1146 NE 97 St (10)IA HDRES VILLAGE
BUILDIN INSPECTION DEPARTMEN
APi.1 LICATI® p4! FOR { -JU LDING PE MIT
Application is hereby made for the approval of the (let, iled statemen' of the plans and specifications herewith submitted for the build-
ing or o h, -ructure her i described This rilicatic is made in compliance and con•o'm ty w.th the Building Ordinance of Mia u
Shores Village, or da, and all pro isions of the Laws tf the State of Fkrid. all o d nances of Mi m Shores Village and all rules and
regu'a•ion of the Budding Div . i of •iam Shot iilage 1' 'I a -0. ipl.ed with, whether herein specified or not. A copy of approved
plans and specificati .m• must be kei at building durin progress of tl.e wcrk.
Owner' Name and Address___._.
Registered Architect and /or Engineer.__
Name nd address of licensed contractor t_ -_
Location and legal description of lot to be built on:
Lot _ Block_._ ___. __ Subdivision
Street and Number where work is to be done
State( ork to be done and purp se of building (by floors) �, >
Chairman
Member _
M e m b e r _
Council Approved
Date 19 -% <�
1
• �� - ___ No Street..
and for no other purpose.
New Building. Rernodeling ____ _ __. Addition____ ____ ___ _____ __ _ Repairs_ - - - No. of Stories
To be constructed of _ Kind offoundation Roof Cov
- :,tal cost of improvements $__ _ , � Amount cf Permit $__ . U
Zone ^ubage required_ __. Plan Cubage
Distance to next nearest building__ _ _ _ _Size of Building Lot
Iliadimum live Load to be borne by each floor _ . _____
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 unde signed appli ant for th's budding permit does hereby certify t gat he understands and accepts his : bligations as an employer
of 1 bor under he Florida Workmen's Compensation Act being S• •tion 5966 Col p led Gen al Laws of Florida P r anen S•ipplt Went,
and h s compl ed w;th he prov•;ions thereof, and will require s•milar comp lance from all contractors or sub - contractors cmplo .ed by him
in the wo k to be p rI -med under th s pern it and ill post or cause to be posted for inspection on the site of the work su :h ublic not' e
n�
or •otices as are requir. d by the Act. The u. d,r ign.•d agrees to employ only such ,�bFontr. ctors, on York to be perfor.A de:- this
permit as are hcensed by M am. Shores ‘11.: ge.
Remarks - (Signed) -� �� �� 0 -
PLANNING BOARD DATE
Member
Member
Member
Date Disapproved __
,
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths c.nd take acknowledgments, personally r p-
peared
to me well known,
and who, being by me first d. ly sworn, upon oath depofes and says that he is the
of tl: abov de c•ibed . Istruction t. • h has careially read the foregoing application, and that he did sign the same, and that all facts
therein by him stated aree tr ie.
Permit No K -� Date__ __ -- /' ��._ Read, Sworn to and Subscribed before me.
Disapproved ~- ..__. _ Date__
�- Notary Public State of Florida
(Signed) ,, a
1� uilding Inspector My Com:nission Expires.
Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application tft'r approval h is been obtained from
the Planr ng Board
A re- inspection fee of $1.00 will be charged when such re- inspection is ms ie necessary by improper notice for inspe :•t'o■ or fa. Ity
materials and /or workmanship.
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