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MIAMI 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 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, whethe erein specified or riot. A copy of approved
plans and specifications must be kept at building during progress of the work.
/
^^ � c ^ Date 1 G
Owner's Name and Address ' 1A'W ✓ L3 L` N' . �
Registered Architect and /or Engineer 4 ___ H. • t�
Name and address of licensed contractor ,:
Location and legal description of lot to be uilt on:
Lot 18- t c "• z 0 Block _ i _____�__ $u� ivision
Street and Number where work is to be done
State work be done and purpose o building ( y floors)_
4_r_7.✓ t 46 osa. s,... ,,Le,.. t. „”' , ot.41.¢3
Ntw Building Remodeling Addition Repairs No. of Stories
and for no othei purpose.
To be constructed of_ C . 3 Kind of f undation 151 . 1XVh f Covering 1 I ,,_ .
,ry O 0
Estimated Total cost of improvements $ Slt2't Amount of Permit $
Zone cubage required _Plan Cubage
Distance to next nearest building %.P y 1L— Size of Building Lot
I 0
Street__
19 "
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 5960, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and. will require similar compliance fr •. a contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted or i . pection on the site of the ,, such public notice
or notices as are required by the Act. The undersigned agrees to employ only such sub •ntractors, on work to bs •er ormed unc r this
permit, as are licensed by Miami Shores Village.
r i
Remarks (Signed) ! (
STATE OF FLORIDA,
COUNTY OF DADE. j 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 fir's duly sworn, upon oath deposes and says that he is the
of the above describ_ fd con Unction, that he h s c refully read the foregoing application, and that he did sign the same, and that all facts
therein by him • • tecd�(are tr e. .
Permit \'o.__,_ � ___ Date_ Alt ta TV / Read; Sworn to and Subscribed before me.
Disap oved Date
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( Signed Notary Public, State of Florida
- _.!
Building Inspe r 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.