920 NE 100 St (5)Date �.Z /0 ,43
Job Address
Legal Description '9" q
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
C Owne >/ Lessee / Tenant /,C,f/i1.4'L /�i574:74v,>c,
4x)/04,w' f/ Tax FolioJl 1Z4 ,4 Meg
/7" otyLeie
Master Permit #(10
Owner's Address MO .vim ,' _ / J7 , ., Sila�r -s F/ jW... Phone (305) 7SB -.39Y9
Contracting Co. 3i/ // 44111 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 SIGN
WORK DESCRIPTION ,,- 0 4i 9A( ex/-4,v ARac%4 4404 ya eo .
7522/ /J", 64) ' / 7 4 / / / 6 ' d o ,51.0z — ( - — ...401.4e /9 /,v
Square Ft. Estimated Cost(value) 1 600. o
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.
ignature of o, er and /o ondo President Signature of Contractor or Owner- Builder
Date: /z/0'0473
•ta y as to Owner ab,
y Commission Expire;
fr. JOSEPHINE CRUNCH
- ' 4 %
ca '
r•n . .
:.� 4 ' °;' Na CC19754S
f ora
Date:
Notary as to Contractor or Owner- Builder
My Commission Expires:
** * * * * * * * * r V * * * L * * *
FEES: PERMIT J ' O # RADON C.C.F. < <7 a NOTARY - e/// TOTAL DUE ■0
Fire Other
APPROVED:
**
Zoning BuildinZ- 7/-7 L Electrical
Mechanical Plumbing Engineering,
,u
N.E. 100TH STREET
100' P. /W.
1010.00' M
11 100.00'14
9'ASPSALT • ALLEY
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