405 NE 101 St (11)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 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 Villar 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 '5'06
r ' ' E /0
STATE OF FLORIDA,
COUNTY OF DADE. SS.
ts ,Architect and /or Engineer
address of licensed contractor (i A..
Location and legal description of lot to be built on:
Lot Block Subd / '�'"/'''
Street and Number where work is to be done 1i . f . 6 l r
MIAMI SHORES VILLAGE
State work to be done and purpose of buildiy
New Building Remodeling
To be constructed of Kind of foundation
Estimated Total cost of improvements $
Zone cubage required
Distance to next nearest building
sas — t
amount
.f ----r L —
� Sf -- 3s
Size of Building Lot
of Permit $x.1
Building Inspector (/ My Commission
Read, Sworn to and Subscribed before me.
Street._y.U
and for no other purpose.
Addition x. Repairs No. of Stories
Roof Covering
.Plan Cubage
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 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, Pennxne•nt Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or .sub 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 arc required by the Act. The undersigned agrees to employ only suc bco work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks..._ (Signed
Bcfore me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
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 e true.
Permit No.._... /1 L. Date / 5
Disapproved ,.g Date..
(Signed)
Notary Public, State of Florida
to me well known,
Expires
PLANNI 1 BOARD DATE
Chairman / Member
Mfernbcr — Member .»
Member sass... __.._._.-- _- -_..---- .• - _ - .. 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 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection at faulty
materials and /or workmanship.