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MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Permit No e'
Date
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the 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 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
/
Owner's Name and Address L
Registered Architect and /or • . /� r,
/ o .- 1.11//!/l Il
Employing Plumber's Nam. �' ` / � Street _ . - � o
Location and Legal Description Lot
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors)
New Building Remodeling
Size .Septic Tank ype of Tank
. F
Feet of Drain Til
Addition
eet of Tank or Drain Field from Well
Street
Repairs---_ No. of Stories. . _._._.
Capacity Gals.__
Nature of Water Supply: City —Wall -Size of Soakage Pit
Amount of Permit $ ( Signed)
Phmibing 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 5988, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similor 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 poster 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 - contractors, on work to be performed under this permit, as are
lionised by Miami Shores Village.
STATE OF FLORIDA, as.
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
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.
My Commission Expires
NOTE: A re- inspection fee of $L00 will be made when such re-inspection is made•necessary by improper notice for inspection, or faulty
materials and /or workmanship.
Notary Public, State of Florida