868 NE 100 St (3)APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the det.'iled stateniem of the plans and specificasions herewith submitted for the build-
ing or o h, :ructure her i described. This tmdicatic is made in compliance and con•o'm ty w.th the Building Ordinance of Mia
Shores Village, .or da, and all pro. isions of the Laws cf the State of hh,rid. all o d nances of Mi .ni Shores Village and all rules and
regu.a ion, of the Building Div.. i of .ram Sho, iilage 1- '1 ,e ^o. ipl.ed with, whether herein specified or not. A copy of approved
plans and specificati ink• must be kei. at building durin,, progress of tl.e wcrk.
Owner' Name and Address__
Registered Architect and /or Engineer.._
Name nd address of licen•,ed contractor.
Location and 1 al descri tion of lot to be built on:
Lot. __. - _3� Block.__ �(�
Street and Number where work is to be do
nk
STATE OF FLORIDA,
COUNTY OF DADE. ss.
(Signed) __
MIAMI SHORES VILLAGE
g Inspector
BUILDIN INSPECTION DEPARTMEN'
ttb6liqion
Sri
(Signed)
Date c a , 19
_ ff
State work to be done and purpose of building (by floors)
and for no other purpose.
Read, Sworn to and Subscribed before me.
New Building modeling_ _ ____ _ _. ddition____ ____ ___ ____ __ _ Repairs. _ _ No. of Storie
To be constructed of_ - Kind f foundation --- -- ov, ''hg--
c �,
Estimated 'I ,ta1 cost of improvements '' 0 0 0 Amount of Permit $._ _
Zone -ubage required_ __. _Plan Cubage_____ 7/ 49'
Distance to next nearest building__ _ _ _ _Size of Building Lot A - -I
Maximum live load to be borne by each floor_
hereby submit all the plans and speciii,c'ations for said building. All notices with reference to the building and its construction may
be sent to
The unde signed appli -ant for th budding permit does hereby certify t'iat he understands and accepts his ..bligations as an employer
of 1 bor under he Florida Workmen's Compensation Act being S. -tion 5966 Coi p led Gen al Laws of Florida P r anen. S fipple cent.
and h s compl ed w he prov';ions thereof, and will require s'milar comp lance from all contractors or sub - contractors cmplo 'ed by hint
in the wo k to be p rf med under th s pern it and ill post or cause to be posted for inspect' n on the site of the wrjrk su :h pub not' e
or •otices as are requir d by the Act. The u. d la‘/perform . r ign. •d agrees to employ only such abc9 jr. ors, on work to la‘/perform d der this
permit as are licensed by M am. Shores \ il': ge.
Remarks__
ll ec.� X %
Before me, the undersigned authority, a notary public, duly authorized to adimnister oaths .nd take acknowledgments, personally ap-
peared
.to me well known,
and who, being by me first d. ly sworn, upon oat 'deposes and says that he is the
of th ahov de .c ibed . istruction. t. ; h has areially read the fo oing application, and that he did sign the same, and that all facts
therein by him stIr d are tr fie.
Permit No. I
-- -- sl �1CI)
Disapproved '
Notary Public State of Florida
My Com_nission Expires.
PLANNING BOARD DATE
Chairman`!_ _. __ Member
Member ____ 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 Iftt•r approval his been obtained from
the Plain- ng Board
A re- inspection fee of $1_00 will be charged when such re- inspection is marie necessary by improper notice for inspe :d'op or fa ity
mater,�i _.
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