Loading...
MECHANICALOwner's Name and Address - Street and Number where work is to be done State work to be one and purpose o . ildi Remarks 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. Date 1/6 19 f ans `---+ 0© c Y No. ` Street Ve I0 Registered Architect and/or Engineer Name and address of licensed contractor Location and legal description of lot to a built on: Lot ( 9 ok/e Block 90 floors). state exte Remodeling Subdivision h A "` P 0 (1 ./ . )1 17 o e /7 o 'f7® 6 colors (s bmit samples) Addition Repairs y‘s 1 - A., No. of Stories nd for no other purpose. New Building To be constructed of Kind of foundation Roof Covering /�� y j Estimated T `� Total cost of improvements S ) 0 Amount of Permit S l e ✓ Zone cubage required Plan Cubage Distance to next nearest building Size of Building Lot Maximum live load to be borne by each floor 1 hereby submit all plans and specifications for said building. All notices with reference to the building and its construction may be sent to 0 ovisio st o he p the Florida ytorkmen's will re ire similar le •.ste. or inspection to be performed (Signed) as amp a abor and t s thereof n. w .. cause to nl such su..�tracto d The undersigned applicant for this building permit does hereby certify that he understands and accepts his ob ' .ns Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement. and has •� plied compliance from all contractors or sub - contractors employed by him in the work to be performed under th'- permit on the site of the work such public notice or notices as are required by the Act. The undersigned agree ,' emp o under this permit, as are licensed by Miami Shores Village. l ss. Before me, the undersigned authority, a notary public. duly authorized to administer oaths and take acknowledgments. perso appeared STATE OF FLORIDA COUNTY OF DADE. 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. 3 ©� ® Date / 1, / Read. Sworn to and Subscribed before me. A Disapproved Date (Signed) Notary Public. State of Florida 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 workmanship. State Certificate# State Registration# Corporate Qualifier# FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY WORKERS' COMPENSATION AFFIDAVIT CONTRACTOR, SUBCONTRACTOR - CERTIFICATION OF NO. EMPLOYEES PERMITTING OFFICE. (Street Address) hereby certify or affirm that the entity named herein has no employees nor uses any subcontractor(s) loyees a will ave no �Qy a or subcontractor(s) to I t filly that, if during the entity named herein becomes an employer or uses subcontractor(s Insurance will be provided to the permitting office named herein. LES Form BCM-44 (12/80) 2e20 Department Witness or Notary Public City /County License or Competency# Signed Print/Type Na p Title (City or County) a Sworn to d subscribed before me this / / day of A.D., 19 PERMITTING OFFICE USE ONLY Ore_ wit employees during the period pe • „ c • vered . affidavit the ploy- - 'ertificate(s of / ith Any employer required to secure the payment of compensation under this chapter who fails to secure such compensation shall be guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not more than five hundred dollars, and /or by imprisonment for not more than sixty days. Such employer may be enjoined from employing individuals and from conducting business until such payment for compensation has been secured; provided, however, that the employer, upon written notice from the Division of Workers' Compensation, shall have seventy-two (72) hours to secure such compen- sation prior to the filing of the complaint by the Division of Workers' Compensation. This section shall not affect any other liability of the employer under this Chapter. (Section 440.43, Florida Statutes) MAIL ORIGINAL TO: Bureau of Compliance, 2728 Centervlew Drive, Tallahassee, Florida 32399.0681