1249 NE 91 Terr (6)- PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 9 a. g Job Address Tax Folio
Legal Description Historically Designated: Yes No
1 /3 sc
Owner/Lessee / Tenant Master Permit #
Owner's Address Phone
Contracting Co. Address
Qualifier SS# Phone
State # 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
Square Ft. Estimated Cost (value) * O O 3
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.
Signature of owner and/or Co do President Date
Notary as to Owner and/or Condo President Date
My Commission F,xpires:. - : : , < . ,.. , ,•,Ft�+a.
FEES: PERMIT
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My Corcmissi^n Expo, A (/76/99
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33" / RADON
APPROVED:
Zoning Building
Mechanical Plumbing
Signature of Contractor or Owner- Builder Date
Notary as to Contractor or Owner- Builder
My Commission Expires: `
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C.C.F. 1 • NOTARY
Electrical
Date
BOND Sp
TOTAL DUE 5 346 :2
Engineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ i ] Holding Tank [ j ] Temporary /Experimental
[ ] Repair ( ] Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 11 which may be used)
(Stock Number: 5744 -001- 4016 -0)
STATE OF FLORIDA PERMIT 1`
DEPARTMENT OF HEALTH DATE PAID !I
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ ' - )/
CONSTRUCTION PERMIT RECEIPT 1 -` ' /
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK: SUBDIVISION:
1
AGENT:
0
T
H
E
R
[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. 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
T [ J [GALLONS / GPDJ SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ )
A [ - ] [GALLONS / GPI)] 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 [ ) SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ) STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ .1 BED [ ]
N
F LOCATION OF BENCHMARK: / `}
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE/ BELOW]' BENCHMARK /REFER NNICA oZ -
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES-/FT] [ABOVE /BELOW } /REF )
L
D FILL REQUIRED: [ r) INCHES EXCAVATION REQUIRED: [ ] INCHES
TITLE:
TITLE:
InstaiicriContrautel
7. '7 0
EXPIRATION DATE:
7 LO
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 I0D -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.
Site Plan Submitted by
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
‘2 (9°61
Permit Application Number
Notes
PART II SITE PLAN
t " t
SIGNATURE
( A
Not Approved Date
TITLE /
By County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
-IRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
;Stock Number: 5744-002-4015-6)
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