11715Disapproved
( Signed)
Chairman
Member
Member
Council Approved
MIAMI SHOR SIVILLAGE
BU LDI NG INSPECTION EPARTMENT
APPLICATION FOR BUILDING PERMIT
Building
ctor
LANNING BOARD DATE
- Member
Member
Member
Date Disapproved
Notary Public, State of Florida
My Commission Expires_______ ____ __________
Application is hereby made for the approyal of the detailed statement of the plans and specifications herewith submitted for the build-
ing or other structure herein described This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
Date_ tif_Ahr , 19.40"
Owner's Name and Address_840,/ es/4 e No. /13, 4 Street_&4 'P' l e
Registered Architect and/or Engineer .84
Name and address of licensed contractor 0 1' 44'04 44 el /33 0 WO/ e
Location and legal description of lot to be built on:
Lot_ Block Subdivision_
4 /e_ Street and Number where work is to be done 3 oo We 2 W
State work to be done and purpose of building (by floors) PA I S C zLt' !?ti,' 7 e
and for no other purpose.
New Building__ ________ Remodeling_ Addition_ Repairs No. of Stories
To be constructed of_ Kind of foundaticm,,, Roof C.2vering
Estimated Total cost of improvements $.
Amount of Permit $ 1.
Zone cubage requirecL _Plan Cubage._
Distance to next nearest building_ Size of Building Lot_
Maximum live load to be borne by each floor__ _ _
Thereby submit all_the plans and specifications for said bnilding_All nottePs with_reference to the building and its construction rnav _
be sent to_
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub-contragors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks_ (Signed)___ _
STATE OF FLORIDA,
COUNTY OF DADE. ss *
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Permit No. Date
Read, Sworn to and Subscribed before me.
Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from
the Planning Board.
A re-inspection fee of $L00 will be charged when such re-inspection is made necessary by improper notice for inspci don or faulty
materials and/or workmanship.