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PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address -�— C o r(/. Zo r- Tax Folio
Legal Description - - - -- r - —
Owner / Lessee / Tenant s
Z. Master Permit #
Owner's Address ✓� ��/03 ��'l ����� Phone
Contracting Co. /4o e'S 'ar, AddressI-A lf-F 17,—
Qualifier /Xl'& / e�/x SS 4 Phone,--?ef--
State 0�PA'009/3 Municipal # Competency # Ins.Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDI G ECTRI L PLUMBING MECHANICAL ROOFING PAVING FENCE SIG
WORK DESCRIPTION
or
Square Ft. Estimated Cost(value)
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO D,
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEN
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOU.
NOTICE OF COMMENCEMENT) .
Application is hereby made to obtain a permit to do work and installation as indicated above, an
on the attached addendum (if applicable) . I certify that all work will be performed to meet th
standards of all laws regulating construction in this jurisdiction. I understand that separat
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 wil
be done in compliance with all applicable laws regulating construction and zoning. Furthermore,
author' a the 0abo -na d co ractor to do 'the work stated.
GGA
S' ure er and/or n o Pr sident Si ature of Codiract Owner-Builder
Date: Date:
�.Npi B B
�By
f1 - 'CY 4",J .�-.- 1
Notary as to ltd o ; ; F; es'id nt Notary +' ;> njr uilder
M Commission° � ` lhru Nay P�9c UrtCcrwrf nre M Commas °
Y y x i- S°JM4,2000
7htoNmyPui�llndsxniters
** * * * * * * * * * * * * * * * **
FEES: PERMIT d✓Q_ RADON C.C.F. NOTARY TOTAL DUE
APPROVED: Fire Other
Zoning Building Electrical
Mechanical Plumbing Engineering