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MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BiTILf PERMIT Application is hereby made for the approval of the en it me an e pla s ci n os i ati uldin mittednor o f fe bui d S o a V a her e herein in ll described. isio This app re ulat onsof the Building Florida, Division of Miami Shores Village e shall be complied with, ordinances whether herein specified or not. A all rules and approved ns of the Laws of g plans and specifications must be kept at building during progress of the work. Owner's Name and Address Registered Architect and /or Engineer Remarks r I c iI Qat and who, being by me first duly sworn, up of the above described construction, that h therein by him stated are true. Permit No Disapproved (Signed) Building Inspector Chairma Member Member Council Approved NOTE: A charge of $1.00 will be made for the Planning Board. A re- inspection fee of $1.00 will be charged materials and /or workmanship. Name and address of licensed contractor Location and legal description of lotto be built 9n: Lot ' '' Block 4 (� Subdivision Street and Number where work is to be done ! State work to be done and purpose of building (by floors) Date No. // { J Y) 'Street PLANNING BOARD Date • • and for no othei purpose. r Addition Repairs $ - No. of ories New Building___ Remodeling ) � �� �A To ___ Ki of foundation 1 � �- " s ' De constr ct i ` Roof Covering d of - ` (' Estimated Total cost of improvements $�' y tJ Amount of Permit $ -� �- Zone cubage required I 1i j 6 _Plan Cubage__ � �- Distance to next nearest building I 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 and has complied with a provis ons the Compnsation similar copliaom ll contractors A req i o mnce require a compliance or sub- contrators e d by lhim d for in the work to required under this e will post or cause to be agrees to employ only such sub on ltors, work ed under s or notices tees as' are e required by the Act. The t /j permit, d) %k `'c • c . (� e. t i- t — — : as are licensed by Miami Shores Village. ' STATE OF FLORIDA, t ss. COUNTY OF DADE. j Before me, the undersigned 'authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared ,ath,,1�eposes and says that he is the as earefu1ly read the foregoing application, and that he did sign the same, and that all facts t ,1 Slid, Sworn to and Subscribed before me. Notary Public, State of Florida My Commission Expires DATE 19 it -- td me well known, Member Member Member Disapproved Date making corrections or changes to this application after approval has been obtained from when such re- inspection is - made necessary by improper notice for inspection or faulty std tikvvcA 4 11 L OCA-VIO N ENGINEERS CERTIFICATE: I hereby certify that the Survey . of the property described hereon ; is true : and correct . to the best of my kno ler'ga and bq as recently sane under n,y dirett;cu and that th ar o' ui ess shorrrt .r oted. t►UGUSY De Wlt Kl. 12 QIYIL ENGINEER t10l�Y1� MIAM1► FIARIdA $ FV Q sCV� '3X, HANGE INSURAN5E ASSOCIATION CHICAGO, ILLINOIS Certificate of Insurance At ti ill 10 (Udall that the EXCHANGE INSURANCE ASSOCIATION has issued to Assured it ing..C, Oiyax't Address...ti6.L !,...195th Street 1da.wl& mores Dade, Florid . POLICIES OF INSURANCE DESCRIBED AS FOLLOWS: Kind of Policy Number Term Limits Locations Covered CIassifications of Work Covered Workmen's Compensation )10 2503 whom we will give 5 9/2?i/51 to 9/24/52 Provided by Workmen's Compensation Law of kurida 551. N.E. 93rd titre in the ti hate of Fl earpentry,Masonry al d all other operation This Certificate is issued at the request of: Name Shores Village Address Mi Lli Shores, Florida re rr . days notice of cancellation 1D r any rior c ange affecting this Certificate. Dated at Iit.? ? ,_ Florida Sep tether -= 214th STAIEREWEIMMEMEONEFAM X -WC CTF 1M 4 -81 Bodily Injury Liability St 5823 9/24/51 to 9/24/52 each person 25;00 each accident5QA I� asst Shores, Dade rida 19...5, C Property Damage Liability SL 5323 9/211/51 to 9/2h/52 each accident 1 }00040 aggregate $ 1,D unty and elsewhere EXCHANGE INSURANCE ASSOCIATION President AC}C aU 1N T S URAI'ICS AGE2 (, IidC. # CI iii irrommrs 1f(hilt(111.1 1f(Jlma1fC9llf ©mi 7 !f�il` r >rn >in>Fn� )TAT OF FLORIDA) S3' COUNTY OF DATE • ) And Further this Deponent says not AFFIDAVI 011N41 'of the Village of'Miaini s3hores, County of Dade and State of Florida, being duly sworn, Both depose and say, that under the provisions of Ordinance No. 185, dated June 1 ,5, 1948, amend* ins Paragraph (d) of ,3•e tion R - 368 of Ordinance No, 97 of the Building Code of Miami Shores Village, he desires to build a on Lot • Block of Subdivision, that he is the owner of said property, and will be the owner of said , that he will do the Mork per;,onally,, and that he will, at such times as are required by the Zoning and Building Direoto4- 1• File plans and specifications and obtain approval of the Planning Board and the Building Inspector. 2* Apply for and secure a Permit. '3. Pay the required fees* 4. Code Execute the work in accordance with the provisions of this • 5. Apply for inspections, . 6. File with the Building Inspector certificates that provisig, has been made to carry the necessary Vorkments Compe cation, Public Liability and Property Damage Insurance • File with the Building Inspector as the job progresses certi- ficates showing the payment required by the Federal Social Security Act to the State of Florida or the United States of k4 rich, Assume the responsibility of not employing other than properly licensed contractors by Miami Shores Village for any part or portion of the work. 9. Not set himself up as a "contractor ", 10. Sign an affidavit before commencing work to the effect that he has read this Article and will do the work personally and Observe all of the requirements o£ the Building, Electrical, Plumbing and Zoning Codes of Miami Shores Village. Such affidavit to be properly notarized upon blanks to be supplied by the Building Inspector 11. In order to prevent abuses and subterfuge the right of such owner builder as herein. provided, ' is limited to but one owner- builder permit each 2 years, and where an owner builder• has once exereized the privilege herein conferred no second application for owner builder permit shall be granted. to less than,2 years, unless the applicant is qualified as a licensed General Contractor under the applicable Ordinances of said Village. J l C WCfftN TO nE, 'ORE ME this • ay of L ,Q..._,. NOTARY PUBLIC. Notary Pubile, State of Float, ut 1255, ' 9 My commission expires Feb. 19, Sons1ei by American Surety Co. of MY, • P.4 - ( t,r t, !yu ,t..�yra;sT+�i .�il'.yelk'YT' t efs 1 ri. F 3--srootiteititokei• 141,04 11Z5=1* Ft 6urger'. 3 .... ti...c..4-ria +%. ..a. .ay0 x ...A 'iR' f .v/4# 1 , '.•-, 11 t, z -fe f17Y. e s. // M' ti fives s •r'.t...4` s.ax� .+• bib .*— 7. ..e.. r+i±.:,.s 4;:`,.,."1..+ .. >. 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