390 NE 101 St (2)MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the appro\'a1 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, wheth herein specified or not. A copy of approved
plans and specifications must be kept t b ding dlrFing progress of the work.
Owner's Name and Addres
Registered A hiteet and /pr Engineer.,—. -.-
Name and address of licensed contractor...
New Buildin
Location and legal description of lot to be built on:
Lot Block
Street and Number where work is to be done 1 7 . 0
Staf work to be don . / . ose of building (by fl • • rs
To be constructed of Kinde� ion
Estimated Total cost of improvements $... t. (..ld
Remodeling Addition Repairs No. of Stories .. —
hoo o
Amount of Permit $, ( p
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 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 pennit 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 f.r spection on the si , of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only sue . •ntr•ctors, on rk to be rf•j ed under this
pennit, as are licensed by Miami Shores Village. , /I
Remarks (Signed / //,�
STATE OF FLORIDA,
COUNTY OF DADE. ss
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and
peared
Notary Public, State of Florida
and for no other purpose.
acknowledgments, personally ap-
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.. _ ° Date /(--- d — Z-- Read, Sworn to and Subscribed before me.
Disapproved __._. . -. Date
(Signed)
Building nspector / r My Commission Expires
PLA NC BOARD _.._ DATE
Chairman Member
Mernber - -.._. 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 hem obtained from
the Planning Board.
A re-inspection fee of 51.00 will be charged when such re- inspection is made necessary by improper. notice for inspection or faulty
materials and /or workmanship.
/VE1OZST
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