5 NE 99 St (3)APPLICPTION 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.
()
Date____ , 19
Owner's Name and Address Doe- m c // g L,& / No Street_1V.Z •__.ff ST.
Registered Architect and /or Engineer
Name and address of licensed contractor .J/e__i 34. 1Pa S. 1144 S, .O /eze 9 ,6.J LLykyo olj
Location and legal description of lot to be built on:
Lot__ . Block Subdivision
Street and Number where work is to be done sr-12_1‘
State work to be done and purpose of building (by floors)____ ff 1. L A
and for no other purpose.
New Building Remodeling Addition Repairs__ No. of Stories
To be constructed of Kind of foundation Roof Covering_
Estimated Total cost of improvements $ Am nt of Permit $
Zone cubage required .Pla Cubage__
Distance to next nearest building._. ___ _ _ ______Si of Building Lot__
Maximum live load to be borne by each floor___
I hereby submit all the plans and specifications for said building\ Al; notices with reference to the building and its construction may
be sent to__.._
The undersigned applicant for this building permit does hereby ce
of labor under the Florida Workmen s Compensation Act, being Secti
and has complied with the p rovisions thereof, and will require similar
m the work to be performed under this permit; and will post or cause to a posted 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 subcontractor , on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
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 tru
Permit No _ Date.. __.(L___ Read, Sworn to and Subscribed before me.
Disapproved
( Signed)
Chairman
Member
Member . -- -
Council Approved
MIAMI SHORES VILLAGE
BU!L.DING INSPECTION DEPARTMENT
that he understands and accepts his obligations as an employer
66, Compiled General Laws of Florida, Permanent Supplement,
iance from all contractors or sub - contractors employed by him
( Signed )
Notary Public, State of Florida
Building Inspect. My Commission Expires__
ANNING BOARD__ __ _ DATE
Member
Member
Member
_Date Disapproved
Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has h.' -n 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 inspc, tion or faulty
materials and /or workmanship.