361 NE 102 St (13)of
My Comm
Date - 3 9 7 Job Address
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant Celfatri 4 C a £•J Master Permit #
Owner's Address 36 l Ai. g_ /a; SF Phone
Contracting Co. �,GV fl r[ H Zd-5 2 J 4 .
RC/1/4.i ' !�� //Address . �,,.; 7
Qualifier R0. AS/4 SS � Phone f 0e> - 0 3 7764
State # 06" &lin OVd 5 Municipal # Competency # Ins. Co. PA,-,4±
Architect/Engineer
Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING LECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION � V4 64- "4" Sys e4
e 40.•• oL a o c7Ps
Square Ft. Estimated Cost (value)' Zi 2
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 regular g construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
President
ature of owner and/or
11
1
to Owner an. o Co 1 "resident
ion E
9
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
1
• FFICIAL NOTARY SEAL
MARIE E RODGERS
COMMISSION NUMBER
CC524247
MY COMMISSION EXPIRES
JAN 25 '
3 (Q / F t. C t" oa r, Tax Folio
a te
ate
FEES: PERMIT RADON C.C.F. C ' NOTARY 5 -
APPROVED:
Zoning
Mechanical Plumbing
Building
ature of Contractor or Own
Notary as to Contractor or Ov+ner-Bui • e r_ Date
My Commission Expires: C.7
P Pao o FICi, •
l h <x-
COf^f ^ c C. ',.
- F, �' .° icy cl,; .. �- -.
Electrical
7S7s'S4)8
uilder
Date
BOND
J
TOTAL DUE .5 6..
Engineering