3965BUILDING 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 nd all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein spectified or not. copy of approved
plans and specifications must be kept at building during progress of the work.
Owner's Name and Address....
Registered Architect and/or Engineer
Name and address of licensed contractor 19 9 t mei •
Location and legal description of lot to be built on:
Lot_ block Subdivision.
Street and Number where work is to be done ($0 et.
State work to be done and purpose of building (by floors ).
/4 .P.0
and for no other purpose.
New Building_________ .............. Remodeling Addition Repairs —______ No. of Stories
To be constructed of Kind of foundation f Covering IL -ere-
Estimated Total cost of improvements $ Per), ife., Amount of Permit $ /47, -. 0 a -I-
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 inspection on the i* e of the work such . ublic notice
permit, as are licensed by Miami Shores Village.
or notices as are required by the Act. The undersigned agrees to employ only such roArkto, on k to
....-i - . orm er this
4
Remarks (Signed)
STATE OF FLORIDA,
COUNTY OF DADE.
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 t
Permit No.
Date 3— -3- Read, Sworn to and Subscribed before me.
37
Disapproved u ht
(Signed)
1\
MIAMI SHORES VILLAGE
Date
Building Inspector
Chairman
Member
Member
• Council Approved __ Date
Member
Member
Member
Disapproved
Date._ 2 7 ., 19 eS
Cvittf-locketiEfe( Street_ le
P/z
1411,- Notary Public, State of Florida
aff
M y Commission Expires
PL G BOARD_ DATE
4
_ to me well known,
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.