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1041 NE 93 St (6)tOES - 1:k& Street and Number where work is to be done Disapproved (Signed) MBAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT AFFLlC TION FOR BUILDING PERMIT Application is hereby Made for the approyal 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 ^omplianee and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State o f 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. Date , 19 Owner's Name and Address !Ai k 04 I Street e 9 Registered Architect and /or Engineer �� t Name and address of licensed contractor Q. ZA-C.) 1 N--L■■( to9 '5 Location and legal description of lot to be built on: Lot Block Subdivision _ 0 04 I NJ- 9 s°t. State wo to be done and purpose of building (by floors) PaL 1 UJ&A• 10 L Cr `'— ©wt_ A OP -_s7r , C-® tom¢ and for no other purpose. New Building Remodeling Addition Repairs No. of Stories To be constructed of 1<Cind of foundation Roof Covering Estimated Total cost of improvements $\---- 1_ g CDC) Oc7 Amount of Permit $ > • C 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 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 pennit 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, Pennanent Supplement, and has complied with the provisions thereof, and will require simil:.r compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cau..e 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 subco on work to be performed under this permit, as are licensed by Miami Shores Village. Remarks (Signed) e_ l'A___. 1 7/4 x_.Ls (c. / STATE OF FLORIDA, c.,...-/').-.c.,...-/').-.1; . y f/ e-�.,._, /c,d'_ COUNTY OF DADE. i 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. 7 / Permit No .__ 75 Date___ —! �iP .._______ _ Read, Sworn to and Subscribed before me. Notary Public, State of Florida uilding Inspecto 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 correctior s 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.