258 NE 100 St (11)l ZZ PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
I l g� 2 S t C P2 too S Date Job Address Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant 9: 2 7'()/( Master Permit # 3 9-e-,3_4
Owner's Address J a -a `7 - 1.S R &o
P
Contracting Co.
Qualifier Phone
State # Municipal # _ Ins. Co.
Architect/Engineer
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
,e
� A)
Square Ft. Estimated Cost (value)
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I
certify that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Signature of owner and/or Condo President Date Signature of C tractor or Owner- Builder Date
Notary as to Owner and/or Condo President Date Notary as to Contractor or Owner - Builder Date
My Commission Expires: My Commission Expires: 04=) 9
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LEES: PERMIT
1 , RADON C.C.F. • -0 NOTARY ` ^. - _.. i TOTAL DUE e- i'6 —
APPROVED:
Zoning Building )/t191 Electrical
Mechanical Plumbing Engineering
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build-
ing or oilier structure herein described. This application made in compliance and con ormity with the Building Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws cf the State of I lurida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Divi;.inn of :' iiami Shore, Village ‘.11-.'11)e complied with, whether herein specified or not. A copy of approved
plans and specifications must be kepi at building during progress of the work.
Owner': Name and Address ' t "` � kS
Registered Architect and /or Engineer _.
Name ■nd address of licensed contractor __.r _
_
Location and legal description of lot to be built on:
Lot
New Building_
To be constructed of
Permit No._ ____
Disapproved _
(Signed)
Member _ _
Council Approved
Block.
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Street and Number where work is to be done
rk to one and rose of building floors)
MIAMI SHORES VILLAGE
APPLICATION FOR BUILDING PERMIT
BUILDINC INSPECTION DEPARTMEN"
Subdivision
Date
_Size of Building Lot
BuildirrIr}dpectoi• My Com:nission Expires
Notary Public State of Florida
No Street_
Read, Sworn to and Subscribed before me.
19
and for no other purpose.
Remodeling__ ____ _ -._. Addition.__ ..__ _.. __._ __ _ Repairs. _ .. _ . _ No. of Stories .. .
Kind of foundation .- _ _ .. __ Ropf Covering.. _
Estimated " ,tal cost of improvements $_ _ Amount c•f Permit $_
Zone 'ubage required __. _Plan Cubage_.____.
Distance to next nearest building__
Maximum live load to be borne by each floor _ . __._. ___ . _. ......... _.
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 1:.bor under he Florida Workmen's Compensation Act, being Section 5966, Compiled Gen -al Laws of Florida, P••r.hanen; Snppli'nent,
and h :s complied with he • provi;ions thereof, and will require similar comn iance from all contractors or sub - contractors emplo'•ed by hint
in the wo k to be p' rf '•med under this permit: and - rill post or cause to be posted for inspection on the site of the work such public notir e
or r otites as are requir d by the Act. The u;chr.ignwd agrees to employ only such subcontr,.etors, on work to be perform. d ,;.der this
permit as are licensed by Miami Shores' illage.
Remarks (Signed)
Before me, the undersigned authority, a notary public, duly authorized to administer oaths r.nd take acknowledgments, personally a p-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the
of th abov. de .. ibed istruction tl,s h, has careiully read the foregoing application, and that he did sign the same, and that all facts
therein by him state are true.
PLANNING BOARD .. DATE
Chairman Member
Member ..__ ._ Member
Member
- _ . .Date Disapproved . Date
NOTE: A charge of $1.00 will be made for making corrections or 2hanges to this. application after approval h s be n obtained from
the Planning Board.
A re- inspection fee of $1.00 will be charged when such re- inspection is mu.:e necessary by improper notice for inspe' term or hu.lty
materials and /or workmanship.