1301 NE 100 St (12)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 specifications must be kept at building during pragress of the work.
Owner's Name and Address
Registered Architect and /or En fieer C,:: ....................:.. __.
Name and address of licensed contractor —
Location and legal description of lot to be built on:
Lot Pe S S - 7-.° Block Subdivision
Street and Number where work is to be done
State work t be done and / pu ose of building by floors)
Before me, the
peared
New Building
To be constructed of
Estimated Total cost of improvements $
Zone cubage required
Distance to next nearest building
Maximum live load to be borne by each floor
STATE OF FLORIDA,
COUNTY OF DADE. j ss
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
uild 17ispector
00;
Chairman
Mcraber
Date...
and who, being by me first duly sworn, upon oath deposes and says that he e.
of the above described construction, that he has carefully read the forg
therein by him suit ed ale true. %r zs
Permit No.._..._ Date
and for no other purpose.
Remodeling Addition Repairs No. of Stories
Kind f foundation Roof Covering
Amount of Permit $.
plan Cubage
Size of Building Lot
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 k such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subcontractors, on work to rformed under this
permit, as are licensed by Miami Shores Village. n
Remarks. .._ (Signed)..
ersigned thority, a nota ublic, duly authorized to administer oaths and take acknowledgments, personally'.ap
OwN6
` ... _ ..._._._..._ 19 ..7 6
JUQ...,C..__. Street„1... .Q. ..S
tome. =well `known,
ation, and that he did sign ' th`4ahie, and that4l1 ,Eacts
, - �) /, fore me.
Disapproved - ate.__...._______.... .._....® � ��4 ) � r (
(Signed)
Notary Public, State of Florida
NOTARY IC STATE OF FLORIDA AT LARGE
My Commission Expires {{}�q{�;S;,p'1 EXPi::Sl1EC 5.1979
BONDED THRU GENERAL INS. UNDERWRITERS.
PLAN b NC BOARD DATE
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 hoard.
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.
43
f 4-
• 3 —
" E_ e. N C c-A
IA C v �.
J