9301 NE 9 Pl (9)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
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Date �' o: 4 / Job Address 10e �S( Tax Folio
Legal Descsipti 1 p p
Owner/Lessee / Tenant 4: ''7 r=te . LV IS Bi fo n c et / G ;
Owner's Address / (0/ E / / L
Contracting Co. 1 a,) ) ' L ) ( C 2 o ' ' - Address
Qualifier
State #
Bonding Company
Mortgagor
Orrira C7
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Sigxpture of owner and/or Condo President
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FEES: PERMIT ✓5, RADON
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Municipal #
Historically Designated: Yes No
Master Permii ? VC
Phone (-" C 7C /
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/Phone / ~O / ":"3
Competency # Ins. Co.
Address /? VD 4 L) 5 op
Address
Address
MECHANICAL ROOFING PAVING FENCE SIGN
Permit Type (circle one): BUILDING ELECTRICA
WORK DESCRIPTION? � � i / �� O
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Estimated Cost (value) / 9 '
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 regulting construction and zoning. Furthermore, I authorize the above -named contractor to do the wort stated.
Owner and/or Condo esident Date
ssion Expi _� n2 : 'rk tj
liltiettttY VTArli C1'IFT=S2C,i
APPROVED:
Zoning Building
Mechanical Plumbing
ntractor or 0
to contractor o
Ion Expires:
C.C.F. NOTARY
Electrical
r- Builder
uild
BOND
Dat
` Date
v--e /� 19
TOTAL DUE 3.. eO
Engineering
LOT:
CONSTRUCTION PERMIT FOR:
[ ] New System f ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [
K [
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK: SUBDIVISION:
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
AGENT:
[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.
] [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: [ ]
A TYPE SYSTEM: r ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED j J
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: [ ] INCHES
0
T
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [: ] INCHES
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TITLE: CPHU
EXPIRATION DATE:
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