500 NE 96 St (4)MIAMI SHORES VILLAGE
BUILDIP G 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 Lalis of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shore: Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building du ring progress of the work. �..
Date e _�..,r
2
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Owner's Name and Address ,
Notary Public, State of Florida
Registered Architect and /or Engineer r4G • .,, , _.
Name and address of licensed contracto 1 ee-dirz . -i e1_ .. t f'l • C • /7/;__' ) .(4 . " 7 4.,
Location and legal description of lot to be built on:
Lot Block _ . Subdivision_
Street and Number where work is to be done t _ _,,,2 `�� `� _ .__
State work to be done and purpose of building (by floors)_ 71 4 s . tZ / _ C...we _.. s - (J_1ld_s.�
__L___,..._ 2 f r
L �''""" f it and for no other purpose.
New Building Remodeling__. Addition Repairs _ No. of Stories
To be constructed of Kind of cation Roof Covering
6
Estimated Total cost of improvements $ Amount of Permit $
Zone cubage required _Plan Cubage
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 Compensatih in 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 syb- contractors employed by him
in the work to be performed under this permit; anc will post or cause to be posted for inspectio,n on the sits of the work such ublic notice
or notices as are required by the Act. The undersigned agrees to employ only such sub�ontr dojs, qrf wbrk. to be performe uder this
permit, as are licensed by Miami Shores Village.
Remarks__. (Signer} �*
_ 19
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 -� Date 1 '/ Read, Sworn to and Subscribed before me.
Disapproved Date
(Signed) r-1J f ,- -. _y-_
Building Inspector / - . My Commission Expires
PLANNING $t5ARD 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.
4o
FR/el
l•for
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