PAINT PERMITPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address / 3 / , 6 / 04 5/ Tax Folio
Legal Description H!)-tt/1 Q, 430-61, I Historically Designated: Yes No 5//
/
Owner/Lessee / Tenant — . Z C A4-31'((y , Master Permit #
Owner's Address 1 I 4)1 , 6, 1 0) _ Phone i c ���- ri _ /) e C ? )
Contracting Co. Address
Qualifier SS# Phone
State # Municipal # Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one).
WORK DESCRIPTIO
BUILD
LECTRICAL PLUMBING MECHANICAL ROO
-'tii/ »• L
Square Ft. Estimated Cost (value)
TO
Sign a■ e / owner and/or Co . President
/
No as to • ���' `r`: r y." �r : /.�,
M ommission expires: GLADy5I V+ILLAR
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC719163
MY COMM LESION IiX P. MAR.
FEES: PERMIT 5 RADON
Date
ate
00
-) /
ilb SIGN
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.
OWNERS 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.
S
ignature of Contractor or Owner- Builder Date
Notary as to Contractor or Owner- Builder Date
My Commission Expires:
C.C.F. ' 6 NOTARY J BOND
62
TOTAL DUE S -
Building / Electrical
Mechanical Plumbing Structural Engineer