41430Date fit Job Address //767) ,%1 0 Tax Folio // -' °f /3‘ - c O o - 0 0 5/d
Legal Description Ilistorically Designated: Yes M Owner/Lessee / Tenant '�✓' �JB �, 'J) I Master Permit #
/�? /rte/ s�l-r p
owner's Address //3 O i a U /V v - Phone 9y9- 3 7 2.S "
Contractin Co. 7 * C, -,,}' £/°T?C 4 21 ') Address 1.1932
Qualifier 1 /EP #641 Kri►.5 SS# _ Phone (R) “ 71- ��/ •
l ��
State # Municipal # Competency # - Co. a4 j Jae'
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
Square Ft an
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 -named contractor to do the work stated.
atir� of cz ' -r aanpd/or Cond Presider tj Date
e c7 r O(1o4 fgsS®t
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
517- ( 7
Mary as to Owner and/or Condo Presid t Date
My Com4osiglExpires: C HARDENBURG
Expires Exp 71164
Bonded by HAI
!F OF F`p 800 -422 -1555
FEES: PERMIT 35 RADON
APPROVED:
Zoning Building
Mechanical Plumb
6-21- e 1 r l
Estimated Cost (value) 2 Sea
Signature of Contractor or Owner - Builder
21
Notary as to Contractor or Owner - Builder Date
My Commission Ex a` 4 LOUISE C HARDENBURG
1 ? 1 * My Commission t 71164
7C Bonded by HAI
OF Ft 800 -422 -1555
C.C.F. 1 M 2k) NOTARY
Electrical
5
D
TOTAL DUE 5eiv2
336" P
Engineering
CO iSTRUCTION PERMIT FOR:
] New System ./ Existing System
] Repair [] Abandonment
APPLICANT: a A l a t' izr
PROPERTY STREET ADDRESS: /ate
LOT: BLOCK:
PROPERTY ID #: 4I
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 DESLGN_ANp ,SPECIFICATIONS
T F/ [GALLONS_/ GPD].rSEPTIC T R AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:
A [ ] [G ONS / 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: [ ]
D
R
A
I
N
F
I
E
L
D
[
[ ] SQUARE
TYPE SYSTEM:
CONFIGURATION:
LOCATION OF BENCHMARK:" J
ELEVATION OF PROPOSED SYSTEM
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED:_
T
H
E
R f "
SPECIFICATIONS BY:
APPROVED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1130-6, FAC
FEET— PRIMARY
FEET
DATE ISSUED 2 _,
HRS -H Form 4016, Mar 92 (Obsoletes
(Stock Number: 5744 - 001 - 4016 -0)
SUBDIVISION:
DRAINFIELD SYSTEM
SYSTEM
[ ] STANDARD [ ] FILLED
[ ] TRENCH [
] INCHES
[ °] Holding Tank [ ] Temporary /Experimental
[' Other (Spedify )
SITE •] [IN HES /FT]' [ABOVE /BELOW] BENCHMARK /REFERENCE PO
FT] [ABOVKPIEE601, BENCHMARK FERENCE POIN
EXCAVATION REQUIRED: [4 INCHES
AGENT: /kik car
[ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
TITLE:
previous editions which may not b ised)
INSTALLER /CONTRA TOR
] MOUND
PERMIT #
DATE PAID
FEE PAID $ '
RECEIPT #
[
T 'S �.�-- i:_a
0
]
a
-- -CPHU
EXPIRATION DATE: S,,
Page 1 of 2
PROVED BY:
TELEPHONE:
TENT:
ING ADDRESS:
SYSTEM DESIGN AND
1SP CIFICATIONS:
. 4 f
DRAINFIELD:._
07jHER:
Permit tracking number assigned by CPHU.
Check type of if "Other" specify type in blank.
Property owner's full name.
Telephone number for applicant or agent.
Property owner's legally authorized representative.
P.O:. box or street mailing address for applicant or agent.
BLOCK, SUBDIVISIGN or
PR PERTY IDIt: 27 character id number for property. (CPHU may require property appraiser ID 11 or section/township /range /parcel number)
- a
Date permit is issued by CPHU.
Minimum specifications from Chapter IOD-6, FAC.
Minimum specifications from Chapter IOD-6, FAC.
Other specifications, such as operating permit requirements, low - volume flush toilets,: variance provisos.
Name of individual providing specifications. If designed by a_registered engineer must be sealed.
County Public Health Unit (CPHU) personnel reviewing and approving permit.
One year from date issued if the system has not-been installed. Permits for system repairi become void 90 days from the date II
issued. 1
..... ........ . ..- -- ..........- ------------ - - - --. -- -PART II - SITE PLAN-
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Notes: 1; it`
J4; ?Li
Site Plan Submitt
SIGNATURE
Plan Approved �J
By .
STATE OF FLORIDA
_,-. ,DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ON SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
7 7 / f /
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
.(Stock Number: 5744-002-4015-8)
Not Approved
Permit Application Number
ALL C GES MUST,BEItpl OVED BY THE COUNTY PUBLIC HEALTH UNIT
7
Date
County Public Unit
Page 2 of 3 ''