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1094 NE 91 Terr (5)(Rev. 10/02/03) RE- OCCUPANCY APPLICATION RE El ilik 1 25 Date J '+y a i .29005 Contact Name 0 M q S °t - y IT_ Phone # 73 ^. C',s Buyer Seller Realtor Uc ,� / Company Name eqn V i- ' w ,l�i'i/ y Property Address /0 9'1 /V , e Y_ City Miami Shores State Fl Zip 3 3 1 3 I hereby certify that I understand that the zoning of the property is for single- family residential use and that it is unlawful for more than one family to reside therein. I also understand that any Certificate of Re- Occupancy that may be issued by Miami Shores Village certifies only that the referenced property is being used for single- family purposes and that such Certificate does not constitute any representation, warranty or certification as to the condition of the dwelling or other structures on the property. OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate. k Applicant Name produced NOTAR PUBLIC: � k—a v ✓�_ The foregoing instrument was acknowledged before me this 21 day o , 20 us by 10 r f2zD -2 , who is personally known to me or who has Sign: Print: My Commission Expires: Building Officials Approval: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795-2204 (305) 756 -8972 Permit No. Z - J ‘2'3 Loc ID as identification and who did take an oath. Re -Occ. $60.00 / Notary $5.00 CCF $0.60 Total , Applicant Print Name APPLICATYJN FOR CERTIFICATE OF RE- OCCUPANCY I, tu , hereby apply fora certificate to re- occupy the single family residence,known as : (address) , Hand Shores, Florida. 33 /35 • Legal Description: Lot: Block PB & PG: I hereby certify that I understand that the zoning of the property is for single-family residential use and that it is unlawful for more than one family to reside therein. I also understand that any Certificate of Re= Occupancy that may be issued by Muni Shores Village, certifies only that the referenced property is being used for single -family purposes and that such Certificate does not constitute any epresentation, warranty or certification as to the condition of the dwelling or other structures on h property. * * * * * *Al * * * * ** *** * * * ** * * * * ** *** **;* s *= w r * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** For purposes of conducting the inspection required by Section 902 of the Mani Shores Land Development and Zoning Code, please contact: Contact Name: Telephone: b uyer Seller _ Realtor Company Name Check No. Approved Denied Date c -- ° t/c 4c &Pplication Fee (550) paid: Cash PAGE I OF 2 Date l$ © 3 i • CERTIFICATE OF RE- OCCUPANCY 1 On behalf of Miami Shores Village, Florida, the undersigned certifies that the property d4senbed in the above application has been inspected for purposes of re- occupancy pursuant to Sections 901.and 902 of the Miami Shores Land Development and Zoning Code and that such property may be re occupied by the above applicant for single - family residential purposes. • MAME eRES By PAGE 2 OF 2 Date of Certification: ORIDA (9H .a 3 THIS CER 1 ii• ICATE VERIFIES THAT THE REFERENCED PROPERTY HAS BEEN INSPECTED BY MIAMI SHORES VILLAGE AND HAS BEEN DETERMINED TO PRESENTLY COMPLY WITH THE SCHEDULE OF REGULATIONS OF THE MIAMI SHORES LAND AND DEVELOPMENT CODE PERTAINING SOLELY TO THE REQUIREMENT THAT EACH ONE - FAMILY DWELLING IS USED AND INTENDED TO BE USED FOR A ONE - FAMILY DWELLING PURPOSE ONLY; HOWEVER, THIS CERTIFICATE DOES NOT CONSTITUTE ANY REPRESENTATION OR WARRANTY AS TO THE CONDITION . OF THE DWELLING OR OTHER STRUCTURES ON THE PREMISES DESCRIBED HEREIN, OR ANY ASPECT OF SUCH CONDITION,'AND INTERES 1 EL) PERSONS ARE ADVISED AND ENCOURAGED TO MAKE THEIR OWN INSPECTION OF THE II PRE SES IN ORDER TO DE 1 �RMENE THE CONDITION, THEREOF. MIAMI S ORES VILLAGE BUILDING DEPARTMENT rI w 305- 795 -2204 Building Inspection Request D /ZS /06 Type Insp'n 2 � - ccc)upci Permit No. O 2005 — /r°3 l Name A lc x l s - Address 10 a 4 N- E c Company Phone # C18(:)) 897 — 8 S Inspection Date 1 z6 v5 Approved Correction Re- Insp'n Fee LeAsA,. n ssAG . ! r�o bcDc. ca retie r Approved Correction MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date Type Insp'n Tit /� , In vrc91PS3 Permit No. 8Pj CO3 — D Name J O cyt (�/ 1 PP. Q � Address tO -I ll - I I 1 r � Company I.Ouu i 'P 1.._ Phone # 0, 754 (2( q For Inspector: 5 9 Name & Date Re- Insp'n Fee ❑ w(2uNco ACOCESS 3 (0 5 Ole OUAPI MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date db _93 Time n , Type Ins )) Permit No. P 03 I o� b I Name _ Address [ 09 . 'j ` C, l 1 Company Phone # For Inspecto 0 3 4 Name & Da Correction Re- Insp'n Fee ❑ /2 ` a G 6-r 6 ff - C�� Date f7-, Time Type Insp'n Permit No. e6 .cO — a-`U ( Name Address \o `"1 4 ` I Ter r Compan \CouVe Phone # For Inspector: 1) Name & Date Approved ❑ Correction Re- Insp'n Fee MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request 0 3 MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date Type Insp'n F' rG I 99AI YY- Permit No. 6Paoo7)- \46 Name JO 1 0 Address e"I Y" E q te r Company 00)(\91K • Phone # Inspection Date Approved Correction Re- Insp'n Fee W16 MIAMI SHORES VILLAGE gu y BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date? I a5 Type Insp'n 'e — Ot-CC. Y Permit No. 20 Z - /b3 Name - r tDr-1 S Da +pr Address Company °CC n cu-) V i C Phone # (18) 891 — 688.5 Inspection Date 7/ L2 /c S Re- Insp'n Fee 1094 HE 9 1 Tc_rr. Cci I . ore qo . . Vee4 C-c& c� a tc( I YC aWOr v 3331 MIAMI SHORES V,ANillAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date �"I g Time - Type Insp'n F 1 1 1 'e Permit No. Ap03 - ` 1'T4� Name \t)(1b JvS +b Address 1 Co + NE g I Company Phone # For Inspector: Approved Correction Re- Insp'n Fee 305. 75 +.O1gI Name & Date (1<v . 04/24/031 Address 10c94 c' 2 _ City Miami Shors The following, .7; ;:. - * rt pf Re-Occupancy This certificate verHies and has been determined re • Land and Development Coth. Building Officials Approval: _ ' S V illage • • Tartment );cupancy _ Zi 10050 N.E.2nd Avenue - Miann F1crrida 3 13 Tel: (305) 795-2204 Fax: (305) 756-8972 Permit No. ZO Z.CCS— 1E:33 Date 7/22.105 been inspected by Miami Shores Village '1-the iicheduif... regulations of the Miami Shores Tile requirement that each one-family dwelling is used and intended to used for a purpose only; this certificate does not constitute any representation or ti,'t condition . of the dwelling or other structures on the premises described hertin, aspe.r.::: of 1 condition, and interested persons are advised and encouraged to make their own the premises in.,order to. determine the condition thereof. MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Datee Type Insp'n 'r'Q (C.( 1'€ Bab- Permit No. rS3 V °-c1 ` Name C_)(- Address IV"t ( A N Company Ci 1 'e Phone # Inspection Date Approved Correction ❑ Re-Insp'n Fee ❑ OWNER'S NAME R jer+n5 J Z 0 r ,3 PRESENT ADDRESS c c . 7 Tee- t _ LICENSE NO. az43 PHONE NO. r JOB LOCATION (ST. OR AVE.) toy 4 NI. Lt. 5 =r eiz�e LOT 12 BLOCK SUBDIVISION 2 1 6 , J47E/a.scr,G F GENERAL CONTRACTOR 11)&0 Ai.te ■,,• • , O e <, ADDRESS PHONE NO. LICENSE NO. BUILDING PERMIT NO. ,r49 0 DATE j PERMIT FEE $ JO BUILDER'S BOND NO. Z 3' Vi DATE 2- Z- J / ZONE / to REQUIREMENTS ere O CU. FT. PLAN CUBE 21,4/ CU. FT. EST. COST 1 --: � O O `� / �",� � 'e'e- <_ DRAWINGS. SPECIFICATIONS. RESTRICTIONS AND CUBE CHECKED BY 4 K, - DATE v �j , z r/ NEW CONSTRUCTION TYPE CPSS' 1 STORIES D u'E ROOF CONSTRUCTION INTERIOR CONSTRUCTION / Gc - L7454C4W200 - 2 d'.,,- / REPAIRS DESCRIPTION o'rC EC. 7 G4'f re"....n .e - A4 $ ,4..9... .c. .3 f ee CC.galC --. ALTERATION DESCRIPTION ADDITION SUBMITTED TO PLANNING BOARD APPROVED REJECTED REFERRED TO COUNCIL REASONS RE- SUBMITTED TO PLANNING BOARD SUBMITTED TO VILLAGE COUNCIL REMARKS CERTIFICATE OF OCCUPANCY NO. . 4 . ISSUED BY TO l'• • , V ' ` �\ BUILDING PERMIT AND INSPECTION RECORD -MIAMI $l -IORES VILLAGE INSPECTIONS I DATE DATE INSPECTIONS TEMPORARY SERVICE DATE BY FOUNDATION AA � -4- ' B A Y c,; ROOF S SEWER S BEAMS & LINTELS $ POOL $ RANGE CONN. $ FRAMING SEWER MOTORS AIR COND. $ FIXTURES FINAL SEPTIC TANK S CLEAN UP S ' SLAB SOLAR HEATER F.. J,Jd437t 0 % C .. _ _ _ SLAB FIXTURES SPECIALS PERMITS PERMIT NO. DATE FEE TEMPORARY SERVICE RE- INSPECT BY S SEPTIC TANK Cr - �O 'Z- I S SEWER S TUB & TOP OUT $ SOLAR HEATER $ RANGE CONN. $ GAS SEWER MOTORS S $ FIXTURES c INSPECTIONS DATE BY RE- INSPECT BY RE- INSPECT BY ROUGHING C .t, _- alp,, Cr - �O 'Z- I S(" 63. ! , ✓� l4 S TUB & TOP OUT RANGE CONN. $ RANGE CONN. , SEWER MOTORS $ FIXTURES SEPTIC TANK S S ' SOLAR HEATER FIXTURES GAS CONTRACTOR PHONE PERMIT NO. I DATE FEE S NEW BLDG. I ALTFRATION I ADDITION REPAIRS SPECIAL PERMITS PERMIT NO. DATE FEE TEMPORARY SERVICE H. W. HEATER CONN S H. W. HEATER CONN. RANGE CONN. $ RANGE CONN. S MOTORS $ FIXTURES FIXTURES & FINAL S S ' INSPECTIONS DATE BY RE- INSPECT BY RE- INSPECT BY TFMP. SERVICE ".4.,,,,,..) r.. J g - ... 2 -IJS'E ROUGHING H. W. HEATER CONN RANGE CONN. FIXTURES & FINAL BUILDING INSPECTIONS F CONTRACTOR PERMIT NO. NEW BLDG. PLUMBING PERMITS & INSPECTIONS I DATE 1 ALTERATION 1 ADDITION PHONE FEE $ REPAIRS ELECTRICAL PERMITS & INSPECTIONS APPROVAL TO POWER CO. FOR SERVICE DATE BY • 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 progress of the work. Owner's Name and Address.... _ _ (' Registered Architect and /or Engineer f er:v- 2 L( Name and address of licensed contractor C Z 'A t• Location and legal description of lot to be built on: Lot .1 Z Block , . Subdivision Street and Number where work is to be done 4 State work to be done and purpose of building (by floors) Chairman Member Member Council Approved Building Inspector 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. .�i G iii= c MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT Date Z/ re,,e I' 3 , ,4P.e4/ and for no other purpose. New Building i Remodeling Addition Repairs No. of Stories To be constructed of_ e. >_6 ! Si Kind of foundation C t Roof Covering T/ Z.. A Estimated Total cost of improvements $ /Pt ,t (2 el Zone cubage required_- __2_as_�cP Distance to next nearest building >/® / Maximum live load to be borne by each floor 4 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 )/ 44. i '*''9 o r kt1 7 "W'C', The undersigned applicant for this building permit dries 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 - contractors 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 Amount of Permit $ plan Cubage Size of Building Lot No Street /'5 C -3 4 permit, as are licensed by Miami Shores Village. Remarks_.._ (Signed) 4 ' U - % g ) - . Notary Public, State of Florida t i ,1959 STATE OF FLORIDA, COUNTY OF DADE. ss Before me, the undersigned authority, ,a a r notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared 0 ,6 ® r4� `` /5 fV / 7 f /J��' u y 6' 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. Disapproved Date (Signed) My Commission Expires PLANNING BOARD DATE Member Member Member Date Disapproved Date making corrections or changes to this application after approval has been obtained from when such re- inspection is mlde necessary by improper notice for inspection or faulty r e� 1 , si, A/ b h o / / 3 n � 1675c 71 1 • J. B. FORD CO. 1774 W. Flag ler Street MIAMI 35, FLORIDA Phones: FR 9-3508, FR 1-0027 2 • 4 6 7 8 `-) rc C Z1 / /50 ORDER NO.2/09-5 FOrf , A 7 CA 7 7.E7.5 li Pef / V S - I HEREBY CERTIFY that the attached sketch represents a survey made under my direction and is true and correct There are no encroachments except as shown. _ • REGISTERED LAND SURVEYOR . 1128 STATE OF FLORIDA TE2 9. 5 \ 0 /0 1 /1 4L %, /5 (9 \ N \ 1 L L 9 /5 r. . 9"-it T _5T , l'ai ) o F. B.26 -28 :0 r v,/947cA/Ar/9 (1) . 435' • .5 20 _ _ 7-Fy.. 1 25'0' I C 222 5_2 ■() / .3 0 ,SVXT Y. E. 9-15T ST. WA .T.LE7-`15E2) According to the Plat thereof as recorded in Plat Book 9 Public Records of Dade County, Florida. Date , at Page /4/ J c STATE OF FLORIDA) SS COUNTY OF DADE ) A F F I D A V I T ) 7/7 of the Village of Miami Shores, County of Dade and State of Florida, being duly snorn, doth depose and say, that under the provisions of Ordinance No. 185, dated June 15, 1948, amending paragraph (d) of Section B -368 of Ordinance No. 97 of the Belding Code of Miami Shores Village, he desires to build a L57i e C )// L. / 4i ( 3 on Lot J y Block 'Y of and will be the owner of said P a . 1 , that he Brill do the work personally, and that he will, at such times as are required by the Zoning and Building Director: - - Subdivision, that he is the owner of said property, 1. File plans and specifications and obtain approval of the Planning Board and the Building Inspector. 2. Apply for and secure a Permit. V 3. Pay the required fees. 4. Execute the work in accordance with the provisions of this Code. 5. Apply for inspections. 1 6. File with the Building Inspector certificates that provision has been made to carry the necessary Workmen's Compensation, Public Liability and Property Damage Insurance. ,o 7. File with the Building Inspector as the job progresses certificates showing the payment requires. by the Federal Social Security Act to the State of Florida or the United States of America. 8. Assume the responsibility of not employing other than properly licensed contractors by Niami Shores Village for any part or portion of the work. / 9. Not set himself up as a "contractor ". / 10. Sign an affidavit before commencing work to the effect that he has read this Article and will do the work personally and observe all of the requirements of the Building, Electrical, Plumbing and Zoning Codes of Miami Shores Village. Such affidavit to be properly notarized upon blanks to be supplied by the Building Inspector. ✓ 11. In order to prevent abuses and subterfuge the right of such owner- builder as herin provided, is limited to but one o :•ser- builder permit each 2 years, and where an owner - builder has once exercized the privilege '.harein conferred no second' ar.plica- tion for owner- builder peg: v?it shall be granted in less than 2 years, unless the applicaLt is qualified as a licensed General Contractor under the applicable Ordinances of said Village. ✓ And Further this Deponent says not: SUBSCRIBED AND SWORN TO BEFORE ME this O.1 4i day of 195. NOTARY PUBLIC A•D., Per a Y . t. r •.. t. 11 •1.1 •4■AZD,■•1.11•J1141:e41• 1: 1■+1 •.'y1 1 1•. VILLAGE OF MIAMI SHORES Building Department L Miami Shores, Florida • _ 1 • ..... 4 CERTIFICATE OF INSURANCE aci iii 1 t0 - lsztift that the following policies have been issued by the Continental Casualty Company and are in at the date indicated below. Name of Insured JOHN J. ROTH P. O. Address of Insured 915 N.E. 91st Terrace, Miami Shores Florida In the event of any material change in or cancellation of said policies the Continental asua t C ompany will xiadit send notice of such change or cancellation to the certificate holder at the address shown herein, . Y.IO 4111 11.. •..,` 41!1 N.1,11414 I* 0;•r aV •41 k ir terjalthEDCURNOW,COMCSadrantiatX Nothing herein contained shall be considered as in any wise modifying any provision of said policies. Dated at Miami, Florida this 28th day of January 19 59 p To cancellation notice will be sent 10-days prior to such cancellatiin by registered mail. CONTINENTAL CASUALTY COMPANY, job: Lot 12, Block 2, Watersedge BALDWIN I*SI A ENCY, Incorporated By `� J Authoriz e4 ent WORKMEN'S COMPENSATION WC 4212072 3 -17 -59 Policy No WC 4212257 ; Effective Date 3 -1 7 - 5 8 Expiration Date Workmen's Occupational Employer's Limits: Compensation $ Statutory; Disease $ ' Liability $ Description and Location of Operations or Work Covered job: Lot 12, Block 2, Watersedge 3 - 17 - 60 3 1 7 - 52_ MC 2804795 PUBLIC LIABILI CAer than Automobile) 2 - 1 3 - 59 Policy No. __ C 33)1t270 ; Effective Date- -13 -59 Expiration Date 2 -13 -60 Limits of l B.I. $ 100 ,000 each person; $ 300,000 each accident; $ aggregate Liability J P.D. $ 5,000 each accident; $ 25,000 aggregate Description and Location of Operations or Work Covered AUTOMOBILE LIABILITY Policy No. ; Effective Date Expiration Date Limits ofi B.I. $ each person; $ each accident Liability 1 P.D. $ each accident; Medical Payments $ each person Description of Automobiles Covered FIDELITY, BURGLARY, PLATE GLASS, INLAND MARINE Policy No ; Effective Date Expiration Date Limits Special conditions, if any ig i V Uertificate of insurance M -2343 D Printed in U.S.A. 5/2/58 THIS LICENSE MUST BE DISPLAYED IN A CONSPICUOUS PLACE A PENALTY IS IMPOIEt POR FAILURE TO KEEP THIS LICENSE EXHIBITED AT YOUR ESTABLISHMENT OR PLACE O F BUSIN SS Date Issued MSV/1958 Village THIS LICENSE E ;P' ma aL,Augtsu nss. A 16 ''4. 1st .NO In consideration of the sum of Two*1t1 rive &lac'. a0400 1F14)04 WA •2 ON � � 0 11 ars ($ 23 Paid to Miami Shores Village, Dade County, State of Florida, Jt .. r: *Is* 915 Li .Z. Olat Tern • is hereby licensed to engage in or operate the business of ter "i">III3: i:� m3 :RR :V6 ice`; - ' 104 '3." 9l 'SHORE/VILLAGE, MIAMI SHdRE VILLAGE, FLORIDA By License 3243 THIS LICENSE NOT TRANSFERABLE WITHOUT THE APPROVAL OF THE WLLAGE MANAGER. APC 6 o C e)c: \--7) 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 progress of the work. Registered Architect and /or Engineer State work to be done and New Building To constructed of Member BUILDING INSPECTION DEPARTMENT Owner's Name and Address.... V U �`� Ac Distance to next nearest building SHORES VILLAGE Name and address of licensed contractor___, 6 ...�.� ' Location and legal description of lot to be built on: Lot. Block Subdivision Street and Number where work is to be done purpose of building (by floors � ` -/ (f6.4, ///.4,C; +' - w Remodeling Addition Repairs No. of Stories Kind of foundation Roof Covering Estimated Total cost of improvements $.r er r Amount of Permit $ Zone cubage required _Plan Cubage 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 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- contractors 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 nctices 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. J 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 f i oing application, and that he did sign the same, and that all facts therein by him stated are true. Permit No Disapproved / ` (Signed) 1/ l Chairman Member Date. PP Read, Read, Sworn to and Subscribed before me. Notary Public, State of Florida p Building Inspector /, PLANNIIVc BOARD - - DATE // Street 19 and for no other purpose. My Commission Expires Member Member Member Council Approved Date Disapproved 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 $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship. Tg MIAMI SHORES VILLAGE, FLORIDA BUILDING TE ✓ PLUMBING PERMIT A A . r _ 195. ELECTRICAL r rat e ROOFING ❑ Owner of Building Architect Contractor or Builder Legal Description Lot • 1i Address of Building 1 c' (, • k., T +1 Bl. Subdi- i vision L& c Sq. Ft Y Z! Value of ildroject $ / 0 Z G+0 e < C. • / re t° Work to be performed under this Permit iel t_. 3 s• r •v Q om.. e r,. Amt. of �Q - Permit $ zstf/ This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the application herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and regulations pertaining to the work covered hereby whether shown on the plans or drawings or in tb5 statements, or specifications and that he assumes responsibility for work done by his agents, servants or employees. ,✓ /- • Signed• .0. J l INSPECTO In consideration of the issuance to me of this permit I agree to perform the work c red hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans awings, statements or specifica ' ns submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibili, or done by either, myself, my ent, servant or employee. CONTRACTOR OR BUILDER BY AUTHORITY Wkili is to ltrsti ft that the following policies have been issued by the Continental Casualty Company and are in force at the date indicated below. Name of Insured JOHN J. ROTH P. O. Address of Insured 915 N.E. 91st Terrace, Miami Florida In the event of any material change in or cancellation of said pohcies the Continental Casualty Company will acixicc x orCto send notice of such change or cancellation to the certificate holder at the address shown herein [� ... a u ..Y .:,.. in: .: VV:Q .:N•a <•.• :1•• .1'1.1•�. • fp••,6 JGfi• , 7.t=• pP O P. 4'0:41,00 • :.Rq '. ;t f•��. Nothing herein contained shall be considered as in any wise modifying any provision of said policies. Dated at Miami Florida this 23rd day o�ff nua cellation nritice will be sent 10 days prior r to cancellation J ellation by regi l stered CONTINENTAL CASUALTY COMPANY, MC Policy No Limits of B.I. Liability P.D. Description and CERTIFICATE OF INSURANCE VILLAGE OF MIAMI SHORES, Building Department Miami Shores, Florida 1 WORKMEN'S COMPENSATION Policy No. W�_l�212257 ; Effective Date 3 -1 7 - 5 8 Workmen's Occupational Limits: Compensation $Statutory; Disease $ Description and Location of Operations or Work Covered job: Lot 12, Block 2, Watersedge BALDWIN INSURANCE AGENCY, Incorporated By 0\J n 64'. Agent (`!/ moo- Expiration Date 3 - 1759 Employer's $ ' Liability 1 PUBLIC LIABILITY an Automobile 2804795 � ,�' 2_13 -59 MC 3,3111270 ; Effective Date 2-13-59 Expiration Date 2-13-60 $ 10,000 each person; $ 20,000 each accident; $ aggregate $ 5,000 each accident; $ 25,000 aggregate :?! Location of Operations or Work Covered job: Lot 12, Block 2, Watersedge 3 AUTOMOBILE LIABILITY Policy No. ; Effective Date Expiration Date Limits of B.I. $ each person; $ each accident Liability 1 P.D. $ each accident; Medical Payments $ each person Description of Automobiles Covered FIDELITY, BURGLARY, PLATE GLASS, INLAND MARINE Policy No ; Effective Date Expiration Date Limits Special conditions, if any Uerhticate of Insurance M -2343 D Printed in U.S.A. 5/2/58 • MIAMI SHORES WI7LLAGE BUILDING INSPECTION DP RTM ENT APPLICATION FOR BUIL ING 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 progress of the work. Registered Architect and/or gineer Name and address of licensed contractor- 2 Owner's Name and Address. Location and legal description of lot to be built on: Lot Block Subdivision Street and Number where work is to be done. 91 41-Z:• State/ rk to be done an purpose of building (by flo©s)___ t 4- y Q c ff " j5TL/_ ,G / Date No._ -_LLJ L Street____ /� of - r6 ,19rs_f and for no other purpose. New Building Remodeling Addition Repairs No. of Stories To be constructed of Kind of foundation Roof Covering Estimated Total cost of improvements $.jn2,5,' Amount of Permit $ 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 mit all the plans and specifications for said building. All notices with reference to the buildin and its construction may be sent to.. .._2" a---74.--fre....4-(4 r �7 uCc �re.c i ,- 4- .-J 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 - contractors 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) Disapproved r.'> (Signed) Mi Building Ictor DaG_ 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 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 — to me well known, Read, Sworn to and Subscribed before me. Notary Public, State of Florida My Commission Expires PLANNING BOARD DATE Chairman Member Member Member Member Member Council Approved Date Disapproved 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 $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship.