1040 NE 93 St (4)Permit No./ . - l'' _✓
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida.
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and spcci ations must be kept at
building during progress of work.
Owner's Name and Address_ . ` No. _ Street
Registered Architect and /or Engineer
Employing Plumber's Name .,_„ _ No Street
Location and Legal Description Lot -/ Block 6 _,f' _ Subdivision/
L �' Street -- -
Street and Number where work is to be performed— No.__ L
_ =__-�
State work to be performed and purpose of building (By Floors)
New Building
Remodeling__. Addition _
(7 Size Septic Tank - - -- _- _ _ -
(i
Dist. Feet of Tank or Drain Field from Well
ss.
( Type of Tank
Feet of Drain Tile .
Nature of Water Supply: City —Well_ ___ ___ _____ ___ Size of Soakage Pit - _ ______
Repairs.
Amount of Permit $ ___ _ (Signed)
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub- contracto-s employed by hint in the work to he
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this pennit, as are
licensed by Miami Shores Village.
(Signed)
Date
Capacity Gals._
No. of Stories
Master Plumber.
r
STATE OF FLORIDA, t
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
CHECK
r
Permit No./ . - l'' _✓
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida.
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and spcci ations must be kept at
building during progress of work.
Owner's Name and Address_ . ` No. _ Street
Registered Architect and /or Engineer
Employing Plumber's Name .,_„ _ No Street
Location and Legal Description Lot -/ Block 6 _,f' _ Subdivision/
L �' Street -- -
Street and Number where work is to be performed— No.__ L
_ =__-�
State work to be performed and purpose of building (By Floors)
New Building
Remodeling__. Addition _
(7 Size Septic Tank - - -- _- _ _ -
(i
Dist. Feet of Tank or Drain Field from Well
ss.
( Type of Tank
Feet of Drain Tile .
Nature of Water Supply: City —Well_ ___ ___ _____ ___ Size of Soakage Pit - _ ______
Repairs.
Amount of Permit $ ___ _ (Signed)
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub- contracto-s employed by hint in the work to he
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this pennit, as are
licensed by Miami Shores Village.
(Signed)
Date
Capacity Gals._
No. of Stories
Master Plumber.
r
STATE OF FLORIDA, t
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
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( 10
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date "�' / / dge Job Address / 9
� JV� Tax Folio
(1'S"
Legal Description Historically Designated: Yes No
e f,7,3 Z.
Owner/Lessee / Tenant Pr PER
Owner's Address /6 /V q.3 3r
Phone
Address .3 S B�TC :�J .��Ar /gyp
Contracting Co. ALL AtiazicAm S /,CGS WO.
Qualifier 'Areas 2 . —7;4/0 f 4- ss # &'/ _ Phone 45 9 % - 5 °CC
State # 1,14C0 44O.6 Municipal # Competency # Ins. Co.
Address
Architect/Engineer
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELE TRICAL PLUIV ING
OOFING _ PAVING FENCE SIGN
/is (3w (,vAZsr3J& `�
Square Ft. Estimated Cost (value) 16 00 ` 00
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 wor be done in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above - ed tractor t- werk stated.
WORK DESCRIPTION
— .3 J
Signature of owner and/or Condo President Date Signature of Contractor r Owner -B
Notary as to Owner and/or Condo President Date
My Commission Expires:
FEES: PERMIT
C.C.F.
Notary as to Contractor or Owner-
My Commission Expires:
Date
OFFICIA TAR S
PU ® (4 BARBARA ANN FUG AZZI
( �
COWNSSION NUMBER
CC723468
4 p MY COMMISSION EXPIRES
or FLO MAR. 29 2002
�. ms s'
BOND
tiCr 00(4Z
TOTAL DUE /'`./ 7,;
APPROVED:
Zoning Building Electrical
Mechanical / % / �/ // 0 Plumbing Engineering
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date j- 2 S Job Address I O C4 0 /c-/ `r 3 .5 Tax Folio
Legal Description Historically Designated: Yes No
Master Permit # St/ 5 &A1b "(
Owner/Lessee / 'tom tP � \l -
Owner's Address / ! /O- Phone
Contracting Co. 2 Cl l I Q 71 O (T(o t' 1 r M . Q t 7 l C' Address C f % • f i i /1 l t/o c (c e ce . S 40 Or"
Qualifier —LOS() ar,\ lA \\'5-7T SS# //, - , _ Phone 4.).6_, s 5:- lo6
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 A (iV Y (Il ` Gc. 7 (QM' N C( jh1 /U n D n (a („, 4 c .
Square Ft. Estimated Cost (value) 4, `3 6..1 00
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.
My Commission Expires:
Signature of owner and/or Condo President Date Si 4 e o o trac :r o Owner- Builder
FEES: PERMIT 3.c i RADON
Date
Notary as to Contractor or Owner - Builder Date
M C q r 11
..- s ac ma L sN 1 EEL
'1 CAS p <.� (c;CU it
' ���,
i� ,� 1 , 11 J , n�E1 I
-
C.C.F. NOTARY • BOND iY/9 5 T� (�
"J TOTAL DUE
i5
Notary as to Owner and/or Condo President Date
i re IY?
APPROVED:
Zoning Building ` Electrical
4
Mechanical Plumbing Engineering
CONSTRUCTION PERMIT FQR:
[ .] "Existing System
Abandonment
[
APPLICANT:
PROPERTY STREET ADDRESS:
LOT: BLOCK:
PROPERTY ID #:
T [
A
N [
K
D
R [
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
• BCTTOt4 CF DRAINFIELD TO BE [
L
D FILL REQUIRED: [ ] INCHES
0
T
H
E
R
] New System
] Repair
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
G ;
[
[
•
SUBDIVISION:
'] .SQUARE FEET PRIMARY DRAINFIELD SYSTEM
] SQUARE FEET SYSTEM
] STANDARD
] TRENCH
Gam] Holding Tank [ - Temporary /Experimental
r
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -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 DESIGN AND SPECIFICATIONS
] [GALLONS / 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: [ ]
[ ] FILLED
[ < ] BED
TITLE:
TITLE:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016-0)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ ] MOUND [ ]
[ ]
'" 1 [INCHES/FT] [ABOVE / BELOW BENCHMARK /REFERENCE POINT
][INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ '\ INCHES
EXPIRATION DATE:
CPHU
Page 1 of 2
LOT:
PROPERTY ID #:
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
TOTAL ESTIMATED SEWAGE FLOW: ',, i GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: ' GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES /SWALES: _ FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC:!.'i FT LIMITED USE: i._ �� FT PRIVATE: � i � y FT NON - POTABLE* FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: FT
SITE EVALUATED BY:
SOIL PROFILE INFORMATION SITE 1
Mupsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
HIGH WATER TABLE VEGETATION: [ ] YES [A NO
HRS -H Form 4015, Mar 92 (0bsoletes previous editions which may not be used)
(Stock Number: 5744 - 003 - 4015-1)
AGENT:
(7,
SOIL PROFILE INFORMATION SITE 2
yL r
PERMIT #
[Section /Township /Range /Parcel No. or Tax ID Number]
SQFT
]r1NCHES /PTJ [ABOVE/BELOW/ BENCHMARK/REFERENCE POINT
UNOBSTRUCTED AREA REQUIRED: SQFT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES Cl NO 10 YEAR FLOODING? [ ] YES [. ] NO
10 YEAR FLOOD ELEVATION FOR SITE: ;', !% FT MSL /NGVD SITE ELEVATION: %'�i. %� � FT MSL /NGVD
Munsell //Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: .4L, INCHES [AB)VE /BELOW) EXISTING GRADE. TYPE: [PERCHED /APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: Y % - INCHES [ ABOVE / BELOW ] EXISTING GRADE.
MOTTLING: [ ] YES O NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: ;� DEPTH OF EXCAVATION INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH (J ] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
Page 3 of 3
AGENT:
APPLICATION FOR:
[ ] New System
[F Repair
[ ]
[
APPLICANT: ,, r � (J� r TELEPHONE
MAILING ADDRESS: t 7 n . 1 ,�
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTI�ON'OR DEED]
LOT: BLOCK: SUBDIVISION: DATE OF .;
l W; ) t& SUBDIVISION:
PROPERTY ID #: j p [Section /Township /Range /Parcel No.] ZONING:
PROPERTY SIZE: ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ - <) PUBLIC
PROPERTY STREET ADDRESS:
/04/0 n R 7
DIRECTIONS TO PROPERTY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
Existing System [ ]_Holding Tank [ ] Temporary /Experimental
Abandonment [—)] OtIl's1 4.4Y)
BUILDING INFORMATION ] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Sqft Served For Commercial Only
1
2
3
4
[ �/] Garbage Grinders /Disposals [Gil Spas /Hot Tubs U Floor /Equipment Drains
[ ) Ultra -low Volume Flush Toilets [A Other (Specify)
APPLICANT'S SIGNATURE: \11)l Z�v
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1] which may be used)
(Stock Number. 5744- 001 - 4015 -1)
PERMIT # /9 o a y
DATE PAID -V�° /" e0
FEE PAID $
RECEIPT #
DATE:
Page 1 of 3
INSTRUCTIONS:
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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
SUBDIVISION:
PROPERTY ID /I:
PROPERTY SIZE:
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
legal description or deed must be attached.
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
27 character number for property. (Health Department may require property appraiser ID# or section /township /ranee /parcel number.)
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 1OD-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
// PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table 11, Chapter 10D -6, FAC.
FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater.
Site Plan Submitted by
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN
11
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Notes:
SIGNATURE
Plan Approved
By County Public Unit
HRS-H Form 4015, Feb 85 (Obsoietes previous editions which may not be used)
(Stock Number. 5744-002-4015-6)
II I Ii
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ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
TITLE
I 1,
Date
Page 2 of 3