10827MIAMI 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 build-
ing or other stricture 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 Arch_tect and /or Engineer
1 Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot Block Subdivision
Street and Number where work is; to be done f g
Date ` ,19 °y /
No. ? Y3 g Street_ t /. *1-
IIIF�_ si' -,._
State work to be done and purpose of building (by floors)
and for no other purpose.
New Building Remodeling Addition Repairs - No. of Stories
To be constructed of__ Rind o oundationn Roof Covering
Estimated Total cost of improvements $ ! Amount of Permit $
Plan Cubage
Distance' to nest nearest building - Size of Building Lot
l
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
Zone cubage required
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 Workmens Compensation Act, being Section 5988, Compiled General Laws of Florida, Permanent Supplement,
and has compli with the provisions thereo , and will require similar compliance from all contractors or sub - contractors employe( by him
in the work to performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
permit, as are licensed d by the Shores enders employ only su - op. bcontiactors, on . work to be performed er this
or notices as ar required by the Act. The undersigned agrees to snip
Remarks (Signed)
STATE OF FIJORIDA,
COUNTY OF ADE.
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 /t 2 7 Date L ® 7., `;- Read, Sworn to and Subscribed before me.
Disapproved Date
Notary Public, State of Florida
(Signed)
Building Inspector My Commission Expires
PLANNING BOARD T)ATE
Chairman Member
Member Member
Member Member
Council Approved Tate Disapproved Tate
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
materiaks workman�Mp.
OERTIFI aArE OF A PPR
rhl that final napes i rapairs dOM
been pile d t awsci $o eamply ttli►a Oode