79 NE 93 St (12)BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of ti e plans and specifications herewith submitted for the huild-
Mg or ether st-ucture 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 al: rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified cr not. A copy c' approved
plans and specifications must be kept at building during progress of the work.
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Date , 19
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Owner's Name and Address - No Street
i
Registered Architect and/or Engineer
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
State work to be done and purpose of building (by floors)____,
and for no other pose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
Estimated Total cost of improvements $ 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
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 perfonned under this permit; and will post or cause to be posted for :nspection on the site of the work such public notice
or notices as arc required by the Act. The undersigned agrees to employ only such sub z'ontractors, on work to be performed mac: er this
perinit, as are licensed by Miami Shorcs
Remarks (Signed)
STATE OF FLOR:DA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclmowledgments, personal.Iy ap-
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peared _
to me well known,
_ ____
and who, being by me first duly sworn, uporfath deposes and says that he is the
of the above described construction, that he ha,; carefully read the foregoing application, and that he did sign the same, and that all facts .
therein by him stated an trae.
Permit No. _ _ Date
Disapproved
(Signed)
MIAMI SHORES VILLAGE
Date
Building Inspector
Read, Sworn to and Subscribed before me.
ti•
Notary Public, State of Florida
My Commission Expires
PLANNING BOARD DATE
Chairman - Member
Member Member
Member Member
Council Approved Date Disapproved Data
NOTE: A charge cf $1.00 will be made for making corrections or changes to this application after approval has been obtained f:om
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 work:nanship.
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