410 NE 102 St (10)Date
Job Address `7 12 77,27./42 . Tax Folio / ..9 -0/7 - O&
Legal Description tr f / l\ i' 81 K c?( srn
Owner / Lessee
Owner's Address
Contracting Co.
Qualifier
State #/O1 T✓�i unicipal #
Architect /Engineer
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION
Square Pt.
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.
AA IF
nature _o Towne
Date:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
/ Tenant 6 Master Permit 4 '/ Y15
2 7//40 7, , /O2_,
t
any;
otary asto /or Condo President
My Commission' ;Expities:
NOTARY PUBLIC STATE OF FLORIDA
MY COMMISSION EXP. MAR. 1,1994
** * * *
VIDEO My GENER *L INS. l' ND.
Address/Y,. ZA)
- Phone 95
Competency # Ins.Co
Address
Estimated Cost(value)
Phone 5 '2 9
- LACA,d.40gigkK
a Tn or Condo President Signature of Con ractor or Owner- Builder
Date:
.i/d. =_/wl `4/ .L
otary as to Contractor or Owner-Builder
My Commission Exp irmnARY PUBLIC STATE OF FLORIDA
MY COMMISSION EX'. MAR. 1,1994
BONDED TNRU GENERAL INS. UND,
* * * * * * * * **
FEES: PERMIT I /71/9 RADON C.C.F. l!S 0 NOTARY TOTAL DUE ij
APPROVED: Fire Other
Zoning Building Electrical
Mechanical Plumbing
Engineering