1200 NE 96 StApplication 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 , 19
Owner's Name and Address No Street
Registered Architect and /or Engineer
Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot Block_ ..yy Subdivision
Street and Number where work is to be done 1_2. A1_ __6 TN_
State work to be done and purpose of building (by floors)
and who, eing by
of the ab ve descri
therein b him state
Permit No
Dis
( 'Signed)
1 l �\
MIAMI SHORE _ _z.R�E
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
NOTE: A charge
the Planning Board.
A re- inspection fee of $1.00 will be charged when suc
materials and /or workmanship.
and for no other purpose.
New Building Remodeling Addition tep irs No. of Stories_ o r
To be constructed of Kind of foundation Q.L! -' Roof Covering
000
Estimated Total cost of improvements $ Amount of Permit $
Zone cubage required Q a _Plan Cubage_______ 1 _
Distance to next nearest building S' e 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,
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)
4111■11=MMr
d, Sworn to and Subscribed before me.
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared _
to me well known,
duly sworn, upon oath deposes and says that he is the
truction, that he h c efully read the foregoing application, and that he did sign the same, and that all facts
Notary Public, State of Florida
Building nspector "' 1 I y Commission
j( Expires
PLANNING BOARD ` 'D
Chairman Member _—
Member �..•�'" Member ""
Member i,,.0- { Member
Council Approved ` e.__I ate Disapproved Date
of $1.00 wi be made for making corjections or changes to this application after approval has been obtained from
re- inspection is made necessary by improper notice for inspection or faulty