180 NE 99 St (3)Date
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address (a O 44 E- qq Tax Folio (') f 3 "
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant R, a& (b EtO (2.0 Gc> 1Z • Master Permit #
Owner's Address 1 ' 0 , E. • Ct q I "m .,A 0/4 ShwgizaPhone
Contracting Co. S C 7t I i( f L IZM S O S v 1 ME L °(�4 Address ( 0 S00 tJ W M. f (4w4;, FL.
Qualifier � nt� LPt. (7Ie2(1‘E14—
SS#
-
State # E F 0 000 � (Z o - Municipal # Competency # Ins. Co.
1 Address
Address
Architect/Engineer
Bonding Company
Mortgagor Address
PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
Permit Type (circle one): BUILDING
WORK DESCRIPTION l '9 OT" � 46 4 4 0— Z
- Co -rdruk 7- V so i 1ie E r
Square Ft. Estimated Cost (value) ( 2..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.
Notary as to Owner and/or Condo President Date Not. ` as to Co
My Commission Expires: My Commissi
i G D
FEES: PERMIT seV RADON
APPROVED:
Zoning Building
Signature of owner and/or Condo President Date Signature f Contractor or Owner - Builder
actor or 0 . - : uilder
Expires:
Electrica
4,01V P(8 OFFICIAL NOTARY SEAL
O ((t <- ANDREA C MARREUO
�)lf * COMMISSION NUMSER
c -a u r 4f CC3 - 12982
Toe. '11Y COMMISSION rxp.
F 1 67 6 , {r
C.C.F. - NOTARY BOND
TOTAL DUE
Phone .3 ()Si l S s' 7 s
Date
Date
Mechanical Plumbing Engineering