1061 NE 91 TerrDates
1
Legal Description
Owner/Lessee / Tenant
Owner's Address
Contracting Co.
Qualifier /4r
State # e R.- C/ % z Municipal #
Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING ' MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address /0, J � � 9) 7f Tax Folio
F Iy)ir �? c4s // Master Permit #
/6‘/ NG / e•
J c4 '�., Se /' c Address 7 7 ( / 14.1 / t /ePdl'
e e
Square Ft 14' a 7 /A Estimated Cost (value)
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.
Notary as to O; der an o do President Date
My CommissionE ices r
n�-ta rq� r a
YYS"yc'aSl NO
FEES: PERMIT RADON
APPROVED:
Zoning Building
Mechanical
2 ■
or Condo President y67�W l 9 6x-
7
Historically Designated: Yes No
ez
C.C.F. / ° - 0 NOTARY °"--
Phone 5 7 c _s
SS# Phone ' CS 9 9 G 2 dze
si gnature of Contr r Owner - Builder
LORRAIN J. ZERO
Notary Publ c, State of FlorldFt
tr,y Gomm. ckpires Oct 24,1999
Notary as to tbtft Iii f %f Owner - Builder
My Commission Expires:
Electrical
Date
ate
BOND 3 0
TOTAL DUES 9, 6
Plumbing Engineering
LOT:
T [
A [
N [
K [
0
T
H
E
R
APPLICANT:
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System
[ ] Repair [ ] Abandonment
PROPERTY STREET ADDRESS:
PROPERTY ID #:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS i
[ l
[ I
BLOCK: SUBDIVISION:
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. 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
] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE•RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED ( l
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: [ ] INCHES
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1] which may be used)
(Stock Number: 5744-001-4016-0)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
Chapter 10D -6, FAC
Holding Tank [ ] Temporary /Experimental
Other(Specify)
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
AGENT:
TITLE:
TITLE: CHD
EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICATION FOR: Check type of permit; if "Other" specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID #: 27 character ID number for property. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -6, FAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes: 1
4 s
DH 4015, 10/96 (Replaoss HRS-H Form 4015 which may be used)
(Stock Nurrber: 5744-002-4015-6)
/
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PART II SITE PLAN
Permit Application Number
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Site Plan submitted by , ; •
Signature
Title
.
Plan Approved Not Approved Date
By
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
County Health Department
Page 2 of 3