1059 NE 98 St (14)Addres
Company
Phone #
For Inspector
Approved
Correction
Re- Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date Time
Type Insp'n
Permit No. P' a00a , /.6'
Name
3aa
-kt,?77
7
9
CERTIFICATE OF INSURANCE
This is to certify that the policy or policies, subject to the terms thereof, desig-
nated below by number and providing the kind of insurance set forth opposite such
number, have been issued by the Company and are in force at this date. The insurance
afforded is only with respect to such and so many of the kinds of insurance as are
indicated by limits of liability, expiration date, and policy number. The name and
address of insured, the operations, and location of the operations to which the in-
surance applies are set forth below.
Name of insured: JOHN R. & MARILYN SIMIONE
Address: 1059 NE 98 STREET
Operations:
Location of operations:
Kind of Insurance Limits of Liability Expiration Policy Number
Workmen's Compensation As provided in applicable law 1/26/55 UNDER BINDER
and INSURANCE CO. OF
Employers' Liability One Accident $ TEXAS
Public Liability One Person $ 10,000.00 1/26/55 L2K8786
(Bodily Injury) One Accident $ 20,010. 1
Public Liability One Accident $ 1,'00. 0
(Property Damage) Aggregate $
Automobile Liability One Person $
(Bodily Injury) One Accident $
Automobile Liability One Accident $
(Property Damage)
Cargo
(Motor Transit)
In the event of material change in or cancellation of such policy or policies, the
Company agrees to notify the party to whom this certificate is addressed of such
cancellation or material change. Ten (10) days notice in writing mailed to or de-
livered at the address of such party as herein stated shall be sufficient notice.
TO
BUILDING & ZONING DEPARTMENT
ADDRESS
MIAMI SHORES, FLORIDA
Per Truck $
Aggregate
(Each event) $
DATED JANUARY 26, 1954
y authorized agent
STATE OF FLORIDA) SS'
COUNTY OF DATE, )
AFFIDAVIT
'of the Village of ' Miam,,ihores,
unty of Dade and State of Florida,, being duly sworn, doth depose awl say,
that under the provisions of Ordinance No, 185,, dated June 15, 1948, amen*.
ing paragraph (d) of Section B -368 of Ordinance 1 ,, 97 of the Building Cole
of Miami Shores Village, he desires to build a ,�
on Lot / Block /7, of S.`�
,�. , .¢
-,,w _Subdivision,
that he is the owner of said property, and will be the owner of said
, that he will do the work personally, and that
he will, at such times as are required by the Zoning and Building Director: -
1, File plans and specifications and obtain approval of the
Planning Board and the Building Inspector.
2. Apply for and secure a Permit.
3. Pay the required fees.
4. Execute the work in accordance with the provisions of this
Code.
5. Apply for inspections.
6. File with the Building Inspector certificates that provision
has been made to carry the necessary Workmen's Compensation,
Public Liability and Property Damage. Insurance.
7. File with the Building Inspector as the job progresses certie
ficates showing the payment required by the Federal Social
Security Act to the State of Florida or the United States of
America.
8. Assume the responsibility of not employing other than properly
licensed contractors by Miami Shores Village for any part or
portion of the work.
9. Not set himself up as a "contractor ".
10. Sign an affidavit before commencing work to the effect that
he has read this Article and will do the work personally and
observe all of the requirements of the Building, Electrical,:
Plumbing and Zoning Codes of Miami Shores Village, Such
affidavit to be properly notarized upon blanks to be supplied
by the Building Inspector.
11. In order to. prevent abuses and subterfuge the right of such
owner.- builder as herein. provided, ' is limited to but one
owner- builder vent each 2 years, and where an owner•- builder-
has once exercized the privilege herein conferred nd second
appaication for owner- builder permit shall be granted...in less
than 2 years, unless the applicant is qualified as a licensed
General Contractor under the applicable Ordinances of said
Village.
And Further this Deponent says not:
SUBSCRIBED AND SW0aN To BF0RE
19
NOT
tary Public, State of Florida at Large'
My Commission r: “,ices Jan. 17, 1958.
Eonde -d by Amer lean F ire aid Casualty Co.