568 NE 102 St (12)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, wheth herein specified or not. A copy of approved
plans and specifications must be kept at , ilding during progress of the work.
Owner's Name and Address .
Registered Architect and /or Engineer......
Name and address of licensed contractor.
Disapproved ...
(Signed)
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
Building Inspector
Location d legal description of lot to ilt on:
Lot Block. �s)rbdi i
Street and Number where work is to be done... . d
State work to be done and purpose of building (by floors)...
Date
Estimated Total cost of improvements $.....:.<
Zone cubage required
Distance to next nearest building
Date...
STATE OF FLORIDA,
COUNTY OF DADE. ss
Before me, the undersigned authority, a notary public, duly authorized to administer
and for no other purpose.
New Building Remodeling Addition Repairs No. of Stories
To be constructed of Kind o oundtlion Roof Covering
Amount of Permit
Plan Cubage
Size of Building Lot
Maximum live load to be borne by each loor
I hereby s t a laps d
be sent to
The undersigned applicant for this building pennit 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 - contract employed by hire
in the work to be performed under this permit; and will post or cause to be posted for in pectin . the site of the rk such public notice
or notices as are required by the Act. The undersigned agrees to employ only such su yyentts.. or., on work to performed under this
pennit, as are licensed by Miami Shores Village.
Remarks __._.___ -._ (Signed)
for said building. All notices with reference to the building and its construction may
oaths
peared
Notary Public, State of Florida
My Commission Expires
and take acknowledgments, personally ap-
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.. Date 6 1 / ) 9 h ............._._ Read, Sworn to and Subscribed before me.
PLANNING BOARD _.._sass ..DATE
Chairman Member
Member Member
Member sass.. 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 hoard.
A re inspection fee of 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection at faulty
materials and /or workmanship.
NEVST