468 NE 100 St (6)Date
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 1 'P 44 /Wo 5-/. Tax Folio 11 s lc2b 9 (O /7 ow v
Legal Description / wZ • !- �� 6.k
Owner / Lessee / Tenant 0 6C�/ L;; 1.1� �`' /1 OlC�l �1� Master Permit # ���` /
4P 4 '6 /o0 5 .
�s
Contracting Co �d/I o /e/J'� F'G`
Qualifier �l /�/
Owner's Address
Phone �/
Address 7. d14 . s'/1
- - Phone I;F:
State J Od # Competency # Ins.Co:
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one
WORK DESCRIPTION
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 compliance with all applicable laws regulating construction id zoning. rthermore, I
authorize the above -named contractor to do the work stated.
=L
gnature of owner and /or
%^ /
Notary as to Own and /4* 1''`i ? ,, ••;
My Commission Expires:
UILDING ELE L PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
07e
o President
OFFICIAL SEAL
ULIO ROBLES
mmission Expires
Junc 4, 1996
`PCORAdenM CC 205953
** * * * * * * * * *
Signature of Cont
Date:
* * *
' A ) / s �s•m
Notary a( to Co at.tue o
My Commission Expires:
iAfML
ROBLES
mission Expires
4, 1996
.n AA. CC 205953
Owner- Builder
**
FEES: PERMIT S 104Z7 RADON C.C.F. `"CU NOTARY TOTAL DUE O(
APPROVED: Fire Other
Zoning Electrical
Mechanical Plumbing_ Engineering