121 NE 100 St (4)Estimated T ;tal cost of improvements $_
STATE OF FLORIDA,
COUNTY OF DADE. j ss.
Building Inspector
MIAMI SHORES VILLAGE
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for rhe build-
ing or oiler 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 Divi:,ion of 'Miami Shore-: 1 illage shag be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kepi at building during progress of the work.
Date 7° r-
Owner's Name and Address S a No Street
Registered Architect and /or Engineer.__
Name and address of licensed contractor.
Location and legal description of lot to be built on:
Lot E._ID ''- _ A.'- - r 7 - -- ._ Block.._ _ -_.. /. ._ Subdivision - .
Street and Number where work is to be done /_ _.bL.� .: l Q_.Q____ .
State work-'to be done purpose of building (by floors)
_ -- 5 -�¢ _ A�_m:: �: k and for no other purpose.
New Building _ . Remodeling_ -____ ..._ Addition_....__ _ -- __. airs..._ ... _ .} ,No. of Stories
To be constructed of Kind of foundation.________ __________.... _ ____ ....... _ .. _..._..... _... Roof Covering
Amount c.` 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 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 iilat he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled Cent ral Laws of Florida, Pernancni Supplement,
and has complied with the provisions thereof, and will require similar coninliance from all contractors or sub - contractors cmplo.•ed by hint
in the work to be perfn - med under this permit; and Ivill post or cause to be posted for inspection on the site of the work such public notice
or notices as are requir-d by the Act. The undersigned agrees to employ only such subcontr..ctors, on work to be performed : mdcr this
permit as are licensed by Miami Shores k illage.
Remarks -- (Signed)
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally app -
peared and who, being by me first drily sworn, upon oath deposes and says that he is the
of thr abov. de,cribed , nstruction, thit h. has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Permit No Date Read, Sworn to and Subscribed before me.
Disapproved Date___
Notary Public. State of Florida
(Signed)
PLANNING BOARD DATE
Member Memer • Member
Chairman
Member Mernber __.
BUILDING INSPECTION DEPARTMENT
My Commission Expires.
to me well known,
Council Approved. _Date Disapproved e. 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 $1.00 will be charged when such re- inspection is m.: le necessary by improper notice for inspcetum or f
materials and /or workmanship.