10303MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specification 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 rubs 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 k u ildi n g during progress of the work.
peered
Date S
e` No E2 Street-e_
Owner's Name and Ad
Registered Architect and /or Engineer � �
Name and address of licensed contractor �.�� r
Location and legal description of lot to be built on:
Lot_ Block _ -- _ _ -- — -- i to Subdivision_
Street and tv.....t,e...,.t.e -e . lc 1.e a....., / 0 . , ' Q
State , work to done and purpose of bui ldin by floors) s �F
New Building_ _ Remodeling Addition Repairs. _ No. of Stories
To be constructed of - -_- .._.. _________ Bind of foundati _.._ Roof Covering
Estimated Total cost of improvements $____7!�� : ' Amount of Permit $___ '"■ "
Zone cubage required_ Plan Cubage
Distance to next nearest building _,Size of Building Lot_-- -
Maximum live load to be borne by each floor
I hereby submit all the plan s 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 5868, 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 sub n .: • . work . be performed under this
permit, as are licensed by Miami Shores Village.
Remarks ( Signed)- ''�<'.
STATE OF FLORIDA,
COUNTY OF DADE. J
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aOnwledgments, personally ap-
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 tl}e foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Permit No.
Disapproved
(Signed) _
Date : " -- a
Read, Sworn to and Subscribed before me.
P ING BOARD__— _DATE
Chairman —_._ Member
Member Member
Member __.__._ __ ____ -- __ Member
Council Approved-- ____ -___ 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.
Notary Public, State of Florida
My Commission Expires
and for no other purpose.
to me well known,
BUILDING ❑ MIAMI SHORES VILLAGE, FLORIDA
ELECTRICAL ❑
PLAIvIBING O - PER MIT-
ROOFING ❑
0 Work to be performed under this Permit
'
Owner of
Building A
Architect
Date
° — contractor%
License No.
19 — , �
Contractor
or Builder " Dr
Legal
Description Lot d I I Bl.
sq. Ft.
Address of , Value of ( Amount of
Building . Project $ + " :" 11 Perna
This permit is granted to the contractor or builder named above t6 construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted 'to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances of if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
441 t
Signed-
In consideration of the issuance to me of this agree c� (INSPECTOR) BY
permit g to p t tf
ermit I a orm the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, ents or ,ePecifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
CONTRACTOR or BUILDER
Subdi-
vision
BY
AUTHORITY