PAINTPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address (oa bO NE Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant Q 7Ol . Master Permit #
Owner's Address Phone 53 -!- rp 51
Contracting Co. 6 ca_D E Address
Qualifier SS# Phone
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
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WORK DESCRIPTION
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Square Ft Estimated Cost (value) l qqG
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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.
Signature of owner and/or Condo President Date
Notary as to Owner and/or Condo President Date
My Commission Expires:
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FEES: PERMIT 4 f) . RADON
C.C.F.
Signature of Contractor or Owner- ilder Date
Notar as to Contractor or Owner- Builder Date
P(/ OFFICIAL NOTARY
O �� <� SANDRA L7 C,7O:�TIt�L
S' COMMISSION RiUL1 LEtl
7;:t. I a CC401261
' • Q' MY COMMISSION .CNp.
OF FL,O 1711) 2a _j
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NOTARY ( TOTAL DUE �
My Co
APPROVED:
Zoning Building `,` ) ` Electrical
Mechanical Plumbing Engineering
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