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MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Type of T» l'
Feet of Drain Tile slat. Feet of Tank or Drain Field from Well
Nature of Water Supply: City—Well. Size of Soakage
Amount of Permit $ 1 '_ (Signed). \ Y C
Leg q
Permit No. . V? Date, !
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for building 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 ordinanecea of Miami Shores Village and all rules and regulations of the Building Division
of. Miami Shores Village shall be complied wdth whether herein or not. A copy of approved plans and
building during progress of wowork., st4 �0 ® Owner's Name and Address ^ r f is t r w ��
Registered Architect and/or En'y - . ' G Z' teP
k '.; its., 33I�'
;Atf / 1,, Sub& IL A
Street and Number where work is to be , :' / / ' No L ` � ./ i d‘-- v e ,..Az. ne l �
State work to be performed and purpose of building (By Fkoors 11 9 .•• J r %ov ,/ '' r'
New Building- _ .- . - -._ -- Remodeling _ -.. _. _ __ Addition.. _ .... _. ... Repairs.. ......._...... No. of Stories ................ .
-- .Capacity
Plumbing Inspector.
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 Pennanent Supplement, and llau com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the wort to be
performed under this permit; and will poet or cause to be posted for inspection on the site of work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on 'rtD this Asermit, as are
licensed by Miami Shores Village. / /—/ C
Master Plumber.
STATE OF FLORIDA, l fe
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclunowledgments, personally appeared
to the above ve described c o construction tthhatth duly sworn,
deposes and says that he is the
he has arefullyy regaing pap on, and that he did slips the tame, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Fkndda
rN E: A re-inspection Imiao n�
pee of $1.00 will be m
be made when seek laseed s it sds•neoattary by improper notice for lapection, or faulty
nate
•
Department of Labor and Employment Security
Bureau of Workers Compensation Compliance
2728 Centerview Drive
Suite 100, Forrest Building
Tallahassee, Florida 32399 -0661
Subject:
Insured: � : ! ' / a t * _
Address: 3•' /O/ C'o l'. r c e . / �/ � . t�. -�
FEIN and Social Security Number: V/y 7O 4'T "'
Policy Number:
You are hereby notified that I, the undersigned sole proprietor, or
partner, or officer of (name of business) do hereby elect to be exempt from
coverage under the Florida Workers Compensation Act.
Sincerely,
gna ur
NQTA Y PU I 1 OF FLORIDX:
MY COMMISSION EXPIRES: DEC. 3. 1991 -
BONDED THRY NOTARY PURWO umoscawarrraii
Gfomdsw
IRRIGATION SYSTEMS
ACCEPTED
3 /2r.9
date
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DAVID P POTTER, INC. /P.O. BOX 600 -425 / NORTH MIAMI BEACH, FL 33160 / 305 - 866-2480
COMMERCIAL AND RESIDENTIAL LAWN SPRINKLER SYSTEMS / PUMPS / WELLS / INSTALLA TON, MAINTENANCE & REPAIR
FLORIDA STATE LICENSE ORX0054830 / DADE CG #•T 7Q
PERMIT APPLICATION FOR MUNICIPALITIES OF DADE COUNTY
O TO RETAIN COPY)
Legal Description
/ Lessee / Tenant , /7 e4 /tom ? rr i 9.'
Owner's Address
Contracting Co . ' o i 0,3014 c / f- Address
Qualifier u /7 • ' eA .2/e SS#
Phone
046 a Y d
Competency# re / 7 7 0 Ins. Co.
Address
Address
Zoning Building
Address
Estimated Cos
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO
DO SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT) .
Application is hereby made to obtain a permit to do work and installation as indicated above, and
on the attached addendum (if applicable). I certify that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING, and MECHANICAL work.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work
will be done in compliance with all applicable laws regulating construction and zoning.
Furthermore, I authorize the above -named contractor to do the work stated.
r or Owner- Builder
Notary as to Contractor or Owner- Builder
My Commission Expires: NOTARY PUBLIC STATE OF FLORIDA
* * * * MY CONVISSION EMPIRES 5/09194
Bonded thru Stembler- Adam & Sweet
Other
Electrical
Mechanical Plumbing ' i
gv Engineering