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285 NE 100 St (13). MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Buil.ing Inspection Request Date 7 Type Insp'n r. PCA Permit No. P 4-1 se . Name Address 2 1 Company Phone # Inspection Date Re- Insp'n Fee - ❑ Permit Type (circle): • BUILDING PERMIT APPLICATIO FBC 2001 Owner's Name (Fee Simple Titleholder) Owner's Address � ( gA l Job Address (where the work is being done) '. SS Describe Work: Submittal Fee $ Permit Fee $ Notary $ �-'— Training/Education Fee $ Scanning $ Radon $ Code Enforcement $ Total Fee Now Due $ (Continued on opposite side) Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No. f 5e 4 n DEC 0 3 tTii Master Permit No. i Electrical Plumbing Mechanical Roofing Phone # 2R1 8S City x.11 _ +L.i State �L_ Zip GU Tenant/Lessee Name Phone # N /— City Miami Shores Village County Miai ' -Dade Zip cj(3U Is Building Historically Designated YES NO Contractor's Company Name VU,LQ 1 Phone # Contractor's Address City State Zip Qualifier State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # $ Value of Work For this Permit . Square Footage Of Work: Type of Work: ['Addition ['Alteration [New ❑ Repair/Replace ❑ Demolition * * * * * * * * * * * * * * * * * * * * * « ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Zoning Structural Plan Review. $ CCF $ ( ( C CO /CC Technology Fee $ - SO Bond $ Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC 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. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection t be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of , 20L { by , day of , 20 _ , by (moo is personally known to me r who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: NOTARY PUBLIC; �. Sign: Print: V i� r f-1_, My Commission Expires: *********************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Chc 05/13/03 f l { z My Commission Expires: * * * * * * * * * * * * * * * * * * * * * * ** • . 6: ******* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Lt, - E 2004 Plans Examiner Engineer Zoning Date Z o.o Owner's Name • Owner's Address City Miami Shores Village Paint Color Approval and Agreement State -{ Job Address (where the work is being done) City Miami Shores Village Is Building Historically Designated YES County Miami - Dade Zip 3I R Phone # Zip c j I S CE -7,g6 z8( g3 Phone #7S62 zl 8974 Contractor's Company Name (if applicable) ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All elements on the site must be listed and indicate the color to be painted Walls \C —W2 gt1 t r� 3, -eAo 1 Lo\r \t- Fascia Drip Cap/drip `" drip Eddge tic G —k� _ r Soffit 14- C. ((r) �� � i) `! Roof ( J /l.- Flower bins OA. Shutters C 91 r ( A GI Awnings / � 1• - Chimney A-C —k-17 q(a'/l (k L,17�AL Doors and door jams l ms Q Garage doors Q( Vl r�SA'm�� c q Railings Fences A- Decorative metal !`-'A- ' f All brick (simulated or re lar) AC --`-�2 %C LAL Stucco banding Nr- Any other stucco features 0/1- -'r Accessory Buildings N/A l - Other t ,1. l C —�Z � ✓l -A, 4Q �� `� L C- ************************************************************************************************************ OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicabl aws r• ating construction and zoning. Signature APPLICATION APPROVED BY: Owner or Agent Attach Color Samples With Numbe's c/a-6314 0 D ate 12- l `-' C-/ Date uos ' i.p s i 6 g - • Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 12 /8/2004 Applicant: BOB Owner: BOURNE JOB ADDRESS: 285 Contractor Local Phone: Parcel # 1132060134700 NE 100 Signed: (INSPECTOR) Signed: (Contractor or Builder) Building Permit Permit Number: BP2004 -1586 BOURNE BOB ST Contractor's Address: Page 1 of 1 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 E1/2 OF LOT 21 & LOTS 22 & 23 BLK 34 LOT Fees: FEE2004 -12267 FEE2004 -12268 FEE2004 -12269 FEE2004 -12270 Description Building Painting Fee CCF Training and Education Fee Technology Fee Total Fees: Amount $60.00 $0.60 $0.20 $1.50 $62.30 Total Fees: $62.30 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 6/1/2005 Construction Value: $500.00 Work: PAINT AS AGREED In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either myself, my agent, servants or employes. BY: PROPERTY OWNER New Construction Name a��ti C,(%(� ,�yyy''�f� / V ` •��u�n Address Alteration Exterior Home Telephon5) �j� D /= C/ Business Teleph a Alteration Interior Fax Demolish TYPE OF MANAGEMENT (✓ ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Add'l Detachment Other Step I. Address: (>2g '5 v Q f" /00 D 6 Folio Number Lot Block PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other Address Apt. PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax /� State scription of Work — ; �V"(�CAbeQi City PERMIT APPLICATION Master Permit No. Subsidiary Permit No. INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village: Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submit- ted along with this permit application. Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the processing of your application, you may be asked to submit additional information. APPLICATION Zip Subdivision PB PG Zoning Linear Feet Current Use of Property S uare Feet Units Floors Proposed Use of Property ue of Work 70 " DO Bldg Value Tenant Information Tax Assessed/Appraised Value Flood Zone Base Floor Elev. ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Page 2 IMPORTANT NO'T'ICES DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m. to 5:00 p.m. No inspections will be conducted on weekends or holidays. 2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris. 3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS. 4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is required for work in or near the street/sidewalk. 5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer which requires a separate permit. 6. PORTABLE TOILETS for a construction site require a separate permit. 7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department. 8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement. 9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers. PERMIT APPLICATION AFFIDAVIT - Please read carefully. Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY, ROOFING and SIGNS and there may be additional permits required from other governmental agencies. I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must conform to the current code requirements of the Building Code. WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at: 22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and Choosing a Contractor. STATE OF FLORIDA, COUNTY OF M AMI -DADE STATE OF FLORIDA, COUNTY OF MIAMI -DADE XA 44 /4- Signature of Owner Signature of Contractor / Qualifier Print Name to and subscribed before me this SEAL: day of Print Name Sworn to and subscribed before me this day of gnature o Publi - S to of orida Signature of Notary Public - State of Florida u 411 Angela M Bed 150048 a My Commission DO SEAL: Expires November 15, 2008 a or s. Personally known OR, Produced Identification V Person known OR, Produced Identification Type of Identification Produced: j�L� D ) /-13 -rs° p161 l tification Produced: SECTION BY D E Zoning 4 >i77 ///d S7O-: Electrical Mechanical Plumbing Fire Public Works Structural / g /�,0 ° " Building Official Page 4 OFFICE USE ONLY ❑ OWNER - BUILDER FORM (Attach) ❑ FIRE DEPARTMENT APPROVAL (Commercial / multi - family) ❑ CONCURRENCY (New Construction) ❑ OTHER (Specify & Attach) ❑ PROOF OF OWNERSHIP (Attach) ❑ HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) ❑ OTHER (Specify & Attach) PERMIT APPLICATION CHECKLIST ❑ CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) PERMIT FEES $3.00 per page (Scanning Fee) Miami Shores Village Bond $ 0 Metropolitan Dade County (C.C.F.) $ (sq.ft. = x/1000 x ¢.60) Inspector State Educational Fund $ State DCA (Radon) $ Code Enforcement Fine Zoning Review Notary $ (¢.005 /sq.ft.) (¢.01 /sq.ft.) TOTAL $�7 - D ISSUING OFFICIAL REVIEWED AND PREPARED BY: DATE: CONDITION OF APPROVAL Revised July 2001 10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com ELEC'T'RICAL 'I'VI'I Minimum Fee on'. 'I'1'PE Dryer Q"1'1'. TVI'E Outlet, Appliance QTY. '1'1'1'1? Service Repair QTY. A/C Central 1 -3 Ton Dryer Vents, Number of Fan Ventilation, Cost Outlet, Wall Ductwork, Cost of Service, Temporary Periodic Inspections A/C Central 4 -7 Ton Fire Sprinkler System Fire Pump Outlet, Switch Fireplaces, Number of Signs A/C Central 8 -15 Ton Fixture - Fluorescent Oven Space Heater (kw) A/C Central 16 -20 Ton Fixture Light Parking Lot Lights Spas/Hot Tubs A/C Central 20+ Ton Flood Lights Plugmold/Strip Subfeeds, No. of Amps A/C Window FPL - Load Central Posts Swim Pool, Commercial Air Conditioners Garbage Disposal Range/Range Top Swim Pool, Residential Chiller Generators, etc. Receptacles Switchboards Clear Violations Heat Recovery Refrigerator, Comm. (p/PH) Temp Serv., Construction Compactor Low -volt, Burglar Refrigerator, Domestic Temp for Test - 30 days Deep Freezer Low -volt, Fire Renew - Temp Service Water Closet Demolition Low -volt, Intercom/Teleph. Repair Circuits Water Heater Dishwasher Low -volt, Television Service, Number of Amps Water Heater New MECHANICAL i'vrE Minimum Fee QTY. TYPE Condensate Drain vv. '1'vpi: Generator QIY. 'I'1'I'E QTY. Refrigeration, Tons A/C Central, Tons Cooling Tower Heating Strips, each Vent Hood, Cost A/C Wall/Win. Tons Dryer Vents, Number of Paint Booth Ventilation, Cost Air Handler, Tons Ductwork, Cost of Piping, Flammable Liquid Periodic Inspections Barbecue Fire Sprinkler System Process/Pressure Piping Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel PLUNIBING Typr. A/C Condensate QTY. TYPE Drains, Roof QTY. TAPE Miscellaneous Fixture Q.Ly. .LYI,I, Soakage Pit ()Ty. Bath Tub Drinking Fountain Miscellaneous Repairs Solar Water Heater Bidet Filter Replace Pool Piping Sprinkler Repair Cap - Fixture Fountain Pump and Abandon Sprinkler System Cap - Water Gas - Appliance Pump, Domestic Supply, AC Well Cap - Sewer Gas - Natural Pump, Fire Stand Temporary Toilet Catch Basin Gas - Propane Pump, Re- circulate Temporary Water Closet Clothes Washer Gas Piping Pump, Replace - Pool Urinal Dental Chair Grease Trap Pump, Sprinkler Utility - Sewer Discharge Well Ice Maker Pump, Sump Utility - Water Dishwasher Indirect Wastes Relay Repair Vacuum Pump Disposal Interceptor Roof Inlet Water Closet Domestic Well Laundry Tray Septic Connection Water Heater Drainfield, 4" Tile/Res. Lavatory Septic Tank Water Heater New Drains, Area Meter Set (Gas) Sewer Connection Water Re -pipe Drains, Floor Minimum Fee Shower Water Service Drains, French Miscellaneous Equipment Sink Well, Supply Page 3 PERMIT APPLICATION INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below. RECEIVED AND REVIEWED BY: DATE: PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Dates 71 02 7/ 9 Address 2c 5 / V . & S / Tax Folio Legal Description Historically Designated: Yes No Owner/Lessee / Tenant .& L / 0 d' S 7749 / f f S E e.... Master Permit ## 3 2 7,7)0 Owner's Address Phone 7s ec - Contracting 7 Co.C�.;crey'Av? g . Se44 �ZP O Qualifier SS# State # Municipal # Competency # Architect/Engineer Address Bonding Company Address Mortgagor Address Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAYING FENCE SIGN WORK DESCRIPTION Signature of owner and/or Condo President Date I•EES: PERMIT 1 y} RADON Square Ft. Estimated Cost (value) c2 i(C) 9 azx /46/cL Notary as to Owner and/or Condo President Date Notary as to Contractor oLOWner-Buildkr-. My Commission Expires: M Co B p resi. I' OTAnV SEIA! I �. sAR'.®na Ll EONTIEL 4s011-.F_\.09- � ra s d,® o g C.C.F. )/5 NOTARY • TOTAL DUE 4 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 Contractor or Owner- Builder Date Date APPROVED )114<!/.' Engineering Zoning Building ""Ui ; Mechanical Plumbing Name MClrqn Address 265 R6 co 5+ Approved Correction Re- Insp'n Fee o 4O2 MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date ‘OIO Time Type Insp'n 'r1Cal Think Permit No. N20021- 2 20 r 10 Company Phone # For Inspector: 10103 Name & Date DATE: OWNER S MIAMI SHORES VILLAGE Paint Color Approval and Agreement ADDRESS: /do SL . ********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ADDRESS OF SITE: S ake 'z q, CONTRACTOR &'LICENSE (if applicable) COMPANY NAME: ********************************** * * * * * * * * * * * * * * * * * * * * * *. * * * * * * ** All Elements on the site must be listed and indicate the color to be painted. Walls Fascia Drip Cap/Drip Edge Soffit Roof Flower Bins k,' Shutters --- rfAd_49-, Awnings Chimney Decorative Metal Doors and door jams Garage Doors /e_. Railings Fences All brick (simulated or regular) Stucco Banding Any other stucco features Accessory'Buildings Other Building Official j) /43 Date ONE PHONE: AA N) CALL FOR FINAL INSPECTION 755 -vao z OWNER'S AFFIDAVIT: I certify that all the forego and that all work will be done in compliance with all - - - - - - - - - -- c o n s t r u c t i o n and zoning. I authorize the above -named contractor, if applicable, to do the work stated. Furthermore , the paint colors will be as per the attached i 1t/ 4/23/01 ignature of Owner Date Signature of Contractor Date *********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED: WHEN PAINTING IS FINISHED, Miami Shores Village 10050 NE 2nd Avenue Building Permit Phone: 305 - 795 -2204 Permit Number: BP2002 -2070 Printed: 12 /2/2002 Applicant: MARTHA MERCER Owner: HATTESEN JOB ADDRESS: 285 NE 100 Contractor Local Phone: Parcel # 1132060134700 This Permit is granted to the contractor or builder named above to construct the b� ordinances pertaining thereto and with the understanding that the work will be perforr and approved by the proper municipal authorities. This Permit may be revoked at an authorization. A further condition upon which this permit is granted is the understand ordinances and regulat .ns pertaining to the ork covered hereby whether shown on by his agents, sery . .r employee Signe (INSPECTOR) In consideration of the issuance to me of this permit, I agree to perform the work co with the plans, drawings, statements or specifications submitted to the proper authoril myself, my agent, servants or employes. X Signed! .wi /k c-. )d), /✓ (Contractor or Bu HATTESEN MARTHA MERCER ST Contractor's Address: Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 E1/2 OF LOT 21 & LOTS 22 & 23 BLK 34 LOT Fees: Description Amount FEE2002 -6838 Building Permit Application Fee $60.00 FEE2002 -6839 CCF $0.60 FEE2002 -6840 Notary Fee $5.00 Total Fees: $65.60 Total Fees: $65.60 Total Receipts: $0.00 Permit Status: Approved Permit Expiration: 5/31/2003 Construction Value: $700.00 Work: EXTERIOR PAINTING AS PER AGREEMENT If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection fee is $50.00, which must be paid in advance before calling for another inspection. Bank of America Advantage' 4522 02-80 63 27/631 8 EL ��� /// �,/ 988 Date : -QC 1 � a2oo 2_ Pay -- -u' v - r - c--4 / / ct � —J $ G s' G o to the order MARTHA M. HATTESEN 285 N.E. 100TH ST. MIAMI SHORES, FL 33138 -2418 ACH R/r 063100277 Page 1 of 1 : °"' -` Z �. , Cam•- -- Dollars ° Arh Bankoferica. ; )2) / Memo 1:063 LOO 2? ?1: 0040L3 LOO L4411' 4522 i T+s� M1 *LORI PA SMTE The Sunshine Slate - MARTHA MERCER HATTEFEN 2,8 5-NE 100 ST MIAMI, FL 33138 -2918 DATE or RIRTN STY NTIGNT R(STTRCTNMS (NDDRSEM(NTS • 01-26-24 F 5 -09 A ❑C(NGUID MUM( R KSUED 01 -29 -92 H325 -553- 24--526- 0(o 01-26 -98 CLASS: E SAES DR IVER- o F ""` 00--00 -00 ■4# 264.22-4229 30292034439 Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building 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 Registered Architect and /or Engineer / Name and address of licensed contractor /47/6 /s / A' �� ?le:6/�L12'Z. Locate ro5 nland� descrii � j�f J /�to be built on: Zee �/ � '/ / 7 A® Lot / 1 Block 11 / Subdivision "7 ` I/ / J°c®1 /i Street and Number where work is to be done ' J y/• /.6 51- State work to be done and purpose of building (by floors). state exterior colors (submit samples) ' ` .//7 1 0 / ei ee'/ef/ rd o -, heix -,sr_ col.• 31, -/e +ee a, -,06 e 5 -4, .e 7 464?.,,, , ,n. 05/4., and for no other purpose. • New Building Remodeling Addition Repairs No. of Stories To be constructed of Kind of foundation Roof Covering / Estimated Total cost of improvements S J (PO U Amount of Permit S � °U Ibage accepts his obligatons as an employer of Labor under the Florida Workmen's ant, and has complied with the provisions thereof. and will require similar ned under this permit: and will post or cause to be posted for inspection ned agrees employ only such su • • ractors. on work . be performed r. tternagtts (Signer/ 0 ' /t /(/ � STATE OF FLORIDA COUNTY OF DADE. Permit No. l P Disapproved (Signed) R40 c I SS. MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Building Inspector Date reN DRWOOD, MOORGARD and MOORGLO are registered trademarks of Benjamin Moore & Co. to t /3/ L'do, 6 2 p Date / . 19 YZ Y No. d J Street /100 Sr Sand Dollar 38B - 1P Before me. the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared Read, Sworn to and Subscribed before me. Notary Public. State of Florida It to 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. Date 6 (11 N My Commission Expires PLANNING BOARD DATE Chairman Member Member Member Member Member Council Approved Date Disapproved Date NOTE: A charge of $25.00 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 $25.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and/or workmanship.