121 NE 100 St (10)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date I 1 6 Job Address k I � � G CCek - Tax Folio
Legal Description Historically Designated: Yes v No
Owner/Lessee / Tenant An L a k/ Master Permit # 1
Owner's A d d r e s s P h o n e S4 -0 4 9z\ 478 ^d Q1 -6
Contracting Co. OOCe..A Address
Qualifier SS# - Phone
State # - Competency # Ins. Co.
Architect/Engineer Address
I
Bonding Company Address
I I
Mortgagor Address
Permit Type (circle one): ELECTRICAL PLUMBING MECHANICAL ROOF G ' ' PAVING FENCE SIGN
WORK DESCRIPTION 1 n J` �/
g�
Wes' E VA
Square Ft. Estimated Cost (value) 420D 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 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 Notary as to Contractor or
My Commission Expires: My Commission Expires:- - -
' V Puu <,,
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Z N. •: ICJ r
F EES: PERMIT G O. gC RADON
Signature of Contr.. or •r O .Ier- Builder
Owner - Builder
I Date
Date
- 7,/iy/7,
C.C.F. 3. NOTARY 4• BOND
TOTAL DUE �g -
APPROVED:
Zoning Building ti ``/ { 51 Electrical
Mechanical Plumbing Engineering