12669MIAMI SHORES VILLAGE
t 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 ed or not A copy of approved
plans and specifications must be kept at building during progress of the work
Address
Ar,/ o
ret%2/7
Date
Owner's Name and
Registered Architect and/or Engineer
Name and address of licensed contractor 31.r../_4&
Location and legal description of lot to be built on:
Lot__ Block
Street and Number where work is to be done
/411 Stel
State work to be done and purpose of building (by floors) en -6°
and for no other purpose.
New Building Remodeling_ Repairs No. of Stories__________
To be constructed Kind of founda0... Roof Covering_
Estimated Total cost of improvements $4 — _Amount of Permit $.
Zone cubage required__
Distance to next nearest building
Maximum live load to be borne by each floor
Plan Cubage
Size of Building Lot__
1 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 so • tractors employed by him
in the work to be performed under this permit; and will post or cause to be 'on on the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only tractors, ormed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed)
STATE OF FLORIDA,
COUNTY OF DADE. j ss •
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments,' personally ap-
peared
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 C2 C-
Date_ / — 1-2 Read, Sworn to and Subscribed before me.
Disapproved
(Signed) _
Date__
BOARD
Member
Member Member
Member
Council Approved
Member
Notary Public, State of Florida
Commission Expires
DATE
to me well known,
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 $L00 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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