PAINTPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date S '1` • 7 Y Job Address V( 1 7 / 0 /✓. L . 9 71. Tax Folio
Historically Designated: Yes
Legal Description ►i'(1 tJ .
Owner/Lessee / Tenaxt7 i g /( iQ5 g4y
Owner's Address 64/6 jki. L - i 5-r
Contracting Co. \l t S Co (nri Rtet NIT( 41C-co Akim1 4
Qualifi
State # Municipal # Competency # 9Yr5 /7 Ins. C
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
I� ►�I � (CRl6R
Square Ft. Estimated Cost (value) 2/L/0.0 . CO
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 fofegbing information is accurate and that all work will be done in compliance with all applicable
laws r ion and zoning. Furthermore, I authorize the above -named contractor to the work stated.
gnature of own - and/or
/
as to Own
stun DYSI VII IAK
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'NOTARY PUBLIC STATE OF FLORIDA
COMKENON EXP.
COMMISSION NO. CC714103
Not
My-Co
FEES: PERMIT
RADON
APPROVED:
Zoning Building
Mechanical
Date
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Date
Master Pennit #
Phone
Address 11212 2 J 4 N " gUi0%.! ST , /41,071A/00
SS# 1Phone
lectrical
MARY LOU CLOCKER
{ I 4OTA.2Y P 4C S T A ;'E OF FLORIDA
, CO dM ES ION NO. CC.472323
TYCO ?,ul LR
COI 1
2/A 1128
Si a ature of Contractor or O ' - Builder Date
Notary as to ' ontra or or Owner - Builder Date
r �
My CO ionExpire
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C.C.F. U ° NOTARY 5.°C BOND
TOTAL DUE 4(b -V
Plumbing Engineering