860 NE 92 St (4)MIA 8 9
BUILDING INSPECTION
ES V_LLAGE
i.,
A PLICATION1 FOR ELHLMNO LSE[ MS t'
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for Hhe build-
ing or other structure herein described. This application is made in compliance and conformity with the Building rdinance of Miami
Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and ail rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified ea rrda%. Al ezIpy of opprmzd
plans and specifications must be kept at building during pr®gress of the wo±.
O wner ' s Name and Address ........V . , 4. ..__ o. Via. i c.3._......x . _„ ,_ Registered Architect and /or EngineeP..... : ,� /' ,• _ , :,. ,t,:4 -•, ,,,,.I,. - • , ...
Name and address of licensed contrtctoe -
Location and legal description of lot to be built on:
Lot Block Subdivision _. _ .'7°
_ ..
Street and Number where work is to be done L' _ •- - - .. - .. - .
State work to be done and purpose of building (by flours)
-.1- t .' \ te ....,._.,,...._ v
Mao..._ _ ��. .
............. .. ;1__ ._ __s ..
.,3......e............ • , ,
and fo' ,. C e2` ' puTirza.
New Building Remodeling Addition Repairs .... Mc. al Stor{cc .
To be constructed of . Kind of foundation Rcoi Covering
Estimated Total cost of improvements $ 2.0 0 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 conscr, :o.ion rn,,y
be sent to..
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an emplo; c'
of Labor under the 'Florida Workmen's Compensation Act, being Section 5066, Compiled Ceaural Laws of Florida, Penn4ne•nt Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub contractors employed by hint
in the work to be performed under this permit; and will post Or cause to be posted for inspection on the site r-f the work suet ,LUl c not,
or notices as arc required by the Act. The undersigned agrees to employ only such cubOOilliactors, bO perform :: :a°tdc
pertnit, as are licensed by Miami Shores Village.
(Signed) ...._.........
Remarks..._ __
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and Halle c::";,eowledgments, personally ap-
peared
to me re well Rte., ,
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 acme, c2d that all fas".,s
therein by him stated are true. ee'
Permit No._ o'
/ P
U ` D ate v --
Read, Sworn to and Subscribed before me.
�__ _ __
Disapproved . ( Date. -....: - - - - .._.. •
,. Notary Public, State of Florida
(Signed) � / /,
Buildin inspector,. My Commission I .apirec
PLANNING BOARD DATE
Chairman Member
Member Member
Member Member
Council Approved Date Discnprcved.,� Dale
NOTE: A charge of $1.00 will be made for making corrections or changes to this e pu ?retio n the Aom-o' : :: h :s it4=crn rsb2as !xt. :r
the Planning Board.
A re-inspection fee of 51.00 will be charged when such ce°in ectic2u is Lx.da ^- :'2;c .r'y by t1131szx3 r 1ft io7 crecpt- tiara faulty
materials and/or workmanship.
Start_
Mileage..
Fuel.
Oil
031_ Res®
_Hyde. 011
Sandi
Cement,
Finish.
Total. Hrs..
Total_ Mi..
Total
Comments
Pate:
In—
Out --
In
Out
Yards
Credit; _for._ _Material.
Addr e s
Mileage;
Ins
Out
Yards
Addre.s s:
--.5 and --
Me ter_Reading-
P deter• Reading
.T'otal Meter Rd..
— Rock __
Mileage.
__To.t.a _ Meter - _Readin
_JP713 }lark
LcL
‘ ? . CS tbEvQ(1.:
g(0c
pkik RA. ,S 5
6S6-: CGNC-Ae
L)3 S cs
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