546 NE 97 St (10))
MIAMI SHORES VI LLAGt
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 Ordinanc e of Miami
Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinance; 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
Registered Architect and /or Engineer
Name and address of licensed contractor___
Location and legal description of lot to b6 built on:
Lot - .L Block-- 4 -- Subdivision
Street and Number where work is to .ISe d ne _ Lr_ ! ? ....4
New Building
Remarks . _ _ ___ __
Building Inspector
State work to be done and purpose of building (by floors)
Remodeling Addition Repairs_. _._ .. No. of Stories
To be constructed of -__ ____:__-___—.:______ Kind of foundation Roof Covering.___.
Estimated Total cost of improvements $_, _ 2__, _l r�___. Amount of Permit $_ _-
Zone cubage required________________ _? ___ d_ __ —__Plan Cubage f Distance to next nearest building Size of Building Lot_____..______
Maximum live load to be borne by each floor _
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for,$fispection on the site of the work such public notice
or notices as arc required by the Act. The undersigned agrees to employ only such gnbbcontractors, on work to be performed under' this
permit, as are licensed by Miami Shores Village.
(Signed
Vg Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
My Commission Expires
Date
No. Street ,i,-
, 19
and for no other purpose.
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, per;onally 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 careful read the foregoing application, and :hat lie did sign the same, and that all facts
therein by him stated ' e true.
Permit No him/stated
3 Date
Disapproved Date
(Signec�l') y- v\s_`
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.
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.
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