10 NE 97 St (14)1
7
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT 1
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
Owner's Name and Address ? f r k=- f F T
Registered Architect and /or Engineer.____- } (/4
Name and address of licensed contractor ____ _ 4111■.L
Location and legal description of lot to be built on:
Lot / /' Block i
r Subdivision__ t /
Street and Number where work is to be done 31_____ ...
- - c- /. ST
State work to be done and purpose of building b floors �!_ r
and for no other purpose.
New Building__ — Remodeling____.. Addition_____ Repairs No. of Stories 4 r ____
To be constructed of - Kind of foundation r ' •' * Roof Covering J' r'
Estimated Total cost of improvements $.___
ing nspector
Chairman
Member
Member _
Council Approved
made for making
Date
No/
Street
4
Remarks ( Signed)_ -
Notary Public, State of Florida
My Commission Expires
PLANNING BOARD �y ATE
Member l
,19Y?
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 ieference 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 ' spection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such su contractors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
STATE OF FLORIDA,
COUNTY OF DADE. I ss.
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 his carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stat are true. ( � (��
Permit No �__ " Date_ ___ � Sworn to and Subscribed before me.
Disapproved , Date
(Signed4'
Member
Member
Disapproved Date
NOTE: A charge of $1.00 will be
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 workmanship.
corrections or changes to this application after approval has been obtained from
1
STATE OF FLORIDA) ss
COUP ?TY OF DADS )
And Further this Deponent says not:
A F F I D A V I T
• of the Village of Miami Shores,
County of Dade and State of Florida, being duly sworn, doth depose and say,
that under the provisions of Oreinanoe iTc. 18, dated June 15, 1YM, araend-
ing paragraph (d) of Lection B--360 of Ordinance Eb, 97 of •the E i±1iir; Cx?.e
of Uiami Shores Village, he desires to built a
on Lot w_ _Block (... of ...\. . o f `'l Su'x'i isicn,
that hells. the owner of said property, and will be the owner of
that he will do the trot -k ire �. cna.11y,
and that he till, at such tunes as are re_uired by the Zoning and 7ilding
Director : -
1. File plans and specifications and obtain approval of the
Planing Board and the Building Inspector.
2. Apply for and secure a Permit.
3. Pay the required fees.
4. Execute the work in accordance with the provisions of this
Code.
5. Apply for inspections.
6. File with the Building Inspector certificates that provision
has been made to carry the necessary Workmen's Compensation,
Public Liability and Property Damage Insurance.
7. 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
America.
8. 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 of the Building, Electrical,
Plumbing and Zoning Codes of Miami Shores Village. Such
affidavit to be properly notarized upon blanks to be supplied
by the wilding 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 exercised the privilege herein conferred no second
application for owner - builder permit shall be granted in less
than 2 years, unless the applicant is qualified as a licensed
General Contractor under the applicable Ordinances of said
Village.
UWNER
SUBSCIID D AHD SWORN TO B: ORS ME this day of A. D.,
19 - •
NOTARY PUBLIC
•
1
Name of insured :
Address :
Operations :
Location of operations: =`5f' L CO'
lori_cie
t,1:1 . T.,p of
Kind of Insurance
Workmen's Compensation
and
Employers' Liability
Public Liability
(Bodily Injury)
Public Liability
(Property Damage)
Contractual Liability
(Bodily Injury)
Contractual Liability
(Property Damage)
Contractors' Protective Liability
(Bodily Injury)
Contractors' Protective Liability
(Property Damage)
Automobile Liability
(Bodily Injury)
Automobile Liability
(Property Damage)
To
Address
Form 7215 -A. 61.1. 1 -48
CERTIFICATE OF INSURANCE
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY
135 SOUTH LA SALLE STREET, CHICAGO, ILLINOIS
(Herein called the Company)
This is to certify that the policy or policies, subject to the terms thereof, designated below by number and providing
the kind of insurance set forth opposite such number, have been issued by the Company and are in force at this
date. The insurance afforded is only with respect to such and so many of the kinds of insurance as are indicated
by limits of liability, expiration date, and policy number. The name and address of insured, the operations, and
location of the operations to which the insurance applies are set forth below.
- t r,, m r . ,
ro ? . o F1r r1r'
�C n c$ / or
Limits of Liability
As provided in applicable law
One Accident $
One Person $1 C, C
One Accident $r, C
One Accident $ 1
Aggregate $
One Person
One Accident $
One Accident $
Aggregate $
One Person $
One Accident $
One Accident $
Aggregate $
One Person $
One Accident $
One Accident $
Dated
American Guara
By
,
t
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Expiration
1 1 /1 F•: 1/1c:
F(
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T,
i h
Policy Number
`,F 715n
2/16/50 1: 3524F1
Note: Use space immediately above for Products, Elevators, Automobile Non - ownership, or other kinds of insurance not described.
In the event of cancelation of such policy or policies, the Company agrees to notify the party whom this certificate is addressed of
such cancelation. Notice in writing mailed to or delivered at the address of such party as herein stated shall be sufficient notice.
ee and I Insurance Company
Duly authorized agent
1888
tilr eirnnt, of c-no13 i of' the i)olicies refev to in this
c , - t'oer1 nntion 1 L iven ti d Cor6,1any
i n t' f ry.ri Vi i r or s P1 orir3: 1
t, 'D.r tOnr shu.) J 1)0 - ff' , - - .ct:Tcy
uch notice to bc Liven 1 j :1 7.. 1 or to t ti .ric; ell pti.on
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