10790BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PER IT
Application is hereby made for the approval of the detailed statement of the plans and speciflcationt herewith , .mi . for the build-
ing or other structure herein described. This application is made in compliance and conformity with .e Buildin Or. .: ce of Miami
Shores Village, Florida, . and all provisions of the Laws of the State of Florida, all ordinances of 110 Shores V : ge and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein r waled or n . A opy of approved
it plans and specifications must be kept at building during progress of the work.
Owner's Name and Address t
S l'�p
Registered Architect and /or Engineer
.Name and address of licensed contractor 1 Wt tb B OP>
Location and legal description of lotto be - built on:
Lot Block, Subdivisi
Street and Number where work is to be done
State work to be :done and purpose of building (by floors)
and for no other purpose.
New Building Remodeling Addition a
$epairs o. of Stories
To be constructed of Sind of founda i
Estimated Total cost of improvements $_._, ( Amount of Permit $
Zone cubage required Cubag-
Distance to next nearest building Size of Building
Maximum live load to be borne by each floor
The undersigned applicant for this building permit does hereby certify that he understands and a « - ... his obligatioonnS as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5968, Compiled General Laws of orid'a, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or b- 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 . erfo ]ned under this
permit, as are licensed by Miami Shores Village.
01.
Remarks �... T
STATE OF FLORIDA,
COUNTY OF DADE. s
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, d that all facts
therein by him stated are are true. ,
Permit No t O V 1 Date — q e S
Building Inspecto
PLANNING BOARD
Disapproved
(Signed) awls
Chairman Member
Member. Member
Member Member
Council Approved Date Disapproved
NOTE: A charge of 01.00 will be made for malting corrections or changes to this application after approval has been obtained from
the Planning Board. _
A re- inspection fee of 01.00 will be charged when such re- inspection is made necessary by irnproer notice for . ....o or faulty
materials and /or workmanship.
Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
My Commission - Expires
DATE
to ine well known,
Date
ez-leci
1
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