1285 NE 101 St (3)MIAMI SHORES VILLAGE
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. ..... 4'
Registered Architect and /or Engineer..._._ ....
Name and address of licensed contractor
Location and legal description of lot to be built on:
Lot Block Subdivision.
Ste work to be done and purpose of building (boors)...
( 10- 64t -54. e ! y ? - e f —
New Building .. Remodeling. 1F Addition
Street and Number where work is to be done 1. _) �
Estimated Total cost of improvements $ ? it I
'/.44--6j444../
To be constructed of Kind of foundation
Zone cubage required
Distance to next nearest building /
permit, as are licensed by Miami Shores Village.
.
r
Date L 0 ? / 19/
No. il�..� Str`e�: /Uj.
!. -1 4 Y:�`
Remarks (Signe 7= a
/0>
Repairs J
411-a 4t e
nd for no other purpose.
No. of Stories
Roof Covering
Amount of Permit $
_Plan Cubage
Size of Building Lot
Maximum live load to be borne by each floor
all tje plans anl�iecifications for d building. All notices with referenpg to the building and it; construction
I hereby
The undersigned applicant for this buil�ifig pennit does hereby certify that he understands ajd accepts his obligations as aq� employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled GenerdI Laws of Florida, Permanent Sup element,
and has complied with the provisions thereof, and will require similar compliant roih all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be p ed,for inspection on •t a site of the yvor uch public notice
or notices as are required by the Act. The undersigned agrees to employ only? h subcontractor , od work to be,P4xformed under this
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.
Permit No
Disapproved 3n',3
Date - Read, Sworn to and Subscribed before me.
D e ' --
/. /C , �---
(Signed) ,Y -:: � �
Building Spector My Commission Expires
Notary Public, State of Florida
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 $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
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