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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 SI • es Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein spec % d or not. copy of approved
plans and specifications must be kept at building during progress of the work. /
/� Date 36 , 19 S
/ /4 L2 e et
es
Owner's Name and Address
Registered Architect and /or Engifieer
Name and address of licensed contractor vim"
Location and le al description of lot to be built on:
Lot Block /1,7 Subdivision
Street and Number where work is to be done
New Building
To be constructed of
and who, being by me first d ly sworn, upon
of the above describ -d constr ction, that he
therein by him state.` are true.
MIAMI SHORES VILLAGE
State work to be done an pose of b ing (by floors)_
490 ___ /9,
and for no other purpose.
a �. Remodeling Add' 'on p No. of Stones
Estimated Total cost of improvements $
Zone cubage required
Distance to next nearest building
o oun
Kind f foundation
Repairs m f � Roof C overing
Amount of Permit $ ��
_Plan Cubage I2 (40 Czb
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 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 ublic notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performe under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed)
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
Date
Date
Member
Member
Council Approved Date
i _ �, Read, Sworn to and Subscribed before me.
deposes and says that he is the_ .
arefully read the foregoing application, and that he did sign the same, and that all facts
D,
Permit No
R
Disapproved
Notary Public, State of Florida
( Sig
ui ding't spector / ` My Commission Expires
NNING BuARD DATE
Member
Member
Member
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 $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
to me well known,
Disapproved Date
(16 C5981 //14 1/
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