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70 nw 94 st septicPERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date Job Address ©NVq T 'SWEET Tax Folio Legal Description Historically Designated: Yes W Owner/Lessee / Tenant V) N N , �q N Master Permit # _dZ� 6 Owner's Address IQ N \N "(� 1 4— ST9E E T Phone 76�o Contracting Co. At "I L LM C PT? G Address 2030 N W q E) S 1 9—EET 3314-7 Qualifier Al2LC--K QFZ-- _1`t1 � SS# State # Architect/Engineer Bonding Company Mortgagor Municipal # Competency # Address Address T Address Phone & 3 -a 9 & e Ins. Co. Permit Type (circle one): BUILDING ELECTRICAL LUMBIN MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION I KSrA-LA, Dah-PN Ef DD Square Ft. t�vN o%moo Estimated Cost (value) + 1 '200. W WARNING TO OWNER: YOU 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-nan)a44$ntractor to_& the work stated. N dry a to Owner My fission Ex FEES: PERMIT 3'S- APPROVED: Zoning Mechanical - 11 fZ3� ate Si ure d Contractor o Owner -Builder bate esident Date Notary as to ContrVo ' Own -Builder ate My C fission Es: y.t �tS�tiVUtttS1�� .• ,;i+,�`SSSSS4i'A .a4:,,•.. , ,, ��r_ Terese Foldfit r i�ip ; :yam Pabf ; + v ° = i Sour k'� �!i� l�iitln r y� 4� � at �Jer�da + �? • �� Goa�is3i�u . CC orn ►yty :�fi'inn Nu CC 48Qg07 rssiou E*M8 D7116" ' + titFc tom++: r !C{Crre�rren+rlrt�rt�er �rrfC ' _ RADON C.C. I NOTARY BOND Building Electrical Plumbing '' Engineering TOTAL DUE=� STATE OF FLORIDA PERMIT # TZIt '3IF0 DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID .dal ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID CONSTRUCTION PERMIT RECEIPT # 1'r'T trS Authority: Chapter 381, FS & Chapter 1OD-6, FAC CONSTRUCTION PERMIT FOR: [ #J] New System Existing System [ ``� Holding Tank [ y ] Repair Abandonment [ F1!] Other(Specify) APPLICANT: . AGENT: Temporary/Experimental PROPERTY STREET ADDRESS: LOT: BLOCK: SUBDIVISION: jA PROPERTY ID #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D-6, FAC REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. SYSTEM DESIGN AND SPECIFICATIONS E T [ ' PQ ] [GALLONS / GPD] SPrP'C'IC' T�/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN SERIES:[ ] A [ ] [GALLONS / GPD] CAPACITY MULTI-CHAMBERED/IN SERIES:[ } N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS} K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ J D R A I N F I E L D [ .tO 0 ] SQUARE [ ] SQUARE TYPE SYSTEM: CONFIGURATION: FEET PRIMARY DRAINFIELD FEET [ �It] STANDARD [ j..(] TRENCH LOCATION OF BENCHMARK: pi-jS ELEVATION OF PROPOSED SYSTEM BOTTOM OF DRAINFIELD TO BE [ FILL REQUIRED: [ -AJ (,] INCHES SYSTEM SYSTEM [ fiJ FILLED [ *(] BED [ h+] MOUND [ �1 SITE [eE,I1 ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT a ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT EXCAVATION REQUIRED: [ -4C ] INCHES nts SPECIFICATIONS BY: TITLE: APPROVED BY: TITLE: CPHU DATE ISSUED: EXPIRATION DATE: i r HRS-H Form 4016, Mar 92 (obsoletes previous editions which may not be used) (Stock Number: 5744-001-4016-0) APPLICANT Page 1 of 2 PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date ,? do Job Address—) o nu-) 9< a- Tax Folio )1- 31017(_]J4 - 0 a / O Legal Description Historically Designated: Yes Owner&,essee / Tenant ,_ _�h Master Permit # No Owner's Address D C) DW 9 4 S__� Phone Contracting Co.-�_Wno Ol -VI L. Address Qualifie -s p f- � SS# - p Phone�J-& I(-Q)(V / State # 7 GT r ®SS� Municipal # Competency # Ins. Co. CQI( Yn Architect/Engineer Bonding Company Mortgagor Address Address Address Permit Type (circle one): BUILDING ELECTRICA PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION Square Ft. 000 �, . Estimated Cost (value)' •'l e' 0 , oo WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN YOUR PAYING TWICE FOR MPROVEMENTS 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 zonin urthermore, I authorize the above- amed contractorLk'L o the work stated. / &h l C�' t ture o and/or Colo t Signantra , or Owner -Builder Date 1 ] SG _A �S�i zao3 IAA G Sly � o Do Notary as -to 'J.-Ju- owirMyCommission�,and,/&Ckgjd& s: GLI'" �'}'I''�ft ARY PUBLIC STATE OF FLORIDA COMMISSION N{1. CC714103 M Y COMMrGz{}N k xTt. 1. ; FEES: PERMIT 2 RADON APPROVED: Zoning Mechanical Notary as-AdContractor or My Commission Expires: GLAMS J ViLI..AR ARY PUMIC STATE OF FLORIDA COMMESION NO. CC714103 'COMMIMSION EXP. MAR. 1-2002 C.C.F. D NOTARY BOND TOTAL DUE 3 { Building 7 Electrical Plumbing Structural Engineer ADDENDUM TO BUILDING PERMIT APPLICATION ( AN APPLE-CAT_ON FOR 37ILDING PERM= MUST ACCON9ANT TfiIS ADDENDUM. IF A I'ASM BEIRMIT EE S B- OBTAINED, T'� Oiv'NER' S NOTARIZ - SIGNATURE =, -- NOT BE P-RtESENT ON SMSEQUENT A:PLICATIONS. ) 1 PLUMBING ! ELECTRICAL MECHANICAL ITEM BATH TLE UNIT FEE ITEMI SWITCi OUTLETS UNIT FEE ITEM UNIT FE` SPACE HEAT B I OET I L I G,T OUT E S CENTRAL. 1 E T 1 NG I j D IS; YiASHER I I I RE�'TACLES I A/C MINI) 01SPWAL ScRVICE TEMPORARY A/C (CENTRAL) OR INKING FCUNTAIN I SERVICE SIZE IN MIS DUCT YORK FLCCR CRAIN I I SERVICE REPAIR/LEM L-.WZ I REFRIGERATION GRFiSF TRAP I I I APPL IANCE OUTLETS f PROCESS ANO PRESS PIPING f I NTEICEPTCR f F RANGE TOP 1 UNDERGRO(M TANKS LAVATORY I OVEN ABOVE GRCUNO TANKS LAL'MItY TRAY I WATER HEATER U_F. PREMAE VEE S CLOTHES WASHER I I MOTCRS 0- 1 NP STEW BOILERS S-CWER I MOTCRS OVER t- 3 NP HJT WATER BOILERS SINK. POT/3 COMP. LIAOTORS OVER 3- S If MEC AN ICAL VENT ILAT ION SINK. RESIDENCE 1 f MOTORS OVER S- 8 If f TRANSPORTING ASSEMBLIES S I HK. SLOP I 1 MOTORS OVER 8- 10 If f UVATS AMi TE.WORARY WATER CLOSET MOTCRS OVER 10- 25 If f f FIRE SPRING LER SYSTEMS UR I HAL I MOTCRS OVER 25-100 HP COOL I NG MOS WATER CLOSET I I MOTCRS OVER 103 If I VIOLATION IW IRECT WASTES I A/C WINDOW REINSPECTION WATER SUPPLY TO: I AIR COM ITIONERS I A/C UNIT f STR IP HEATER FIRE SPRINKLER I j GDIERATCRS 1RAN6r 46M :'rATER-NEW INST. I GENERATORS TRANSFMS 1 HEATER -REPLACE GEINERATCRS FRS LAWN SPRINKLER -YELL I SPECIAL PURPOSE f SX I W I NG POOL f OUTLETS COMIAEF CIAL f WATER SERVICE f SIGN TUBES SEWER CONNECTIONS I SIGN TRAtWCRM+`RS UTILITY -SEWER j SIGN TIME CLOCK UTILITY -WATER j FIXTUIES SEPT I C TANK( f ANTEw f RELAY �:2oc] J> I / I TELEVISION OUTLETS ORAINFIELD, 4' TILE/RES. I VIOLATION PL&P & ABANDON Sc TIC TANK f RE INSPECTION SOAKAGE PIT CU. rT. CATM W I N OISCHARGE WELL 1 DOLESTIC- WEL I AREA CRAIN I ROOF I NK.ET SOLAR WATER HEATER j FIRE STATP1PE I POOL PIPING j I LAWN .P'RIWLER SYSTEM j GAS RAHGE METER SET (GAS) GAS PIPING STATE OF FLORIDA PERMIT # DEPARTMENT OF HEALTH DATE PAID ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID CONSTRUCTION PERMIT RECEIPT # Authority: Chapter 381, FS & Chapter 1OD-6, FAC CONSTRUCTION PERMIT FOR: [ ] New System [ ] Existing System [ ] Holding Tank [ ] Repair [ ] Abandonment [ ] Other(Specify) I_ ' [ .] Temporary/Experimental APPLICANT: ' AGENT: PROPERTY STREET ADDRESS: LOT:f BLOCK: SUBDIVISION: C [J rn PROPERTY ID CNO�NGE/PARCEL NUMBER] [ORTAXIDNUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC. REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. SYSTEM DESIGN AND SPECIFICATIONS :n;� kIn T [ ] [GALLONS / GPD] SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN SERIES:[ ] A j 1 [GALLONS / GPD] —_ _. CAPACITY MULTI—CHAMBERED/IN SERIES:[ } N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONSJ K [ J GALLONS PER DOSE DOSING TANK CAPACITY DOSE -RATE [ ] PER 24 HRS NO. OF PUMPS: [ ] D R A I N F I E L D O T H E R ( ]'SQUARE FEET PRIMARY DRAINFIELD SYSTEM [ ] SQUARE FEET SYSTEM TYPE SYSTEM: j ] STANDARD [ ] FILLED [ ) MOUND [ ] CONFIGURATION: 1 1 TRENCH [ ] BED [ ] LOCATION OF BENCHMARK: 1-) �, i "{ C' ELEVATION OF PROPOSED SYSTEM SITE [ j [INCHES/FT] r[ABOVE/BELOW BENCHMARK/REFERENCE POINT BOTTOM OF DRAINFIELD TO BE [ a `� ] [INCHES/FT] [ABOVE/'$EI:OW] BENCHMARK/REFERENCE POINT FILL REQUIRED: !, ] INCHES EXCAVATION REQUIRED: [ ] INCHES UNDER goTTOM, Of DRAINFIELD r •j. ri L 1!"TiO f CED 00 Lii1FlFI SPECIFICATIONS BY: TITLE: APPROVED BY: ��- TITLE: DATE ISSUED: DH 4016, 10/96 (Replaces HRS-H Form 4016 [page 1] which may be used) (Stock Number 5744-001-4016-0) CHD EXPIRATION DATE: Page 1 of 2 --A STATE OF FLORIDA DEPARTMENT OF HEALTH - APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number ---------------------------PART II - SITEPLAN------------------- Scale: Each block represents 10 feet and 1 inch = 40 feet: Site Plan submitted by: Plan Approved By Not Approved Date County Health Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) Page 2 of 4 (Stock Number: 5744-002-4015-6)