CONCRETE REPAIR3
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date l -I1GY /J ,ZJob Add ress tgiv 11
Legal Description 4- ' / . / ✓ , Ir2 / / MP
/ Lessee / Tenant i(i 4 krAfzt`tlIE gpef. Master Permit
Owner's Address Z N, er$
Contracting Co. N/
Qualifier l W:4/
SS#
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor
Permit Type(circle one UUILDIN' ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION _. :.: 0/4s r f Cv G.,. iF i 1 4_
ANA ,. nem 1, ;7A1hAf gE f Pao. (
Square Pt. Estimated Cost(value) t i 7 4-0
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 -namo stated.
0 , 0` g ` 4 4:. JOSEPHINE CHURCH
r (;, :Notary Public, State at Ronda
Signatur of owns and /c r' •' "•. '' `��' 30, Signature of Contractor or Owner Builder
1 / t.(/ Print type or stamp name of Notary Public
Nj ary as to Owner andillsisotailthhtpvpirpfcrakiced
My Commission Expires: Type and t b Lproduced: //
Address
Address
Date:
Tax Folia 5=
Phone 75 180
Phone
Notary as to Contractor or Owner- Builder
My Commission Expires:
0 DID take an oath, or
** * * * IND NOT take an oath.
RI * * * * * * * * * * * **
FEES: PERMIT-3 RADON C.C.F. `S NOTARY _6 ---4)() TOTAL DUE � - ®o
APPROVED: Fire t Other
Zoning ildi.n5 ` Electrical
Mechanical Plumbing Engineering
75
80
3255
IIIIM
CH
/
/ICE. 98 .S�7.PEET
COO
aic
0•
LOT DETAILS
SCALE: 1" 2Q'
7 s' 3/4/ 'o ' 72.C,E
<..1p'po Swi77
s /ajW4L�'
740
\V /
9
6.1'
16'
v
• B.2
S.2
jSr$-
CBS
DouBcE
G- 4R4GE-
o o
LOCATED IN:
�,�$RiCJC
W4LK
34
TA) . Tt' C3g
2 T _ _
sly
v JAG.
ZR -S
Tic w L V.DG. oi/ L,u 100
6 S
:1) /5 /qa 8 ' PAVED
0 O 'V "? 1- zt 4vtf
moo- 6o
w,0re4" mom(
rw wA�
/JSYNA� -T
peKhN
4
n
,/ // 7 /t J #01F,S
7,? COUNTY, FLORIDA