PAINT/ , M ••1Y
' \/,
D i r � or,_ Job Address /o/c 95' Sr Tax Folio
U s aoe R / Historically Designated: Yes No
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Owner/Lessee / Tenant L �/;? % C 7 Master Permit #
Owner's Address `( O /t/ / �
C - Phone 7 SO -- p 7 7.
Contracting Co. / L_ Address
Qualifier
State #
Architect/Engineer
Bonding Company
Mortgagor Address
WORK DESCRIPTION
My Commission Expires:
FEES: PERMIT
RADON
Municipal #
Signature of owner and/or Condo President Date
C.C.F.
SS# Phone
Competency # Ins. Co.
Address
Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MEC CAL ROOFING PAVING FENCE SIGN
Square Ft. Estimated Cost (value)
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.
Signat . - of Contractor or
Notary as to Owner and/or Condo President Date Notary as to Contractor or Owner- Builder
My Commission Ex >ses:
NOTAR 1 SEAL
2 � , , {- SC:.7T W DAVIS
N a te i�� ; A . COMMISSION NUMBER
`t_ _ei Q CC255237
- d- MY COMMISSION EXP.
CF (� JaN. 26.19g7
NOTARY TOTAL DUE
a(_11
6
Da
Date
APPROVED:
Zoning Building VIPJ / 471c, Electrical
Mechanical Plumbing
Engineering
ivy 5 03/0
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 fr l I 1939_
Owner's Name and Address '''4 ' C C. T�4' Y0 No. / Street NE 9571
ST.
Registered Architect and/or Engineer
Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot l 7 Block O� /
Street and Number where work is to be done
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
0 w A)Ek
/66 NE 9s 71 Er
- 75 4
Subdivision Yfiglite/ /h1 /1 A` 2 ! . 01e(( � y �
State work to be done and purpose of building (by floors). state exterior colors (submit samples)
E7(7 /oR pm-oh OF ROOF q, cduALL.C.
cH ic ,eA -CH) 4' Ii Itk
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
Estimated Total cost of improvements 5 • 6 •ft 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
1 hereby submit all 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 obligatons 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 such public notice or notices as are required by the Act. The undersigned agrees to employ only such subcontractors. on work to be performed
under this permit, as are licensed by Miami Shores Village.
Remarks (Signed)
3 A /1/
Permit No. Date
STATE OF FLORIDA
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public. duly authorized to administer oaths and take acknowledgments, personally appeared
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.
Read. Sworn to and Subscribed before me.
Disapproved (\ 441k Date
\ Notary Public, State of Florida
(Signed)
Building Inspector My Commission Expires
PLANNING BOARD DATE
Chairman Member
Member Member
Member Member
Council Approved Date Disapproved Date
NOTE: A charge of $25.00 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 $25.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and/or workmanship.