BUILDING•
BUILDING 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 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.
Owner's Name and Address .
Registered Architect and /or Engineer ... ...... r� ..
Name and address of licensed contractor e
Location and legal description of lot to be built on:
Lot Block
Street and Number where work is to be done
permit, as are licensed by Miami Shores Village.
Permit No
Disapproved
r
(Signed)
Building Inspector
MIAMI SHORES VILLAGE
Date
Date
ci
Subdivision .......... ............ ......�
Date
No
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 loved 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 suer ubl• notice
or notices as are required by the Act. The undersigned agrees to employ only such sub crtractors, o work to be perform u er thi
Remarks (Signed)
State work to be do *nd purpose f buil (by floors) ,, r ,A.-.-
t-- ' !f� (/ 6l , {..c•c- y -t.-c- c -7.4.-4— Cat -,,,z u . � �a >:-".� u '
�� anddd for no other purpose.
New Building Re nodeling A ition A Repairs No. of S on /
To be constructed of ,:_.�t.i Kind of foundation i -t-- Roof Covering
Estimated Total cost of improvements $..__ ._ .._5 - Amount of Permit $
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 sisifica ons for said building. All notices with r erence t the building and its cops
r ction may
a�.� < - /
be sent to,�c<x' _ _ L'.� . ti"' "____' .. . �' S f C ` L,.�' r .S ... � (. l �,.. � A i
C
U 1
V
r
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 true.
1 d
__�._ Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
My Commission Expires
ANNING BOARD DATE
Chairman / Member
Member Member
Member . . Member
Council Approved Date Disapproved 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 51.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
Owner's Name G(/,
Job Add foss 1 ' ` ° c p'; Black
Nnniclpality Subdivligion
Cost cC :cob
Shaw: Electrical service and soptio tank looatioia.
Indicate North
Note:
A -12
pe
be
r
of
it
to
fro t the potti
ifd eatod on
Fill in dimensions of lot.
Front