15810BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval 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 piipgress of the work.
Disapprov
(Signed)
Building Inspect
Chairman
Member
Member
Council Approved
NOTE: A charge of $1.00 will be made for
the Planning Board.
A re- inspection fee of $1.00 will be charged
materials and /or workmanship.
MIAMI SHORES VILLAGE
Date.....»........._..... -..�.0 _ ..19 Z
Owner's Name and Addres
Registered Architect and /or Engine(
Name and address of licensed contractor I: _.1
Location and legal description of lot to be built on:
Lot .... Block... ...._... Subdivision
Street and Number where work is to be done
State wok to be done ar4 purpose of b ilding (b floors ) •'' S ■=2.- 5 awiti � - / �✓
(),
New Building Remodeling 4 ,
To be constructed of Kind of foundation
Estimated Total cost of improvements $..,1 � �� __.__ Amount of Permit 5,....._ . :
Zone cubage required _ _ . __ -plan Cubage
Distance to next nearest building _.___._ ...Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to
The undersigned applicant for this building pennit 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, Pennanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors employed by hint
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, o ' work to be perfo ed under this
permit, as are licensed by Miami Shores Village.
Remarks.
(Signed)
__.. _ _.._. ..__., .._._. _...... ..... for no other purpose.
Addition Repairs No. of Stories
Roo ®Covering
STATE OF FLORIDA, I
COUNTY OF DADE. f ss
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
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 O true.
Permit No. _ .
` _Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
My Commission Expires
P NNING BOARD.-_ .__..._DATE
Member
Member___ _._._......._ .
Member
Date Disapproved .. _...
making corrections or changes to this application after approval
when such re- inspection is made necessary by improper notice
t � s c ' L ■ (iJDS i 2 tc
to me well known,
Date
has been obtained from
for inspection or faulty