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432 NE 100 St (7)441$ OCT 0 6 2005 IAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date Id4If6 . Type Insp'n F114I Roir Permit No. ' 722x5 - 133'1 Name tbAald 5'((X', Address 432 IU E 10057 Company aUkti Phone # 786/663 -4621 Inspection Date 1615106 Approved LK ,&', v Correction ❑ Re- Insp'n Fee ❑ Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 9/16/2005 Applicant: DONALD Owner: SHOCKEY JOB ADDRESS: 432 Contractor Local Phone: Parcel # 1132060170370 Signed: NE 100 Signed: (Contractor or Builder) Building Permit Permit Number: BP2005 -1337 SHOCKEY DONALD ST Contractor's Address: Legal Description: AMD PL OF MIAMI SHORES SEC 4 Permit Status: APPROVED Permit Expiration: 3/13/2006 Construction Value: $1,200.00 Work: PAINT AS AGREED (INSPECTOR) BY: Page 1 of 1 PB 15 -14 LOT 7 & 8 BLK 89 Fees: FEE2005 -12495 FEE2005 -12496 FEE2005 -12497 FEE2005 -12498 Description Building Painting Fee CCF Technology Fee Training and Education Fee Total Fees: Amount $60.00 $0.60 $1.50 $0.20 $62.30 Total Fees: $62.30 Total Receipts: $0.00 SEP 1 6 PAID cis 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. i BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): City Owner's Name (Fee Simple Tit o der Ow .-r' Address Tenant/Lessee Name Job Address (where the work is being done) City Miami Shores Village Is Building Historically Designated YES $ Value of Work For this Permit / Q- 0 0 Type of Work: Describe Work: Submittal Fee $ Notary $ Scanning $ Code Enforcement $ State Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Total Fee Now Due $ r 2 ` 33 OCT 0 4 PAID (Continued on opposite side) Elec is Plumbing Mechanical `� Roofing c5),\ Y ` (Vey Phone # 6,5- ! 7 `�$f C71) it Y Zip 3' N6 O)N 6 County Miami -Dade NO ❑Addition ['Alteration ['New RP. FGiri-7 ex / Permit No. 15P0 Master Permit No. Phone # Contractor's Company Name Contractor's Address City State Zip Qualifier Phone # State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Square Footage Of Work: ❑ Repair/Replace ❑ Demolition Zip 58G ( 3313g ECENZn SEP 1 4 2 * * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * ** * * * * * * * * * * * ** Permit Fee $ CeO , 0 CCF $ O , ) . CO /CC Training/Education Fee $ 0,7Q Technology Fee $ 1 Radon $ Zoning Bond $ Structural Plan Review. $ 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 will not be approved an,' 0 reinsp; ction fee will be charged ��A k / , � A , �.'t /a.J� 4 . Signature Own: or Agent Contractor The foregoing instrument was acknowledged b= a me this / C1 The foregoing instrument was acknowledged before me this day of Se,/ ' . , 20 V5, by (j nrt lA .SinG (Jf day of , 20 by who is personally known to me or 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: 0 L\ I/ d) W I' n_54 Print: My Commission Expires: Lynn W Bernstein My Commission Expires: * * * * * * * * * * * * * * * * * * * * * * * * ** $ ******* v g*************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** �a pi Expires Septern e 11 2005 ******************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * *** * * * ** *fit * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Signat NOTARY, Sign: chc 05/13/03 UBLIC: /)) APPLICATION APPROVED BY: 15 0\1 Plans Examiner Engineer Zoning Signature • Date Owner's Name Own- 's Address City APPLICATION APPROVED BY: Miami Shores Village Paint Color Approval and Agreement Phone # (3b—c — 772 , r 0 g() 1 •A=-Aril Owner fr Agent Zip Flower bins Shutters go 'At) ife -6.4 . pgcN >coi Pv - If - � ho& Awnings Chimney ) 93 Doors and door jams f e Job Address (where the work is being done) q( N 1 ,A,- \ 6.-fr zA� City Miami Shores Village County Miami -Dade Zip e3c� l T Is Building Historically Designated YES NO ; \ Contractor's Company Name (if applicable) Phone # ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All elements on the site must be listed and indicate the color to be painted Walls / ? 3 rnoA N ( A ) I 1 J)e � w Fascia tr /T _ Drip Cap /drip Edge 1» t4-ct L ez to 12, ( ok burrs'ititio ) )� Soffit U) rT l -ke Roof (ly - ' Garage doors Railings Fences l ( Decorative metal f �"'+ FO 54- WA- � -L _ — ��O (yea 5 04 39 All brick (simulated or regular) 11_ Stucco banding W l I -1-- Any other stucco features Accessory Buildings JJ3 morning dew Date Date 1493 \ BENJAMIN MOORE 046 Other ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** 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 constructio and zoning. A pl) chc 6/18/07 �+ Permit No. -�' Na MIAMI SHORES VILLAGE BUILDING DEPARTMEN Buildin • 305- 795 -2204 Inspection Reques (e0/ g P Date Time Type Insp'n For Inspector: Approved' Correction Re- Insp'n Fee 0 Address [ Company Phone # Name & Date MIAMI SHORES VILLAGE Paint Color Approval and Agreement DATE: 1 Lo - OWNER' S NAME: Ni,12(A \J t_AF (IJ PHONE: -83 ADDRESS: G- 2 Ng 100 ST. I ` -t P.4 -L. - g 5 l �' ***************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ADDRESS OF SITE: CONTRACTOR & ,ICENSE (if applicable) COMPANY NAME: APPROVED: a2.9-k Building Offi;'al Date PHONE: ********************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** All Elements on the site must be listed and in� the color to be painted. Walls .F% t� - .�adn�t- `L ���% Fascia Drip Cap/Drip Edge 1--e. Soffit Roof , A- LK-Q-O -cat Flower Bins WA Shutters CA) Lt.gt Awnings Chimney • ' • �� Doors and door jams 0 Garage Doors /,4 Railings Ai/A Fences Decorative Metal 1 I 1,^MTI[E 27C All brick (simulated or regular) illi Stucco Banding (il4SS , -v-) L.--- Any other stucco e atures ' a ' y f ��� • - Is SI C CLASSIC SAND B- 1070`" Accessory Buildings ther ed 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. I authorize the above -named contractor, if applicable, to do the work stated. Furthermore , the paint colors will be as per the attached samples. Pce,t v Signature of Owner Date Signature of Contractor Date *********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** WHEN PAINTING IS FINISHED, CALL FOR FINAL INSPECTION 4/23/01 PROPERTY OWNER p O / W � ame / i / M kR V .. L✓"T Ft /" Address ti*, / v �— ( 0 0 1 ( M I sb Rif t_- 33 r Home Telephone 3 or 7.1 F 3 3 3 Business Telephone s o r_ '6' _ g9 5, 3 x 3 al Fax ! � O ,5 — 11-4 — O2I . TYPE OF MANAGEMENT (✓ ) New Construction • Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Add'I Detachment Other INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village: Step 1. 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 Job Address: S tate Zip Folio Number (� ' � 7 17--0? escription of Work TC (,tl ' La ou. 1.Latee Lot X Block"` Subdivision -t,('Q f pp�� � PBts -- p / L t PG Zoning Linear Feet Current Use of Property ..00C -- ID 1(-A9V 2 / Square Feet Units Floors Proposed Use of PropertyaLl` Value of Work I t-f'r O O Bldg Value Tenant Information 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 submitted along with this permit application. Address Par PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other 10 - P A / 1 ..C#o/ S C.. ? 313K Apt. PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax PERMIT APPLICATION Master Permit No. Subsidiary Permit No. do 1. a) ( E City ax Assessed/Appraised Value Flood Zone i 0 Base Floor Elev. ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Page 2 lI tPORTA NOTICES 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. 1. 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. S ATE COUNT y OF MIAMI -DADE STATE OF FLORIDA, COUNTY OF MIAMI -DADE i>c Signature of Owner U 1 4 Signature of Contractor / Qualifier D MA-A1,4 V. Lick...( t•I Print Name -ex. Print Name S rn to 0 annd subscribed before me this 1/ day of Sworn to and subscribed before me this day of Signature of Notary Pu SEAL: tc .:. to of Hlon UDIA CK UwJ., - MY COMMISSION # CC 893589 EXPIRES: April 8, 2004 Bonded Thru Notary Public Underwriters Signature of Notary Public - State of Florida SEAL: PERMIT APPLICATION Personally known OR, Produced Identification Personally known OR, Produced Identification Type of Identification Produced: Type of Identification Produced: SECTION BY D TE Zoning /�/�� j� . 02— Electrical � �/ Mechanical Plumbing Fire Public -Works Structural ' 4 j/z#' Building Official Page 4 OFFICE USE ONLY CHECKLIST ❑ OWNER - BUILDER FORM (Attach) ❑ FIRE DEPARTMENT APPROVAL (Commercial / multi- family) ❑ CONCURRENCY (New Construction) Cl OTHER (Specify & Attach) ❑ PROOF OF OWNERSHIP (Attach) ❑ HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) ❑ OTHER (Specify & Attach) PERMIT FEES $3.00 per page (Scanning Fee) $ Miami Shores Village Bond Metropolitan Dade County (C.C.F.) Inspector State Educational Fund $ State DCA (Radon) $ Code Enforcement Fine $ Zoning Review $ �o ' ISSUING OFFICIAL REVIEWED AND PREPARED BY: (sq.ft. = x/1000 x ¢.60) (¢.005 /sq.ft.) (¢.01 /sq.ft.) PERMIT APPLICATION ❑ CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) TOTAL $ 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 ELECTRICAL TYPE Minimum Fee QTY. TYPE Dryer QTY. TYPE Outlet, Appliance QTY. TYPE Service Repair QTY. A/C Central 1 -3 Ton - Heating Strips, each Fan Outlet, Wall Service, Temporary - Paint Booth A/C Central 4 -7 Ton Fire Pump Outlet, Switch - Piping, Flammable Liquid Signs A/C Central 8 -15 Ton Fixture - Fluorescent Process/Pressure Piping Oven Space Heater (kw) A/C Central 16-20 Ton Pressure Vessel 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 TYPE Minimum Fee QTY. TYPE Condensate Drain QTY. TYPE Generator QTY. TYPE Refrigeration, Tons QTY. A/C Central, Tons Q'I'V Cooling Tower - Heating Strips, each Vent Hood, Cost A/C WaU/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 Pump and Abandon Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel Gas - Appliance - PLUMBING TYPE A/C Condensate QTY. TYPE Drains, Roof QTY. TYPE Miscellaneous Fixture QTY TYPE Soakage Pit Q'I'V 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: �a,9 / (1�r Date 1 ''yt' "! ( Job Address 432 ioc c c DO '�° Tax Folio PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Legal Description Historically Designated: Yes No Owner/Lessee / Tenant M 42 I A ( L,4 f Owner's Address l 3 2 (Do Master Permit # 7q5 Phone .1 OS — --� �" 0 3 B 3 Contracting Co. D k .Q V Address Qualifier SS# Phone State # Municipal # Competency # Ins. Co. Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION ?V`-� --S C Le-cub `6 �© r cu,(-0,,, x .l.rrf:r )4eAr l DV rpotii (4 (r) (D pxliAtc - l vCe:\I--2 Square Ft. Estimated Cost (value) R S-00 ° 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. luwuta U C Signature of owner and/or Condo President L / 0 5-5 9 s- .s - 0 1 1)1 1 . «�:.: . .1 - 0 ICIAL NOTARY GLADYSI VILLAR NOTARY PUBLIC STATE OF FLORIDA COMMISSION NO. CC714I03 MY COMMISSION EXP. MAR. 1,2002 No : as to Owner and/or My Commission Expires: L/-0 FEES: PERMIT RADON Date 4.00 C.C.F. !' g° NOTARY 5 Signature of Contractor or Owner- Builder Date Notary as to Contractor or Owner- Builder Date My Commission Expires: BOND APPROVED: TOTAL DUE �� �✓ Zoning . Buil I ' I / / l I l 'f Electrical Mechanical Plumbing Structural Engineer (S.J L A -c 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 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. r . 19 ?/ Owner's Name and Address l +t . � t'< • /d lJ l it) f No. L1 t;;, 2 Registered Architect and/or Engineer Name and address of licensed contractor 041/ys ie- Location and legs description of lot to be built on: �� ® / /1 �n / Lot Block e9 Subdivision ,-NO P 1 t l / / f(� �treet and Number where work is to be done L4 t0' - \ 0? ( Mate work to b one and purpose of building (by floors). colors (submit samples) l and for no other purpose. New Building Remodeling Addition Repairs No. of Stories To be constructed of Kind of foundation Roof Covering � 7 ��� [/Estimated Total cost of improvements S i +00 Amount of Permit $ .7 ) v 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 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 obligatons 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 undersign . s ` .loy only such subcontractors. on work to be performed under this permit, as are licensed by Miami Shores Village. Remarks (Signed) STATE OF FLORIDA COUNTY OF DADE. ss. Before me, the undersigned authority. a notary public. duly authorized to administer oaths and take acknowledgments. personally appeared 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 foregoin application, and that he did sign the same. and that all facts therein by him stated are true. Permit Na /■? Date / Read. Sworn to and Subscribed before me. Disapproved `� �y Date Notary Public. State of Florida (Signed) t /v � Building Inspector 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.