BUILDING (2)BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUrLDING 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.
r
Owner's Name and Address
To be constructed of 1. Kind of foundation —
Estimated Total cost of improvemeenn s $$ / _Amount of Permit $
Zone cubage required / ___c . 1� __.Plan Cubage
------ - - - - -- /
Distance to next nearest building ' "2.. Size of Building Lot
Maximum live load to be borne by each floor
STATE OF FLORIDA,
COUNTY OF DADE. Ss.
Disapproved
(Signed)
Council Approved
MIAMI SHORES VILLAGE
to
Date
19- `t-
No. __ ! Streett LL
r
Registered Architect and /or Engineer i:
Name and address of licensed contractor t- -s-- _ " - A,S__1 V c_.a --_- :1.. c __ .........
Location and)g9 descr' tion of lot to be built on:
Lot ' - • --1 -i 2.- Block--- - - - -L { Subdivision - -1---I1 , .LL.�.._L... ter- ;�_ C.
Street and Number where work is to be done _ ____ __ �Pl.!
State work to be done and purpose of building (by floors)
c
and for no other purpose.
New Building — Remodeling ____ Addition ..— Repairs No. of Stories
Roo Covering 4 -` C G... .
U
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 1 l_l` ,..c__5. Y C. �- �`- — . l •
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 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 t be performed under this
permit, as are licensed by Miami Shores Village. /
t ,ter
Remarks .___ ( Signed
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
Notary Public, State of Florida
Building Inspector .� ' f My Commission Expires
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 caref lly read the foregoinfr- application, and that he did sign the same, and that all facts
therein by him statgd ar true.
Permit No Date Read, Sworn to and Subscribed before me.
PLANNING BOARD DATE
Chairman Member
Member 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 been obtained from
+1,,. Planning Board.
` "' nn ....11 hp charged when such re- inspection is made necessary by improper notice for inspection or faulty
STATE OF FLORIDA) SS
COUITTY OF DADS
A F F I D A V I T
of the Village of Miami Shores,
County of Dade an StofFlorida, being duly sworn, loth ch.poiie and say,
that , )ndor the rrovision- of Ordinance i ?c , ;, eaten June 15, Tc,I1, amend-
ing p:.r_'.C: - a - ph ;G) of Seotion D -36£3 of O ci._a , :e 17o. 97 of�th3 a. r. .i J Code
of iIi•uii Snores Vi]_la ;e, he desires to bi i LCD ,.t
on Lot y _�Diock of � i % _,L, &_.,; r 1.✓ sien,
that he is the owner of said pro rty, and Will be the owner of s
e , e , that he will do the work pe ^ :,cn<lly,
and that he 1i11, at such times as are re ;uired by the Zoning and ,_. lc.iing
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 certificate;: that provision
has been made to carry the necessary Workmen's Compen3c ion,
Public Liability and Property Damage Insur aide
7. File with the Building Inspector as the job i_ro:resses certi-
ficates showing the payment required by the Iochia1 Social
Security Act to the State of Florida or the united States of
America.
S. Assume the responsibility of not employing other than properly
licensed contr'ctors 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 permit each 2 years, and where an owner - builder
has once exercised the privilege herein conferred no second
application 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:
SUBSC UTBLD AAD St•10RN TO BEFORE ME this :24i - day of
15 �• i
l
�� ___ ~- NOTARY PUBLIC