57 NE 93 St (12)Owner's Name and Address IN •
Registered Architect and /or Engineer
Name and address of licensed contractor
Permit No. //
Disapproved _.
(Signed) __._
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, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
Date------ - - - - --
Date
Date
N
k 6rr 7 ��
Street.__
Building Inspector / My Commission Expires_
Location and legal description of lot to be built on:
Lot__ Block Subdivision j
Street and Number where work is to be done 5 7 2V '� 1 3
State work to be done and purpose of building (by floors).______ e S Uir d' "QC t' FX / 5) `r/
19/VD f/ VP&' 3/o /2ge!9_- -jCRo, 5 7h e /rlovr
Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
PL ; ° ING BOARD.. __ _ DATE
Chairman Member
Member Member
Member . - _ Member
Council Approved _Date Disapproved
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval
the Planning Board.
A re- inspection fee of 51.00 will be charged when such re- inspection is made necessary by improper notice
materials and /or workmanship.
DJIve
and for no other purpose.
New Building Remodeling Addition
To be constructed of Kind of foundat Roof Covering
Estimated Total cost of improvements $ °L 6 22_ Amount of Permit $
Repairs No. of Stories
Zone cubage required _Plan Cabage_
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
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 suc public notice
or notices as are required by the Act. The undersigned agrees to employ only such su ntractors, on work to be perfo l ed under this
permit, as are licensed by Miami Shores Village.
Remarks _. __ __ . _.. ___ .___ .._ (Signed)
STATE OF FLORIDA,
COUNTY OF DADE. sus
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 ar true.
7i
Date
has been obtained from
for inspection or faulty
M`.
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