1217 NE 100 St (18)BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby wade 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 spccifications must be kept at building during progress of the work.
Owner's Name and Address .
Registered Architect and /or
MIAMI SHORES VILLAGE
eer
Name and address of licensed contractor ,1.4!.._
Location and legal description of lot to be built on:
Lot / Block s.. Subdivision e .. _..
Street and Number where work is to be done j02.2. , 7 2 Z . ‘ ) . . 1 .
State work to be done and purpose of building (by floors)
/ j Date. 9 ' , 1�
__ No..1 x , . Street. '
A A
9a • 3 PT-
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
Roof Covering
1s: c90
To be constructed of Kind of foundation
Estimated Total cost of improvements $ J..4/ 11 0 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 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 public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractor on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed) .t'./�(C%
STATE OF FLORIDA, `
COUNTY OF DADE. j ss
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, persortally 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.
Permit No._- .. 1- . 7, 1.4 Date 5 Read, Sworn to and Subscribed before me.
Disapproved Date
Notary Public, State of Florida
(Signed)
Building Inspector My Commission Expires
PLANNING 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► oft faulty
materials and /or workmanship.
'I LIE IIAR'I'FOP
1\ >c1SA \cl: GltoLr
.•<ATFOAU. CONNECTICUT
. 1 hi, i, to certify that the company designated 1Co. Code 1
hrrcin by Co. Code has issued to the named insured I 5
;he policies enumerated below.
The policies indicated herein apply with respect to the hazards and for the coverages and limits of liability indicated by
specific entry herein but this certificate of insurance does not amend, extend or otherwise alter the terms and conditions
of the insurance coverage in the policies identified herein.
Ilazards
General Liability
1 'rc m i,e.- Operations
Independent Contractors
Completed Operations;
Products
Cont ract naI (as described
below)
Hazards
Automobile Liability
(■cncd Automobiles
11irc•d Automobiles
Non-Owned .\titontobiles
�1 orkmen's Compensation
and
Employers' Liability
Umbrella Liability
Form .V. -I2 -,S 1';i ;h•d in 1'. \.
II Hartford Fire Insurance Company ;
[J Ilartford Accident and Indemnity Company
4I] Hartford Casualty Insurance Company
Policy Number
and
Policy Term
21SMP115432
12/15/73 -76
n
Policy Number
and
Policy Term
21 C 785744
12/15/74 -75
n
21 wH617849
12/15/74 -75
I f policy is canceled, 10 Days
written notice will be given to:
CERTIFICATE, OF 1'NSURANCE
(SINGLE LIMIT)
Bodily Injury and
Property Damage Liability
each
occurrence j aggregate
$ 300 ,000
$ ,000;$ ,000
$ 3Q0 ,000
S ,000
H & H SCREEN ENCLOSURES, INC.
P. 0. BOX 660450
MIAMI SPRINGS, FL. 33166
Qq ,000
0 ,000
$
(SINGLE LIMIT)
Bodily Injury and
Property Damage Liability
*each I aggregate
occurrence
8 ,000 XXXX
$ ,000 XXXX
$ ,000 XXXX
ll.tte 09/23/75+ By.„. ........
Coverages and Limits of Liability
,000
$
$
$
$ C6] New York Underwriters Insurance Company
!7j Twin City Fire Insurance Company •
Named Insured and Address
s 100
u00
$ 100
Bodily Injury Liability
each
occurrence
,000
,000
,000
$ ,000
Coverages and Limits of Liability
(DUAL LIMITS)
Bodily Injury Liability
*each
Each person
occurrence
,000
,000
,000
$ 300
$ 300
Compensation - Statutory
Employers' Liability
$ ,000,000
(DUAL LIMITS)
aggregate
8 300 ,000
,000
,000
Miami Shores Bldg. Dept.
11050 NE 2 Avenue
Miami Shores, F1. 33153
Property Damage Liability
each
occurrence
aggregate
XXXX S ,000 S ,000
XXXX $ ,000 S ,000
$ ,000 $ ,000 $ ,000
XXXX S ,000 S .000
Property Damage Liability
*each aggregate
occurrence
S 50 ,000 XXXX
S 50 ,000 XXXX
$ 50 ,000 XXXX
- $ 100 ,000
'If ith respect to Automobile Liability the Policy Number entered above includes the symbol GB, AZ, MVP, MAG or PGI3, the sword "occurrence"
is amended to read "accident ".
Location and description of operations, automobiles, contracts, etc. (For contracts, indicate type of agreement, party and
t i i t t •.1 ALL OPERATIONS IN THE STATE OF FLORIDA
MITCHELL & CO., INC. 220788
Authorized Representative