584 NE 102 St (12)Date
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
9� Job Address 5 04 / -le, / S') Tax Folio // 3a 1? /a/ GI-
Legal Description / y a el /// / g 1 L -
Owner / Lessee / Tenant P z,c�C F' 'nQL Master Permit #5 #5
Owner's Address 3 V 17 t' AO Phone
Contracting Co . °P /C_ PYC Address :3v 6 7
Qualifier/60"A/672- e_ C4
Ss# ` Phone 62 7 -6:v& ,2
State Ite* Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Compahy Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBIN
WORK DESCRIPTION % /z-i_ 4 / 77 »'L of -
3 7z7N 7 2 / ,vz /0It
Square Ft. f 1 (J' (7
APPROVED:
*
- Cc,e, G /.(-/Lv
Estimated Cost(value)
ROOFING PAVING FENCE SIGN
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 complianc- with all ap licable laws regulating construction and zoning. Furthermore, I
authoriz he, : ov: name cont rcic`yt to do the work stated. ---
( v
Sign tur of o er nd /or Condo sident l/, _-Sr( nature
Date: Date'
/d /O#
trr
r Owner- guilder
JO/4
Notary as to Owner and /or Condo President
My Commission Expires:
N OTARY' f%IBLIC ST3i 07 PLOfIDDN
HY C ".Lselaa E ;:a. VA/1.27,1994
** T J G2* ,RAL W . UND. • :
• 1
FEES: PERMIT 7 RADON C.C.F. /0 O NOTARY TOTAL DUE �✓ �,
Fire Other
Building Electrical
Plumbing Engineering
/ J '/0
Notary as to Contractor or Owner - Builder
My Commission E x STSTR 07 aL°�R:D<1
GOIMSsIG:7 E;;P. t 9:^a.27,1s$0
BGirDED Mall G%ti_:R ^ . 4:•4:4 !SD.
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