441 NE 101 St (8)02 ,2_D/ PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date — / Job Address 4 i/ /U• 5. / 0 / ST Tax Folio // 2- 0(,0 / 7 r0 (v
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant A4 G //73'ki n gk C pN Master Permit #
Owner's Address '? /E / / S ( Phone 3 O . \� �J ! l .0e
Contracting Co. M ) 7 ST---r .cr, t 7 / S V ' c - c Address ) 7 0-7 /VIA/ 4.-g S7 #// C7
Qualifier 0 /M dc 2 ) I t_L2,--e ss# Phone 78g 33 / C?
State # (cc 0000 f G I 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) 1 t S/ D 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 at
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I unders
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all wor be done in compliance with all applicable laws regulating
construction and zoning. Furthermore, I authorize the above -named contractor to do the ted.
Sign
Notary as to Owner and/or Condo President
My Commissio Aires.
OF
FEES: PERMIT
APPROVED:
Zoning
Mechanical
er . or Condo President
� iitj V 7 Lq/ S Je Line AZ/3/4</i --1
Date
a/
ate
` <o
r NOTARY
to PUBLIC
R. A. CHIN
My Comm Exp. 5/25/2003
No. CC 840214
I 1 Personally Known 11 Other I.D.
6 C.C.F. 1.12
Z� ( c -f
Signature of Contractor or Owner- Builder
Notary as to Contractor o r O wner- Builder
My Commission E
NOTARY ✓0
Building Electri
d addendum (if applicable). I certify that all work
separate permits are required for ELECTRICAL
Are
R. A. CHIN
My Comm Exp. 5/25/2003
No. CC 840214
11 Personally Known 11 Other I.D.
BOND
TOTAL DUE
Date
//y°/
a te
Plumbing Structural Engineer