ROOFINGOwner's Name and Address
APPLICATION FOR BUILDING PERMIT
Application is hereby u'nde for the approval of the detailed statement or use plans and specifications herewith submitted for the build
in 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 eupy of approved
plans and specifications must be kept at building during progreu of the work.
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
Registered Architect and /or Engineer.. ......... /-
Name and address of licensed contractor Li . .
Location and legal description of lot to be built on:
Lot Block ,,,...lubdivislon
Street and Number where work is to be done
State work to be done and purpose of building (by floors)..
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Disapproved Date
(Signed)
Building Inspector
NOTE: A charge of $1.00 will be made for
the I lannir.g Board.
A re m.pection fee of $1.00 will be charged
materials anti /or workmanship.
Date..._... ».. .. .._._......_� .
.... No.. 01.7.. . Street_..
t1! ,,,•••ttt ten»n•rt:• Vet ,,,e, Mt, !TIt
- 9 Eq
_.. and for no other purpose.
Ncw Building Remodeling Addition Repairs No. o Stories ( _
To be constructed of Kind of foundation....,. R�Covering / L S..JCi ............_..__
Estimated Total cost of improvements $ g. 10 - Amount of Permit S.
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 NVorkincn'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 site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under th1
permit, as are licensed by Miami Shores Village.
Remarks
Chairman
Member
Member .. .. �....._......_..._._ ...._
Council Approved Date
making corrections or changes to
(Signe dd��• r r�
5 * ?- 49-
5k X o3Y753
0A354
Member
Member
Member
Disapproved
PLANNING BOARD DATE
Notary Public, State of Florida
My Commiuion Expires _
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 true.
..e�
Permit No 1/6/ Date ) / V' Read, Sworn to and Subscribed before me.
........ Date
this application after approval has hecn obtained from
when such re- inspection is made necessary by improper notice for inspection or faulty