1226 NE 100 St (15)MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
30 5- 795 -2204
B 'Wing Inspection Request
Dates
Type Insp'
Permit No.
Name
Address
Company
Phone #
For Inspecto S
Correction
Re- Insp'n Fee ❑
• 0 / PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date - l Job Address \ ). , Imo) 1� I oo s - V'v ) Sins Tax Folio
Legal Description LET G ! 3 Lock 1 C I V I L f4
Owner/Lessee / Tenant � E k i H C C o rt K / /4
Owner's Address I S' o R.) ti,! S; l K C fu P B FL 3 `( 1,
Historically Designated: Yes No I
Master Permit # 1--
30s -) S 99z9
Phone 'Cc. I 9 G 1 9 S° 9 1
' f
Contractin Co. 1*. RD) t= � �� i I } /2 Address
Is. Co
Qualifier
State # ( f ') (/> / '7 / Municipal # Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor
Signa
c .
No : as to
My 'it ommis
Permit Type (circle on:: BUILDIN ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION f . �.� L /ter 7 2# v �, r� i 5 � S /c r 7
FEES: PERMIT [ V RADON
APPROVED:
Zoning
Mechanical Plumbing
4
Square Ft. Estimated Cost (value) _2_ U C/
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 • ork will be d•pe in compliance with all applicable laws regulating
construction and zoning. Furthermore, I authorize the above -nam - . contractor to do the ork stated. /
,of owner and/ Condo Presid
Date
of
Address
C.C.F. ) , B D NOTARY . BOND
TOTAL DUE 1,u,Na
Date
Structural Engineer
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