1122 NE 97 StMIAMI SHdRE8 VILLAGE
BUILDING INSPECTION DEPARTMENT
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.
Owner's Name and Address___ 1
Registered Architect and /or Engineer
Name and address of licensed contractor
Location and legal description of lot to be built on:
APPLICATION FOR BUILDING PERMIT
Lot__ ° __ Block Subdivision O_ / 1
Street and'\:ur ibcr wl:crc work is to be done__ _P !"
S a'n -yolk to be done and purpose of building (by floors) J __
R \
li
New Building
Date 1/ , 19
No Street
and for no other purpose.
Remodeling Addition Repairs No. of Stories
'"-� h' •cteci of - Kind of foundation A
cost of improvements $___ Amount of Permit $
'ne _.. ge required _ 1- plan Cubage
Distance to next nearest building Size of Building Lot
Msvimum live 'cat 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
Roof Covering
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 Fi )rida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has comp'ied witi the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be per'ormed 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 arc 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.
vow Remarks_
(Signed)
1
STATE OF FLORIoA
COUNTY OF DAD 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 133. 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 ste.ted are true.
Permit No._ _ ' Date Read, Sworn to and Subscribed before me.
Disapproved . Date
(Signed)
Building Inspector My Commission Expires
Notary Public, State of Florida
// PLANNING BOARD DATE
Chairmar Member
Merbd Member
Merl" r ____ Member
C:rorcil Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from
tut Punning 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.