PAINT PERMITSBUILDING 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, 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 Architect and /or Engi er
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
MIAMI SHORES VILLAGE
l ")'?-E.
Date
No Street
State work to be done and purpose of building (by floors)
dpi .
/Q- /9 sue/
Notary Public, State of Florida
.f t- 8 s
,19
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
0 0 / n,4—
Estimated Total cost of improvements $ 6 41 Amount of Permit $
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 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
m 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 erformed under this
permit, as are licensed by Miami Shores Village.
Remarks ( Signed )[\
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 i Date / c7 — (- a Read, Sworn to and Subscribed before me.
Disapproved to
( Signed) v
Building Ins ctor 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 51.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
PERMIT APPLICATI FOR MIAMI SHORES VILLAGE
Date /9 Job Address 4/39 ,(J '901 Tax Folio /7 — 0/V - 0250
Legal Description Historically Designated: Yes ' No X
wn
Oer ee / Tenant, Tick/A/6'7/6 n4E/E ` 4 Master Permit # ` 2 6'5
Owner's Address F 7 T Phone 75
Contracting Co. (t) YVA(r to Address
Qualifier Phone
State # Municij Competency # Ins. Co.
Architect/Engineer _ Address
Bonding Company _ Address
Mortgagor Address
Permit Type (circle one)q3 ECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION 69(rtie/ /-701/5E
Square Ft.
�3G 5/0
1
ature of owner and/or C.ond• resident
Notary as to Owner and/or Condo President Date
Commission Expires:
,3 /9 98"
ate
FEES: PERMIT L- RADON C.C.F.
Buildin 7.1q /'0
Estimated Cost (value) 4 C5
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I
certify that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
• Si',f�`'f eof Contractor or Owner -Bui der Date
Notary as to Contractor or Owner- Builder Date
My Commission Expires :..,.__.. _ - --
FA > `
1 i>; MMISSlON NUMBER
K v ° T :' , ; C C4012 &1 1
1 " v , Z.' c, :� : • .. *I ISSSILfl EXP.
1,,,,,- d NOTARY S BOND
TOTAL DUE
APPROVED:
Zoning
Mechanical Plumbing Engineering
Electrical