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Owner's Name and Address_!
Registered Architect and /or Engineer
Zone cubage required
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
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.
t
a r —
Name and address of licensed contractor ___4 __ __ - Q ��� - _ _
Location and legal description of lot to be built on:
Lot Block Subdivis' _ -_ —
Street and Number where work is to be done___ - � _ — n E. 0 (21-z
State work to be d• - • an. . ose of building ( doors )... -
Estimated Total cost of improvements $______ _!___ __l __ ._ .-- __________Amount of Permit $
and for no other purpose.
New Building Remodeling Addition Repairs X No. of Stories______ _______ ___ ___
—
To be constructed of Kind of foundation Roof Coverg_____ _______________________
__ Plan Cubage
Distance to next nearest building _ _____________Size of Building Lot
Maximum 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 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 s bcontractors,,on work to be performed under this
permit, as are licensed by Miami Shores Village. 1 r,
Remarks (Signed) 4a�
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,
and who, being by 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 stated are true.
Permit No.___,_____ -3 Date s Read, Sworn to and Subscribed before me.
Disapproved Date
Notary Public, State of Florida
(Signed)
Building Inspector My Commission Expires_
PLANNING BOARD DATE
Chairman Member
Member Member
Member — Member - -- – – — – — __ -- — —
Council 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
the Planning Board,
,9 re -ins thin 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.
WORK DESCRIPTION
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Da 9 T Job Address ` YJ OJL. G Tax Folio
Legal Description /
Lessee / Tenanv � - 'e ( �5 1JL )C1 ter Permit # - 3�pd �,Q,
`
� \L
Owner's Address 4S LYE A ! C,
�S-t Phone ic
Contracting Co. O6C.// Address
Qualifier SS# - - Phone
State # Municipal # Competency 0 Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle oche): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
Square Ft. Estimated Cost(value)
P'°
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR
NOTICE OF COMMENCEMENT).
Application is hereby made to obtain a permit to do work and installation as indicated above, and
on the attached addendum (if applicable). I certify that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regu struction and zoning. Furthermore, I
authorize the above -named contractor to do the work
** * * * * * * * *
FEES: PERMIT a RADON C.C.F.
APPROVED: Fire
Zoning Buildin
Mechanical Plumbing
Signature of Contract
Date:
Notary as to Cont
My Commission Expi
* * * * * * * **
NOTARY
akm
-- ;> *
e n 0
r Owner- Builder
TOTAL DUE
ICIAL NOTARY SEAL
R NUMBER
CC360191
MY COMMISSION EXP.
MAR. 29,1998
Other
Electrical
Engineering