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1131 NE 91 Terr (12)` //9/ €�// /l,2' /(i /�!9d Date � -� Job Address. � i Tax Folio f Legal Description Owner / Lessee / Tenant , 6- 4.a,-„, Owner's Address lift g / / .c Co. Qualifier State # ( • PERMIT APPLICATION FOR MIAMI SHORES VILLAGE f Municipal # Competency # Ins.Coo Architect /Engineer Address Bonding Company Address Mortgagor Address Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN VWORK DESCRIPTION r, �1 r `� /.' c � Square Ft. 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, 1 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: ** * * * * * * * * FEES: PERMIT RADON C.C.F. /� O'° NOTARY Ae%' TOTAL DUE % ` ( / APPROVED: Zoning Buildin_ Electrical Mechanical Address Master Permit it, ���X Phone Aty Oz 1 ,1 Signat re of Contractor or Owner-Builder Date: r4,/`n taw as to Contrk, My Commission Exgir * * * * * * ** Fire Other Engineering PL(CATION Peas ] Nees System Q ] Existime System Q ] olding Tart Q D ` em ooc S3 /E2ver mom , ] epaim APPLICAR'T s AGENT :�� MAILING ADDRESS: O ICE CCOMPL TED MY APPLICANT OR APPLICANT'S AUT's(MIZEI AGENT. ATIC°t.Ciu; MUMMIG I Id OI E PLAN S :OW.0 ,'( PERTINENT FEATURES REQUI D BY C =; TER 1© MGR= DaJ AnMIN`I'STRAT v ' PROPERTY INFORMA=N QII? LOT l:5 NOT IN A RECORDED SUBDIIVIISION, ATTAC lc,,Av a,r Ill sclulprl,r,o lLO2 s PROPERTY 7,D : OPERTy SE2E: LOCK: PROr.ERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: BUILDING INFORMATION APPLICANT °S SIGNATURE: STATE OF FLolunn PERM= # DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE P AIn =SITE SEWAGE nASPOSAL SYSTEM FEE Al 6' APPY,ICRTION FOR CONSTRUCTION PERMIT RECE:a # Authority: Chapter 381, FS & Chapter FAC [ ] Abandonment SU DIVIISIION: ACRES QSgfft /43560) f / C; [ ] Garbage Grinders /Disposals [ ] Ultra-low Volume Flush Toilets [ ] Other(Specify) 1 ] RESIDENTIAL {RS -ii Form 4015, Mar 92 (Obsoletes previous editions which may not be used) (Sttc -ex Number: 5744 -G01- 4015 -1) "nit Type of No. of Building # Persons No Establishment IBedrooms Area Sgft Served TELEPHONE: M2E ©u [Section/Township/Range/ t rc oR Lac o ] 80 ,rIIY s PROPERTY M TE SUPPLY: Q ] p3aVmI' [ ] COMMERCIAL usi ess Activity For Commercial Only_ [ ] Spas /Hot Tubs [ D Floor /Equipment idra:i.nu [ ] Other (Specify) DATE: Page 1 3f 3 CONSTRUCTION PERMIT FOR: [ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental, [ > %] Repair [ ] Abandonment [ ] Other(Specify) APPLICANT: PROPERTY STREET ADDRESS: LOT: BLOCK: PROPERTY ID #: SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ D [ , ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED I CONFIGURATION: [ ] TRENCH [:,;71 BED N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE [ E BOTTOM OF DRAINFIELD TO BE [ L D FILL REQUIRED: [ ] INCHES 0 T H E SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM •CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744-001- 4016-0) CPHU -White Applicant - Canary SUBDIVISION: AGENT: PERMIT # DATE PAID FEE PAID $ RECEIPT # [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER :.OD 6, ?AC 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. ] [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: [ ] [ ] MOUND [ ] [ ] ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ ] INCHES � r , TITLE: TITLE: EXPIRATION DATE: CPHU Page 1 of 2 Installer /Contractor -Pink Building Department - Goldenrod INSTRUCTIONS: PERMIT NUMBER: Permit tracking number assigned by CPHU. 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. (CPHU may require property cppraiser ID I/ or section /township /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 1OD-6, FAC. DRAINFIELD: Minimum specifications from Chapter 1OD -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 n registered engineer must be sealed. APPROVED BY: County Public Health Unit (CPHU) personnel reviewing and approving permit. DATE ISSUED: Date permit is issued by CPHU. 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. S;te Plan Submitted by ?:e.:^ Approved STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CCNSTRUCTION PERMIT :3y __ COL r.ty ..I. a'ANCI_f M.' „ .3 ? A PI' Rovr q r Y 1h COUNT'' 5 I .FS i = c777 1:1E, Peih a5 icbsc:. t. s p:o✓icus editions which may not be used) StGNATURE Permit Application Number -PART II - SITE PLAN ®...n., - ..,,.,:.o�a:.::�., T.TI E Not Approved :Date _ Datd 1 1111SHORES VILLAGE NG DEPARTMENT 3b5-795-2204 Building Inspection Request , ' Phone # For Inspector: Approved Correction Re- Insp'n Fee Type Insp'n Permit No. N a m e Address Company ❑ _5, b 1' MIAMI SHORES VILLAGE =DING DEPARTMENT 305- 795 -2204 p Building Inspection Request Date/ 2 /5/ a T Type Insp'n Permit No. 72_ Address Company Phone # For Inspector: a2. Approved Correction Re- Insp'n Fee