987 NE 96 St (3)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date/ 7 -q7 Job Address 1g 7 / i el 6 sr, Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant gob,C t 3r Master Permit # � �7f7
Owner's Address FO 7 /1/4 Phone 7 c$' --sgo
Contractin Co. X9 )3k-7T 4 Co0,7 Address �(72 / . ACC- C ,9L- /0
Qualifier /' SS# 5f3 `G 79
State # Municipal # /fl c gf� Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
Fi //V �
WORK DESCRIPTION / IC/q i � 0 ' 0-e '0 os E c 1, TLS � ( 574Af r
Square Ft. Estimated Cost (value) 2$o 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 contractor to do the work stated.
ture of owner and/or Condo President
otary as to Owner and/or Condo President Date
My Commission Expires:.
`te (r l ey -•
;F I,
■ : •
�fl
FEES: PERMIT - l® .
RADON
7 -y
Date
cs,a,ezt-72 j 2 -97
Signature of Contractor or Owner - Builder Date
/)
Notary as to Contractor or Owner - Builder Date
My Commission Expires:__ __ _ _
p(2Y PU, i��/ L ZVITA V C37AL
A � 9 i(L
II i i t �} Cs?,
v 7 q
C.C.F. 2r NOTARY BOND
TOTAL DUE
A6 ..D
APPROVED: 1 � Electrical
Mechanical Building I /
Zoning g
Mechanical Plumbing Engineering
STATE OF FLORIDA,
COUNTY OF DADE. ss..
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for tilt build-
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of■Miami
Shores Village, Florida,a�d all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the B 1ding Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approged
plans and specifications must be kept at building during progress of the work.
��jj�� Date �� ° ' 19 < /
Owner's Name and Address �4 C F�l No p / Street %�� ( L _ _ + -
Registered Architect and /or Engineer V
Name and address of licensed contractor____ '11 , ' �'' L° t_,,,,,,,
Location and legal description of lot to be built on:
Lot Block Subdivision_ _______________ _______________________________
Street and Number where work is to be done
State work to be done and purpose of building (by floors )__ ' ( 'L/ 1124,___
Building Inspec
or
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind ffou _ Roof Covering
Estimated Total cost of improvements $_ _Amount of Permit $
Zone cubage required__ _Plan Cubage
Distance to next nearest building __________Size of Building Lot _
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed)
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has care ully read e foregoing application, and that he did sign the same, and that all facts
therein by hum state aR true #
Permit No ______ __ / Date Read, Sworn to and Subscribed before me.
Disapproved __ Date
Notary Public, State of Florida
( Signed)
My Commission Expires _
PLANNING BOARD DATE
Chairman Member
Member Member
Member Member
Council Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for Taking corrections or changes to this application after approval has been obtained from
the Planning Board.
A re- inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build-
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
Owner's Name and Add( d `-
Registered Architect and /or Engineer
Name and address of licensed contractor
Permit No
Disapproved Date
( Signed)
Building Inspector
Chairman
Member
Member
Council Approved Date
NOTE: A charge of $1.00 will be made for making corrections
the Planning Board.
MIAMI SHORES VILLAGE
Date..._ u , 19 -5—
No Street
fi e. -�-e
Location and legal description of lot to be built on:
Lot Block Subdivision
Street and Numbef where work is to be done
State work to be done and purpose of building (by floors)
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
�
Estimated Total cost of improvements $ Amount of Permit $ -G% 0
Zone cubage required -Plan Cubage
Distance to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, o work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed)
STATE OF FLORIDA,
COUNTY OF DADE. j ss
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the.
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Date Read, Sworn to and Subscribed before me.
PLANNING BOARD DATE
and for no other purpose.
Notary Public, State of Florida
My Commission Expires
Member
Member
Member
Disapproved Date
or changes to this application after approval has been obtained from
A re- inspection fee of 51.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
Date / Job Address / ?7 AJE? 57
Lessee / Tenant 60 O t{/9cif
Owner's Address qf, D 7 AIL= Q6 67
Legal Description /5 /1
Mortgagor
Signatu
Date: /
** *
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
f/Z1'
o ner and /or Condo President
'�':►qti
JOSEPHINE CHURCH
} 1' • t impcommessiewitini 3o.
CC19754s
ota•y as to Owner
My Commission Expir
* * *
FEES: PERMI1 " 0
Zoning
* * * * *
RADON C.C.F.
Fire
Buildin
Tax Folio // 1206 1 i4a 6
Address
Signat e
Date: f % 11'Y
My Commission Ex
Master Permit # 5.3
Phone Zs
Contracting Co. fio 3 PT N COReF}r Address //70/ we)- $ /c5e 6frwii /RD•
Qualifier gO8 t � 1.111�i 7 Phone g73
/ 9 .
State # /54.- Municipal # No c Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING � PENCE SIGN
WORK DESCRIPTION PATcssoRE c'.LEf1IV AND 02 /AfT —/4� /R% S S ///r7L^
Cc1-OR (wl /irE)
Square Ft. Estimated Cost(value)
s O
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 com.liance with all applicable laws regulating construction and zoning. Furthermore, I
authorize - 'above -named contractor to do the work stated.
ntractor or Owner- Builder
t lOSEPHINE CHURCH
'No CC197545 Mt
**
NOTARY .5:06 TOTAL DUE 4 1 9 O
Other
Electrical
Mechanical Plumbing Engineering
CONTRACTOR
New Construction
Name _ '
�w(�JJ
/
Name C
..0jl `1 L `� in _ ,�„i..
i
"� �•• ' ` '7`
7 0i
Address
9 of 96
MA /f ,
tKr
License No.
y 1 ?
J /
Repair
Business Telephone
Address
/►pry /, Az
Fax
Demolish
Telephone Curie fend / L+ Fax g
Q � 7 �}
J /'
fj
pd
G
Qualifier Name
'/ t
Foundation Only
P OPERTY OWNER
New Construction
Name _ '
�w(�JJ
(�_ , /_ 4
//L VC/�
Address
9 of 96
S
Home Telephone
Repair
Business Telephone
Alteration Interior
Fax
Demolish
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'I Detachment
Other
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Step 1.
Master Permit No.
Subsidiary Permit No.
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. ,Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
.iJob Address: ?81 1 M E I t cchtet
Address
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
Apt.
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
Miami Si1OWS
City
Tax Assessed/Appraised Value
PI--
State
PERMIT APPLICATION
33/38
Zip
Folio Number Description of Work 0 p K 9 at J ' # '
Lot Block /
Subdivision PB PG Zoning Linear Feet
Current Use of Property Square Feet Units Floors
Proposed Use of Property Value of Work Z 3/4t Bldg Value
Tenant Information
Flood Zone Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
Page 2
IM PORTA NT Nun C I.S
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1° Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORIDA, COUNTY OF MIAMI -DADE
J y
o
Signature wner
g/i2 a.be ' M RacJ
Print Name 2
S o to and subscribed before me this 3 day of
Signature of Notary Pu
SEAL:
Personally known
OR, Produced Identification
PERMIT APPLICATION
STATE OF FLORID , C1 OF MIAMI -DADE
Print Name
Signature of Contractor / Qualifier
/ I C A' V
Sworn to and subscribed before me this
tart' Public - fate of F,ls da
SEAL: 9002'51 jagwanoN sat! x3 f
stag 1,0a uo ss!wwo �WV
A vis
Personally known 1,0 „,,0 0d OR, Produced Identification
Type of Identification Produced: Type of Identification Produced:
ELECTRICAL
TYPE.
Minimum Fee
QTY.
TYPE
Dryer
QTY.
TYPE
Outlet, Appliance
QT1'.
TYPE
Service Repair
Q'I'Y.
A/C Central 1 -3 Ton
Dryer Vents, Number of
Fan
Ventilation, Cost
Outlet, Wall
Ductwork, Cost of
Service, Temporary
Periodic Inspections
A/C Central 4 -7 Ton
Fire Sprinkler System
Fire Pump
Outlet, Switch
Fireplaces, Number of
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE Q'I'Y.
Minimum Fee
TYPE
Condensate Drain
QTY. TYPE
Generator
QTY. TYPE QTY.
Refrigeration, Tons
A/C Central, Tons
Cooling Tower
- Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
- Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
- Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
- Process/Pressure Piping
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
PLUMBING
TYPE
A/C Condensate
QTY.
TYPE
Drains, Roof
QTY.
TY
Miscellaneous Fixture
QTY.
TYPE
Soakage Pit
QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
SECTION
BY
D TE
Zoning
� 4.'
// S /O a
Electrical
(/
y
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
/ 1 j, �-•
Page 4
OFFICE USE ONLY
CHECKLIST
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi - family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) $
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
❑ PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
O IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
(sq.ft. = x/1000
x ¢.60)
$ ((t.005 / sq.ft.)
(¢.01 /sq.ft.)
REVIEWED AND PREPARED BY:
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $
DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
t
MEMO
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 11/6/2002
Applicant: ELIZABETH
Owner: HACH
JOB ADDRESS: 987 NE 96
Contractor COMPLETE HOME PAINTING Contractor's Address: 1476 NE 130 STREET
Local Phone: 305 - 895 -1368
Parcel # 1132060143240
Work:
COMPLETE HOME PAINTING BY MICHAEL
MICHAEL IWASKEWYCZ
1476 NE 130TH ST. PH. 305 -895 -1368
NORTH MIAMI, FL 33161
PAY TO THE
ORD t F
W : •: ' in : n Mutual
Was gton Mutual Bank, FA
North Miami/125th Street Financial Center 1728
900 NE. 125th Street
1.800.788.7000
North Miami, FL 33181 24 now Customer Serra
EXTERIOR HOUSE AND ROOF PAINTING
I /
►. n_L /L_3 L is 83111/33511 3 5 7 7
Legal Description:
Fees: Description
FEE2002 -6277 Building Permit Application Fee
FEE2002 -6278 CCF
FEE2002 -6279 Notary Fee
Total Fees:
Permit Status: APPROVED Permit Expiration: 5/5/2003
HACH
ELIZABETH
ST
# If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection
"/ fee is $50.00, which must hp Hair+ in ;tion.
63 -8413 -2670 3 5 7 7
/4/4
$ (or �C�
DATE
Building Permit
Permit Number: BP2002 -1901
DOLLARS
MIAMI SHORES SEC 3 PB 10 -37 LOTS 13 & 14 BLK 77 LOT SIZE 100.000 X
Construction Value:
Amount
$60.00
$1.80
$5.00
$66.80
BY:
BY:
$2,400.00
Page 1 of 1
Total Fees: $66.80
Total Receipts: $0.00
be equipment or device described in the application herefor in strict compliance with all
with any plans, drawings, statements or specifications that may have been submitted to
s not done in compliance with such ordinances or if the plans are changed without
:tor or builder named above assumes the responsibility for a thorough knowledge of the
igs or in the statements or specifications and that he assumes responsibility for work done
compliance with all ordinances and regulations pertaining thereto and in strict conformity
s Village. In accepting this permit I assume responisibility for all work done by either
Paint Color Approval and Agreement
DATE: /0 30/D�-
OWNER'S NA : /
ADDRESS: f''7 /t/e- 9j
********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
ADDRESS OF SITE: 9(7 tie._ 9d
CONTRACTOR & LICENSE (if a•plica +le)
COMPANY NAME: PHONE:
* * * * * * * * * * * * * * * * * * * * ** * * * * * ** * ** * * * ** *. * * * * * * * * * * * * * * * * * * * **
All Elements -on the ) site must be listed and indicate the color to be painted.
((
Walls , f 7 2 6
Fascia 2'D
Drip Cap/Drip Edge uJ
Soffit ��✓
Roof
Flower Bins
Shutters Ay /Ai
Awnings
Chimney Gv !t
Doors and door jams GO ,
Garage Doors k
Railings ti/17
Fences Ad / �` "
APPROVED:
MIAMI SHORES VILLAGE
a /3
Building Offic' 1 Date
Decorative Metal /0/`9
All brick (simulated or regular) /
Stucco Banding �ugq�sf w ti, I:e )
Any other stucco features
Accessory Buildings
Other
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. I authorize the above -named contractor, if applicable, to
do the work stated. Furthermore , the paint colors will be as per the attached
samp
Signatu of Owner Date Signature of Contractor (/ Date
*********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
1/A
WHEN PAINTING IS FINISHED,
CALL FOR FINAL INSPECTION
4/23/01
260