830 NE 91 Terr (12)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 _.;. .i
Registered Architect and /or Engineer
Name and address of licensed contractor
Locat � io �� es
and ,gal gal descri i on of lot to be built on:
Lot. - !.Z Q �% Block 3
Street and Number where work is to be done..
Building Inspector
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
/ Date
F
Subdivisio -.. _ __ /�R
it 9/ 7 •
New Building Remodeling Addition
To be constructed of Kind of foundation,.
State wo-k to be done and purpose of building (by floors)
and for no other purpose.
Repairs No. of Stories
Roof Covering
Estimated Total cost of improvements $ 1 Amount of Permit '0
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 bmit all ds plans an ifications for said bui] ing.. AAlrll notices ith refere th siding and its construction may
be sent to.._U.Y.. "� CC`_- 7J �
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 po inspection on the si - of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ onl such su cor4ract. , on w to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks ( Signed
76—
r r
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
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) ..
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.
�.. am .
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