PLANSMIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approyal 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 �i� , •�• - , 19
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Owner's Name and Address ._....._. 6 --L- " - . <__.._. -0- .-- .----- - - - - -- No. Street
Registered Architect and /or Engineer - S. 3 4 -
Name and address of licensed contractor 1.+.J -a
Location and legal description of lot to be built on
Lot ... Block Subdivision.
/Gw )--) • - I 6
Street and Number where work is to be done
State work to be done and purpose of building (by floors) - - - - - -- -/ � %/
(Sign
Remarks ( Signed) It /
PLANNING BOARD DATE
and for no other purpose.
New Building Remodeling � > Addition ._...._. ........ .......... Repairs No. of Stories
To be constructed of Kind Qf foundation Roof Covering
Estimated Total cost of improvements $..
. OiJ Amount of Permit $ q-11- - �� ,
Zone cubage required Plan Cubage4 V ' / 4 �'vc' brio (,
g
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,
an 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 inspe n on the site of the work such pul ic notice
or notices as are required by the Act. The undersigned agrees to employ only such su cog a €tors, on work to be pe s1.,_u
permit, as are licensed by Miami Shores Village.
STATE OF FLORIDA, ! ss
COUNTY OF DADE. j
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 cOth deposes and says that he is the.
of the above described construction, that he h carefully re)cl the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true
Permit No t _ ate j
Date ii. t'.'3 ' 5 Read, Sworn to and Subscribed before me.
Disapproved _(. r- -- •
Date
_ - - - -- - S ni
r Ig Inspector
Notary Public, State of Florida
My Commission Expires
Member
Member
Member
Chairman
Member
Member .. - -.
Council Approved
NOTE: A charge of $1.00 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 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
Date Disapproved Date
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CERttFICAl ! HerebyCertify that
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Ffi GE U( ENGi4. #136
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