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423 NE 92 St (9)( Signed) Chairma Member Member Council Appr.v STATE OF FLORIDA, COUNTY OF DADE. ss. MIAMI SHORES VILLAGE z wt . 16 , 4® / © / BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMITAet e p Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for 6,bu4 ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Mini 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 prbgress of the work. Date Owner's Name and Address r S� .3 11 • �• . eet_ Registered Architect and /or Engineer d y' State work to be done and purpose of building (by floors) Building Inspect6r PLANNING BOARD Name and address of licensed contractor - - Location and legal description of lot to be built on: Lot / / 4' Block 3 67 Subdivision_ 1 '` Street and Number where work is to be done `� 2 1'1 2 and for no other purpose. New Building Remodeling Addition Repairs No. of Stories ,e Roof Covering ___ 0-,--.-c., be constructed of a s• Kind of foundation__ __ __� P $ + �/ l� timated Total cost of improvements " y`� r / -- --�__ 7 f ?" •' Amo unt of Permit $ � � � i Lone cubage required it ' <-" �. o c� O _ _Plan Cuba 1 " P (! ry Distance to next nearest building �— _Size of Building Lot 1 d x 1 �f e 1 6 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 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 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 performed under this permit, as are licensed by Miami Shores Village. Remarks ( Signed ) __ 2. 1 Z Notary Public, State of Florida My .Commission Expires___ _ 1 ' __DATE 19.4 Before me, the undersigned authority, & 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 C of the above described construction, that he has carefully read the foregoing application, and that he did sign. thin same, and that all facts therein by him stated are true. Permit No t / 1 Date ___ " Read, Sworn to and Subscribed befpreme. • Disapproved Date Member Member Member Date Disapproved 1=_Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtined 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 failty \ tenals and /or workmanship. � \ t / , • • 1 ■ POLICY NUMBER EXPIRATION DATE TYPE OF POLICY LOCATIONS TO WHICH THIS CE APPLIES " '01,5 ,.ii, ...n. ,« :" 1 - •.:7, i71‘. r..-, . ;` .. . '-- , - 1,-, ---:----1, ' ' ' Cy Y4 C : '• ti? '..; " `' ) 7.1.p;. alf!, '' : ':: 21 7 . :":".:rna GENERAL LIABILITY HAZARDS INSURED LIMITS OF LIABILITY COVERAGE A BODILY INJURY EACH PERSON RASH ACHNDENT n ; . 74, % ' " s•I'----4" 7, -" r '''' ,:! ' t %:' , . I. C ' . 4,11 , r !.. :Itnt''71'n ` Cr.!) 1 'rlIn0 tr./0 CO WORKMEN'S COMPENSATION POLICY NUMBER LIMITS OF LIABILITY UNDER PARAGRAPH ONE (13) EACH PERSON AND EACH ACCIDENT. EMPLOYER'S LIABILITY POLICY NUMBER LIMITS OF LIABILITY EACH PERSON EACH ACCIDSNT This is to Certify that n L Special Provisions: 'L? .7:4TS1 7, LFIKERTY MU SECRETARY 13 CLA.A.01APS 6 awsuruacE COMPANY BOST014,, LIASSACHUSEITS a CERTIFICATE OF INSURANCE 1 is, at the date of this certificate, insured by the Company with respect to the business operations hereinafter described, for the types of insurance and in accordance with the provisions of the current policy contracts in use by said Company, hereinafter described. Description of Operations: f rci : ( 3 .- 1 j- 4r r .q`' ri.`:..-, :. .::.:_23t; 7 .;':" 1 ,.1, 4 . '," `-"..::,:i":-? e Z,: - .. tilt (1" !_,''..- . —, ;._';.-.. r,...,' ,r';:'. 1 ...•2: ' '':,)".. ''! s.' ."; i": .."" :: l' t, ,V1: 4 LISt. i ,ed/e'Pol fiR/ /" *ecl Countersigned 66A U Ed. 6 25M 7.46 TUAL 41. Name and address of Insured. LIBERTY MUTUAL INSURANCE COMP esident or Authorized Representative