1155 NE 102 St (10)Application is hereby made for the approval of the detailed statement or Inc 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 iuilding 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. 7
a / 41� "E � ate
Owner's Name and Address (
Registered Architect and /or 1;nglncer .....T��(1n k r
Name and address of licensed contractor C P
Location anVgal description of lot to be built
Lot
New Building
To be constructed of
APPLICATION FOR BUILDING PERMIT
Disapproved Date
(Signed)
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
(L-t
Block / ...1.. S
Street and Number where work is to be done /0 2
State work to be done and purpose of building (by floors)
and for no other purpose.
Remodeling Addition Repairs No. of _ Stories f . .
Kind of foundation Roof Covering of 4 ( - . .�.!`_*4�.
tof
Estimated Total cost of improvements $ Z ,QOO Amount of Permit & 10% .00
Zone cubage required Plan Cubage 33 )'6 4
Distance to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby
be sent to..
bmit e p an n spec' ica ens for said building.
Building Inspector
ivision. : ........,, __.._.
5c _.. 115 .. 02.•S-L.
s
All
3 / _
Ai " t ._ No Street
otices with refer
C.O. L.$
,.the buildin and its nstruction may
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, Permanent Supplement,
and has complied sdith the provisions thereof, and will require similar compliance from all ./ tractors or sub - contractors employed by h s
in the work to be performed under this permit; and will post or cause to be posted for ' spe tion on the site of the or such public no ce
or notices as arc required by the Act. The undersigned agrees to employ only such su :actors, �n work to rformed is
perrnit, as are licensed by Miami Shores Village.
Remarks (Signe
STATE OF FLORIDA,
COUNTY OF DADE. } ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
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. 11,��(f �
Permit No Date )‘)1`) Read, Sworn to and Subscribed before me.
Notary Public, State of Florida
My Commission 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 after approval has been obtained from
the 1'lennir,.. Board.
A re- rn.trection fee of 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection os faulty
materials and /or workmanship.
1