PAINTPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date � 7 f Job Address y \ \Lok ST Tax Folio
Legal Description Historically Designated: Yes No
/ Tenant X � b f\l 65z- - 1 /J Master Permit # 4 3
Owner's Address Phone �( 5 T t - p2s
Contracting Co. Address
Qualifier SS# Phone
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor ? 4dres( 3 0
Permit Type (circle one): BUILDING ELECTRICAL PL MBINMECHANICAL ROOFING PAVING FENCE SIGN
1
WORK DESCRIPTION � 5 SS.3 Z e C-\ SQ ‘5 _ � o N g oa ll'
4 k t T „ A ` N 1 S.A & Q (c K
cro
Square Ft. O C�(> Estimated Cost (value) a T .
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 o Lite work stated.
Signature of owner and/or Condo President Date
Notary as to Owner and/or Condo President Date Notary
My Commission Expires: My Co
FEES: PERMIT ,
/
RADON
APPROVED:
Zoning Building .
Mechanical
C.C.F. • NOTARY
x,'30 111
•
*ssion NOTARY SEAL
NOIARYPUBL]C s j VILI_AR
COMMISSION STATE NO. C 410
Y COMMISSION EXP. C AR. 1 MAR. ] 002
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igna a of C
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er- Builder
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tractor or Owner-Builder ge Q
/ t - 9 / Date
Electrical
BOND
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TOTAL DUE ,
Plumbing Structural Engineer