810 NE 100 StDate /1/1Z-/q? Job Address 5/O// /gOsr, Tax Folio f / 3 DD6o �S
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Legal Description i /L1
Lessee / Tenant aV4//e_i Acv/. , �2 o 6.�i �� Master Permit # «o
Owner's Address g /O O!/, i / /% Ak.141 ; ��ip,�Ps X , Phone 7 c 7 .3 Z / q
Contracting Co. d‘1//ii ',1 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 FENCE SIGN
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 and zoning. Furthermore, I
authorize the above -named contractor to do the work stated.
i /
Signature of owner and /or Condo President Signa of tractor or Owner-Builder
Date: Date: if/ /� � 7 _
Notary as to Owner and /or Condo President
My Commission Expires:
** * * * * * * * * *
APPROVED: Fire
Zoning Building
My Commission
; FEES: PERMIT r ' y°' RADON C.C.F. NOTARY t _3 D TOTAL DUE �� ‘
**
Other
Electrical
Mechanical Plumbing Engineering
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