55 NE 100 St (8)L.
Date 3 AAIr Job Address 3 /02E. /220 Tax Folio
Legal Description ZeP /d' 14/Yb %Z 0,4" LoT /7 AA/4) Z2 C ' /z eoT '9 6e/1 /G
Owner Lessee / Tenant AiGe ti S o,eth¢JtG Master Permit #
7y '78
Owner's Address SS /1/E• /0O' 5
Contracting Co. Address
Qualifier SS# - - Phone
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING
WORK DESCRIPTION /X/..X TAI- L, J ,'Y °E ,4 W,V..b P1ev' 2 Ty /C.1 G / /VA
Square Ft. 300 10 L_ C.l:, NC6Estimated 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 and zoning. Furthermore, I
authorize t h above -na'-• contractor to do the work stated.
1 -
Signatur- , f /or Condo President
Date:
Ate,_o. Cr/i()
owner and
A BARBARA ANN FUGAZZI
N ' . * COMMISSION NUMBER
y ' ,a . a CC360191
5 �c cp MY COMMISSION EXP.
** * * *F f\ * MAR. *29 19t3 * * * * * * * * * **
RADON C.C.F. W 5 NOTARY TOTAL DUE ;
Notary as to
My Commissio
FEES: PERMIT (
APPROVED:
Zoning
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
n
Phone 3
300 -
Signature of Contractor or Owner- Builder
Date:
Notary as to Contractor or Owner- Builder
My Commission Expires:
SIGN
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Mechanical Plumbing Engineering
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