77 NE 100 St (5)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date da/f Job Address /?/.4" /od Tax Folio
Legal Description No
Owner/Lessee / Tenant / elira.a._ a.44e4.40)
Owner's Address 73 Ak /d el , 5/3y
Contracting Co. /L/ t? 4/ Address .57 rA/ ) , 57= -
Qualifier Qualifier l Z1 SS# / Phone S I -- pdea_s"
State # e 00� 7--- Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING E CTRI ' LUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
4
Signature of own eA
r
Notary as to 0 ,W'
My Commission Expires:
FEES: PERMIT �.J ` Gtr RADON
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 and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Cond. ' FiC1 SEALD ate
JU R 6LES
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• d 4, 10
nSiOriksififiItCC • 0
Historically Designated: Yes
Master Permit #
Phone
Signature o Contractl
t
Notary as to Contract61:4;w "'_ * er - er
My Commission Expires:
Building Electrical
Da
C.C.F. /a NOTARY '`— TOTAL DUE 3- .
APPROVED:
Zoning
Mechanical Plumbing Engineering