301 NE 102 St (2)CONTRACTOR
a nn //�� ,,� q
Name CPrf'�t't/l�l) 7)30 C:.f�'to=k k/
License No. rys /� V sCv/ of `0 _ t/ Sbe
Address 33q NJ f 0 44 sr
inkk 'vvv Ft_ 3 313 g
Telephone 000 /C7 -gill Fax (305 ) 757 —gii r
Qualifier Name biqVi 0 L1=C
g_ROPERTY OWNER
New Construction
e _ Sow) G i
Address
blA.,� s_ 33���
Home Telephone 3/Ss 7s9 _ q C / J
J/[
Business Telephone 3 0 S —? 0 If D I �
hit Fax
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'I Detachment
Other
Step 1.
J� Address:
• PB I I ,, n PG
Current Use of Property �P S I d,.ltiT -C
Proposed Use of Property S 1f'lC
Tenant Information N/A
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
Address Apt.
c 3.so S�
lock 3
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
Description of Work
Zoning
Square Feet
Value of Work
Flood Zone
PERMIT APPLICATION
Master Permit No.
Subsidiary Permit Na o
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
olio Number
of
Subdivision
City State Zip
(oo
O s -
Tax Assessed/Appraised Value
(coo Gcuc, y e �Jorn
Linear Feet
Units
Bldg Value N /el
ry /4-
Base Floor Elev.
N /A-
Floors
ENGINEER
Name
License No.
Address
Telephone
Fax
Page 2
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. • SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9 . Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, certify that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
are required for ELECTRICAL, PLUMBING, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORID , CO
JOHNSON
s MY COMMISSION # CC 903127
/ 0t 110 EXPIRES: ]an 18, 2004
1-800-3-NOTARY Fla. Notary Service 8 Bonding Co.
nt Name r
Sworn to and subscribed before me this O'1 day of J
Personally known
MIAMI -DADE STATE OF
OR, Produced Identification
Type of Identification Produced: 0/ t 4 SOC 301- Sj - l'rq- 0
Signature of ontractor / Qualifier
Print Name
biwid tee-
Sworn
and subscribed
4
Signature of Notary ' is - . t • 0 . • .
SEAL:
PERMIT APPLICATION
A, COUNTY OF MIAMI -DADE
re me this d- S day of J lA-L1/
t 4' ' 1 / 411r °1 0% JENNIFER JOHNSON
MY COMMISSION # CC 903127
OF ���0 EXPIRES: Jan 18, 2004
1-800-3-NOTARY Fla. Notary Service 8 Bonding Co.
Personally known OR, Produced Identification
Type of Identification Produced:
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 8/6/2002
Applicant: GEORGE
Owner: SAUVIGNE
JOB ADDRESS: 301 NE 102
Contractor CRAWFORD DOOR CO INC
Local .Phone: 305 - 757 -4113
Parcel # 1132060135050
Fees:
FEE2002 -4286
FEE2002 -4287
Permit Status: Approved
Work: REPLACE GARAG
If there is no permit pact
fee is $50.00, which must t
This Permit is granted to the cor
ordinances pertaining thereto and
and approved by the proper munic
authorization. A further condition
ordinances and regulations pertaii
by his agents, servants or employ
Signed:
In consideration of the issuan
with the plans, drawings, statements or
myself, my agent, servants or employes.
F
PAY
0
TO THE
ORDER OF
Description
°• •aHlnn Permit Application Fee
Fist Union National Bank
firstunton,
Or g. 003 R/T 067006432
pgruJ' sp
Building Permit
Permit Number: BP2002 -1353
SAUVIGNE
GEORGE
ST
Contractor's Address: 339 NE 69 ST
Page .1 of 1
Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOTS 13 & 14
Amount
$60.00
$0.60
CRAWFORD DOOR COMPANY
PH 305- 7 57 -4113 INC.
339 NE 69TH ST
MIAMI, FL 33138
DATE= da-
r vt` � d
,U4y e a
ri A:a-"tt- Sh oreS
1
1 60
I1s000 006 / 53
.... ,. _ •06 700643 21:2666 70080193
...............
(Contractor or Builder) BY:
BLK 37 LOT SIZE
Total Fees: $60.60
Total Receipts: $0.00
DOLLARS $
1 0066
63 .643/670
BRANCH 13093
M I A M 1•DADE
PRODUCT CONTROL NOTICE OF ACCEPTANCE
DAB Door Company, Inc.
12195 NW 98 Avenue
Hialeah Gardens ,FL 33018
The expense of such testing will be incurred by the manufacturer.
APPROVED: 08 /09/2001
\\ s0450001 \pc2000 \ \templates\notice acceptance cover page.dot
Internet mail address: postmaster @buildingcodeonline.com
MIAMI -DADE COUNTY, FLORIDA
METRO -DADE FLAGLER BUILDING
BUILDING CODE COMPLIANCE OFFICE
METRO-DADE FLAGLER BUILDING
140 WEST FLAGLER STRI:Gr. SUITE 1603
MIAMI, FLORIDA 33130 -1563
(305) 375 -2901 FAX (305) 375 -2908
CON'I'ItACI'OR LICENSING SECTION
(305) 375 -2527 FAX (305) 375 -2558
CONTRACTOR ENFORCEMENT DIVISION
(305) 375 -2966 FAX (305) 375 -2908
PRODUCT' CONTROL DIVISION
(305) 375.2902 FAX (305) 372 -6339
Your application for Notice of Acceptance (NOA) of:
Sectional Residential Garage Door
under Chapter 8 of the Code of Miami -Dade County governing the use of Alternate Materials and Types of
Construction, and completely described herein, has been recommended for acceptance by the Miami -Dade
County Building Code Compliance Office (BCCO) under the conditions specified herein.
This NOA shall not be valid after the expiration date stated below. BCCO reserves the right to secure this
product or material at any time from a jobsite or manufacturer's plant for quality control testing. If this
product or material fails to perform in the approved manner, BCCO may revoke, modify, or suspend the
use of such product or material immediately. BCCO reserves the right to revoke this approval, if it is
determined by BCCO that this product or material fails to meet the requirements of the South Florida
Building Code.
ACCEPTANCE NO.: 01- 0516.03
EXPIRES: 08/09/2006 Raul Rodriguez
Chief Product Control Division
THIS IS THE COVERSHEET, SEE ADDITIONAL PAGES FOR SPECIFIC AND GENERAL
CONDITIONS
BUILDING CODE & PRODUCT REVIEW COMMITTEE
This application for Product Approval has been reviewed by the BCCO and approved by the Building
Code and Product Review Committee to be used in Miami -Dade County, Florida under the conditions set
forth above.
Francisco J. Quintana, R.A.
Director
Miami -Dade County
Building Code Compliance Office
Homepage: http : / /www.buildingcodeonlinc.com
DAB Door Company, Inc. ACCEPTANCE NO: 01- 0516.03
1. SCOPE
1.1 This approves a Sectional Steel Door as described in Section 2 oft Notice of Acceptance, designed to comply
with the South Florida Building Code, 1994 Edition for Miami -Dade County (SFBCC) for the locations where
the pressure requirements, as determined by SFBC Chapter 23, do not exceed the design pressure rating values
indicated in the approved drawings.
2. PRODUCT DESCRIPTION
2.1 The Dab Sectional Door and its components shall be constructed in strict compliance with the following
documents: Drawing No. 01 -09, titled "Sectional Residential Garage Door" prepared by Al- Farooq Corporation,
dated 02/01/01 with no revisions, Sheet 1 to 3 of 3. It bears the Miami -Dade County Product Control Approval
stamp with the Notice of Acceptance number and approval date by Miami -Dade Product Control Division.
These documents shall hereinafter be referred to as the approved drawings.
3. LIMITATIONS
3.1 Units with dimensions equal to or smaller than those shown on the approved drawings shall qualify under this
approval.
3.2 This approval requires the manufacturer to do testing of all coils used to fabricate door panels under this Notice
of Acceptance. A minimum of 2 specimens shall be cut from each coil and tensile tested according to ASTM E-
8 by a Dade County Approved Laboratory selected and paid by the manufacturer. Every 3 months, 4 times a
year the manufacturer shall mail to this office a copy of the Test Reports with confirmation that the specimens
were selected from coils at the manufacturer's production facilities. And a notarized statement from the
manufacturer that only coils with yield strength of 39,000 PSI or more shall be used to make door panels for
Dade County under this Notice of Acceptance.
4. INSTALLATION
4.1 The Sectional Door and its components shall be constructed in strict compliance with the approved drawings.
4.2 The installation of this door does not require a Hurricane Protection System
5. LABELING
5.1 Each door shall bear a permanent label with the manufacturer's name or logo, city, state and the following
statement: "Miami -Dade County Product Control Approved
6. BUILDING PERMIT
6.1 Building Permit shall be accompanied by copies of the following:
6.1.1 This Notice of Acceptance, including two copies of the approved drawings as identified in section 2.
6.1.2 Any other document required by the Building Official or the SFBC in order to properly evaluate the
installation of this system.
APPROVED: AUG 0 9 2001
EXPIRES: AUG 0 9 2006
NOTICE OF ACCEPTANCE: SPECIFIC CONDITIONS
Candid() Font, PE, Sr. Product Control Examiner
Product Control Division
DAB Door Company, Inc. ACCEPTANCE NO.: 01-0516.03
APPROVED: AUG 0 9 2001
EXPIRES: AUG 0 9 2006
NOTICE OF ACCEPTANCE STANDARD CONDITIONS
1. Renewal of this Acceptance (approval) shall be considered after a renewal application has been filed and the original
submitted documentation, including test - supporting data, engineering documents, are no older than eight (8) years.
2. Any and all approved products shall be permanently labeled with the manufacturer's name, city, state, and the
following statement: "Miami -Dade County Product Control Approved ", or as specifically stated in the specific
conditions of this Acceptance.
3. Renewals gf Acceptance will not be considered if:
a) There has been a change in the South Florida Building Code affecting the evaluation of this product and the product
is not in compliance with the code changes;
b) The product is no longer the same product (identical) as the one originally approved;
c) If the Acceptance holder has not complied with all the requirements of this acceptance, including the correct
installation of the product;
d) The engineer who originally prepared, signed and sealed the required documentation initially submitted is no longer
practicing the engineering profession.
4. Any revision or change in the materials, use, and /or manufacture of the product or process shall automatically be
cause for termination of this Acceptance, unless prior written approval has been requested (through the Fling of a
revision application with appropriate fee) and granted by this office.
5. Any of the following shall also be grounds for removal of this Acceptance:
a) Unsatisfactory performance of this product or process.
b) Misuse of this Acceptance as an endorsement of any product, for sales, advertising or any other purpose.
6. The Notice of Acceptance number preceded by the words Miami-Dade County, Florida, and followed by the
expiration date may be displayed in advertising literature. If any portion of the Notice of Acceptance is displayed,
then it shall be done in its entirety.
7. A copy of this Acceptance as well as approved drawings and other documents, where it applies, shall be provided to
the user by the manufacturer or its distributors and shall be available for inspection at the job site at all time. The
engineer need not reseal the copies.
8. Failure to comply with any section of this Acceptance shall be cause for termination and removal of Acceptance.
9. This Notice of Acccptancc consists of pages 1, 2 and this last page 3.
Candido Font, PE, Sr. Product Control Examiner
Product Control Division
END OF THIS ACCEPTANCE
-3-
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE
Dryer
QTY
TYPE
Outlet, Appliance
QTY
TYPE
Service Repair
QTY.
A/C Central 1 -3 Ton
Fan
Dryer Vents, Number of
Outlet, Wall
Ventilation, Cost
Service, Temporary
Air Handler, Tons
A/C Central 4 -7 Ton
Piping, Flammable Liquid
Fire Pump
Outlet, Switch
Fire Sprinkler System
Signs
A/C Central 8 -15 Ton
Bath Fan - Vented, #
Fixture - Fluorescent
- Pressure Vessel
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE
Minimum Fee
QTY. TYPE
Condensate Drain
QTY. TYPE
Generator
QTY. TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C WaH/Win. Tons
Dryer Vents, Number of
Paint Booth
Ventilation, Cost
Solar Water Heater
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
- Process/Pressure Piping
Cap - Fixture
Bath Fan - Vented, #
Fireplaces, Number of
- Pressure Vessel
Pump and Abandon
PLUMBING
TYPE
A/C Condensate
QTY.
'TYPE
Drains, Roof
QTY.
'TY'PE
Miscellaneous Fixture
QTY.
TYPE
Soakage Pit
(QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
CHECKLIST
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.)
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
❑ PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
(60.
(sq.ft. = x/1000
x ¢.60)
$ (¢.005 /sq.ft.)
$ (¢.01 /sq.ft.)
REVIEWED AND PREPARED BY:
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
PERMIT FEES
TOTAL $ 6 t
ISSUING OFFICIAL
DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2"`° AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
Date
Legal Description
Lessee /
— Owner's Address
Contracting Co. e g
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 30/ PE /D�h W S/
Tax Folio // 3� 06 /3 -5D/
sic / tb /0-70
Qr� a rl l hosq j 3 ster #,q6/,
7 b_i< 39 As
Tenant
Sane -e S it) mir
Qualifier SS# - -
State #
P Municipal # Competency #
Address
Phone
Ins.Co.
Permit
Phone
Architect /Engineer Address
Bonding Company Address
Mortgagor Address'
— Permit Type(circle on : BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
(oor 1 n k ,' coorS &qk
— WORK DESCRIPTION IIe_
Estimated Cost(value) E00 • 00
Square Ft. / SQ FJ—► - e.
WARNING TO OWNER: WOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR
NOTICE OF COMMENCEMENT).
Application is hereby made to obtain a permit to do work and installation as indicated above, and
on the attached addendum (if applicable). I certify that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating construction and zoning. Furthermore, I
authorize the above -named contractor to do the work stated.
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
er- Builder
E INE CHURCH
•••
+: t
tary as to Co
y Commission E
** * * t * * * * * * * * * * * * * 2 **
PEES: PERMIT J /� RADON C.C.F. ,,,�Y NOTARY 6 -." TOTAL DUE 1 (✓ s
APPROVED: Fire Other
Zoning Building Vigi Electrical
Mechanical Plumbing Engineering
Owner's Name and AddressE • k'
Registered Architect and /or Engineer
Disapprove D. e
(Signed)
Building ns • ` -ctor
MIAMI SHORES VILLAGE
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 kept at building during progress of the work.
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
c - & 1 6__ (a
Name and address of licensed contractor '1
Location and legal description of lot to be built on:
Lot 1- Block a 7 Subdivision. -
Street and Number where work is to be done O L • /OA • --5
Stat work to be done and purpose of building (by floors)
s eer / S ./6 (at ll0. - .a ._ 4....3.0 I t 1 &7$C 4 04 � a
�°'.)• ",,of "- ✓,_. -- and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind of foundation Roof Co ring
e3
Estimated Total cost of improvements $ f <6".6 6 Amount of Permit $
Zone cubage required _Plan Cubage
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 all contractors or sub - contractors 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 are required by the Act. The undersigned agrees to employ only such subcontractors g o %o ork to be performed under this
permit, as are licensed by Miami Shores Village.
• a..„_
Remarks (Signed)
dV, V
STATE OF FLORIDA,
COUNTY OF DADE. j 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.
Permit No ....... �_ f Date ' �` a 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 Planning Board.
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.