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For Inspector:
6'(/,/
Approved
Correction
Re- Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Type Insp'n /941r&I G/ . i -
Permit No. L ) 6' 1 /V
Name (.
Address r O3 4 1 �-,
Company r4_ 1 `i ,z.4'(A -,'
Phone # 3e .,W 4 d `'3 7
- 0 L Name & Date
❑ 34747' 7
� MIAMI SHORES VILLAGE
BUILDING 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 building 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.
Owner's Name and Address
Registered .Architect andror Engineer
Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot
,20S /✓E .'7-/ "Jai ' s ,z_. 331.
State work to be done and purpose of building (by floors). state exterior colors (submit samples) ( 0//1- n
P(-ex(' 5 S',1 ` -SGT MivcXed drauh a/G ; SPEO 7704 0'
M M/J e cc- crn ICAO and for no other purpose
Remodeling Addition S(6i✓ Repairs No of Stories
�
hl 41 g ?1/l/
To be constructed of Ple I R;S Kind of foundation Roof Covering
Estimate° Total cost of improvements S t���,DO Amount of Permit S 32 -�
Zone cubage required Plan Cubage
Distance to next nearest building Size of Building Lot
Street and Number where work is to be done
New Building
Maximum live loan to be borne by each floor
51
I hereby , ubmit all plans and specifications for said latuidiag, All notices with reference to the building and its construction may he sent to
5 &E
The undersigned applicant for this permit noes hereby certify that he uneerstands and accepts his obligatons as an employer of Labor under the Flnnaa Workmen
Compensation .Act. aeine Section 5966. Complied General Laws of Florida. Permanent Supplement. and has complied with the provisions thereof. and will require , in:u,:r
:ompuance from ail contractors or sub-contractors employed by him in the work to be performed under this permit: and will post or cause to be posted :or inspection
on the s:te of the work such public notice or notices as are required by the .Act. ;he undersigned agr employ only such s_bcontractors. on work to be pertormeu
under tn:s permit. as are licensed by Miami Shores Village.
Remarks _ (Signed;
STATE OF FLORIDA
COUNTY OF DADE. } ss.
Before me. the unaersignea authority. a notary puolic. duly authorized t administer oaths and take acknowledgments. personally: acpeareu
r ` • BA wbo
and who. being by me first duly sworn. upon oath deposes and say tha‘he iS the 16 Al CO
of the above describe° construction. that he has carefully read the foregoing application, and that he did sign the same. and that all facts tnerem by him stateu are true
Permit No.
Disapprovea
(Signed(
- 10?
Block Subdivision
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Building Inspector
Date
Date
Date
Read. Sworn to and Subscribed betore me.
My Commission Expires
No
PLANNING BOARD DATE
6 /6 19 gdi
Street v//
0
to me wed known.
Votary Public. State of for 'a
tlo42ry Pau, We a Ho1iias
1'1y Comamissiorr Fxpirpc Sept. 1B, 1989
Bondod Thru Troy Fain • Insurance tnc.
Chairman Member
Member Member
Member Member
Council Approved Date Disapproved Date
NOTE: A charge of 525.00 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 $25.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and or workmanship.
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