PAVINGPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
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Date J ob Address Tax Folio
Legal Description' '"' °` -� 03 Historically Designated: Yes
Owner/Lessee / Tenant
Owner's Address
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Contracting Co. Q t eR Address `�—
Qualifier �- ---` SS#
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING (PAVING? FENCE SIGN
WORK DESCRIPTION
Square Ft.
Sign
FEES: PERMIT
APPROVED:
Zoning
Mechanical
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Burlamg
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RADON
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Address
Mastery/Permit ## —
Phone (30S ) q 2 S
hone
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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. F ermore, I authorize the above -named contractor to do the work stated.
+ e of ogler and/or Condo President Date Signature of Contractor or Owner - Builder Date
1
Notary as Own t to Notary as to Contractor or Owner- Builder Date
My Commission Bcpires: GLADYSI v ij j My Commission Expires:
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC714103
I+IY COMMISSION EXP. MAR 1,2002
C.C.F. b NOTARY S BOND O O ^�
TOTAL DUE 3 4 � b O
Electrical
Plumbing Structural Engineer
Thiarni Sliore�
STATE OF FLORIDA)
COUNTY OF DADE)
The undersigned Affiant, 1 FOP r`/ S LIT r , does hereby attest that the
(property owner)
attached survey, performed by R , T, Rv 1 A sJ o c. _' N C.
(n of surveyor's company)
(O t d
performed on Th AVC h 0 , Z is an accurate representation of the existing conditions and
(date of survey)
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the
property without first providing a survey less than six (6) months old. The Affiant, as property owner, further
agrees to remove or obtain permits for any structures which now may exist on the property which are not
permitted or which may violate zoning or building code regulations. The Affiant further understands that the
existence of any such structures may affect final inspections as applicable to this or other permits..
Further, Affiant sayeth naught.
Witness(sign and print) Witness(sign and print)
// Atdit
• is an operty owner
SWORN TO AND SUBSCRIBED before me this day of
Affiant is personally known to me, produced as identification.
Notary
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htbU :Records of OO,CttunEy,. Fiaris :
.TWPERTX; ... CIRTIFED ti x'" F SATED M0 .AC ..
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