350 NE 100 St (13)Date %', fq( Job Address 350 . G •/e94, • Tax Folio l / 3o2.6(n 12/1 2
Legal Description
Owner / Lessee / Tenant
WORK DESCRIPTION
e of own and
Signat
Date'
Notary as to
My Commission
** *
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
or Condo President
k. 4ndJor Co .President
Aires':
Owner's Address 3SQ - / 79 Phone 7,52 66(p/
Contracting Co.
Qualifier / . .i .:..!�. ' s #__ - q .b n2 /,3.S
State # (, 60 &"'[K f pal # Competency # Ins.Co.(/Z,��11 IL
Architect /Engineer Address v
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL UMBING MECHANICAL ROOFING PAVING PE E SIGN
Square Ft. Estimated Cost(value)
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 co,•liance with all applicable laws regulating construction and zoning. Furthermore, I
au -•rize y:' :med contractor to do the work stated.
ignature of C
Date:
gp , CO t rax'CVYn.:� r. - bwn`etu
LOTi XP *es i
.
otary as
My Commis
*
®7)
FEES: PERMIT L3D RADON C.C.F.
APPROVED: Fire
Zoning Building
Mechanical Plumbing
Master Permit # ;7e/0
NOTARY
ractor or Owner- Builder
Other
Electrical
Engineering
*
5ys� —
lder
**
TOTAL DUE 3 V=