117 NE 102 St (9)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 Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kev at building during progress of the work.
Owndo Nntia nti 1 Addreed...
Registered Architect and /or En ineer �Name and add ress of licensed contractor I
Locat'
d sc f lot to "'lit on:
Lot / ! J j ��» lock - ! / � ,./3/n igt
Street and Number where work is to +e done.
State wary be Ao
Permit No
Disapproved
(Signed)
MIAMI SHORES VILLAGE
Date
Building Inspector
Date 1
._.s ............ . ....� .: Nei MIL 1:: :,::a.. 8 • ;, :i ::::
:\
Read, Sworn to and Subscribed before me.
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind f = .pion Roof Covering
Estimated Total cost of improvements $_.1. / Amount of Permit $,.
Zone cubage required .Plan Cubage T -'
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 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 with the provisions thereof, and will require similar compliance from 1 contractors or sub - contractors employed by um
in the or notices r as t are required by the Act. The will es to employ such f } r •nectiors on o ite k be,erfouch u licerothis
permit, as are licensed by Miami Shores Village.
Remarks___ (Signed)
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.
(3 & 3 3
Notary Public, State of Florida
My Commission Expires
PLAN NG 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 Planning I3oard.
A re inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
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