293394p
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. `� l
- e?
5� - 1
Date ( / , 19..�..
Owner's Name and Address f & ` � '— . " % f7 /, _ _ CU Q&� �..... Nob =Y_ ` Street € 1 9.b g r
Registered Architect and /or Engineer
Name and address of licensed contractor Ail 6
Location d legal description of lot to be built n:
Lot_ / Block
Street and Number where work is to be done 0)09- / 6 q (i S r
State work to be done and purpose of building (by floors )_ 116 P .6AC1. ?AL 6._._30 C gLk
Subdivision
and for no other purpose.
New Building__..___.__ ........ ____ Remodeling ... ......... ._____.. Addition Repairs _ No. of StorIes.._..._ ....._._.....
To be constructed of _.____ Kind . ..un4a ion rei" _ Roof Clvering
Estimated Total cost of improvements $ _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 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 ' • .,- .
'on on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such su. • • ctors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed)
Disapproved
(Signed)
Chairman
Member
Member ._.
Council Approved__
to t
PLANNING BOARD DATE
Member
Member
Member
Date Disapproved
s ,.., tary Public, State / o on
Buil• \ g Inspector My Commission Expires - - -L0. 22---
STATE OF FLORIDA, 1
COUNTY OF DADE. ss'
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared 1 --11/4,2.._G 14 w
. to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the_ .._ C-194/7 V
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. X ___. .._ Date_
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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