
Other
Electrical
Engineering