RC025-1265RE- OCCUPANCY
APPLICATION
Date 2
Contact Name
Buyer
Property Address
Sign:
Print:
Rev. 10/02/03)
Seller
12t
City Miami Shores State Fl Zip 331 a Zt
I hereby certify that I understand that the zoning of the property is for single - family residential use and
that it is unlawful for more than one family to reside therein. I also understand that any Certificate of Re-
Occupancy that may be issued by Miami Shores Village certifies only that the referenced property is
being used for single - family purposes and that such Certificate does not constitute any representation,
warranty or certification as to the condition of the dwelling or other structures on the property.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate.
Applicant Nam
Signature �► , _
The foregoing instrument was acknowledged before me this / c day of b ec. , 20
by On, , who is personally known to me or who has
produced as identification and who did take an oath.
NOTARY PUBLIC:
My Commission Expires:
Miami Shores Village
Building Department
DEC
Realtor
1
1
ti LOIS E. LINDLEY
;,1 MY COMMISSION # DO 361851
' cam ber 1 5, 2008
`? Bonded Thru Notary Public Underwritero
Building Officials Approval:
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795 -2204
Fax: (305) 756 -8972
Permit No. C C 6 l 2 -Co b
Loc ID
Phone# (so) coq/ —4180
Company Name
Re -Occ. $60.00
Notary $5.00
CCF $0.60
coo . On
Total
DEC 1 9 PAID
4-64- �
121 NE 92 ST
Passed
6
Inspector Comments
Failed
Correction
Needed
Re- Inspection
Fee
($75)
No Additional Inspections can be scheduled
re- inspection fee is paid.
until
Inspection Date: 12/20/2005
Inspector: Grande, Claudio
Owner: ORGREN, JOHN
Job Address: 121 92 Street NE
Project: <NONE>
Contractor:
Miami Shores Village, FL 33138-
Building Department Comments
Monday, December 19, 2005
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phony: (305)795 -2204 Fax: (305)756 -8972
Block:
Phone Number
Lot:
51265
Permit Type: Residential Construction
Inspection Type: Re Occupancy
Work Classification: Re- Occupancy
Parcel Number 1132060133160
Page 2 of 2
Type Insp'n
Permit No.
Name
Address
Company
Phone #
Approved
Re- Insp'n Fee
c
6-0 — Ir — Lx S c
MIAMI SHORES VILLAGE
BUII DEPARTMENT
305- 795 -2204
Buildin I spection Request
Date is
Inspection Date f
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1PaY P OFFICIAL NOTARY SEAL
° G SANDRA M MONTIEL
2 1 * COMMISSION NUMBER
g ` ��' CC401261
7, tits MY COMMISSION .EXP.
°F FL- AUG. 17 1998
STATE OF FLORIDA
DEPARTMENT OF STATE
Division of Archives, History
and Records Management
DS -HSP 3AAA Rev. 3.79
Site Name
Address of Site: 121
Instruction for locating
NE 2nd Ave,
Location: Miami Shores Sec. 1 Amd. 23 E 1/2 16 &all_ _
subdivision name block no. lot no.
County: Dade 808= =
Owner of Site: Name: Cogswell, Edwina
Address: 121 NE 92 St., Miami Shores, Fla, 33138.
Type of Ownership pri vate $48= = Recording Date
Recorder:
Name & Title: tnfi 1 <, Marty
Address: MgHPB
Condition of Site:
Check One
❑ Excellent
❑ Good
21 Fair
❑ Deteriorated
863 = =
863 = =
863= =
863 = =
❑ Moved (
NR Classification Category:
Threats to Site: none
Check One or More
❑ Zoning( )(
❑ Development( )(
❑ Deterioration( X
❑ Borrowing ( )(
❑ Other (See Remarks Below):
Areas of Significance
Significance:
FLORIDA MASTER SITE FILE
Site Inventory Form FDAHRM 802 = =
1009= =
Site No.
830 = = Survey
NE 92 St., Miami Shores, Fla.
N side of NE 92 St. between NE
Integrity of Site:
Check One or More
M Altered
❑ Unaltered
858= =
858= =
M Original Site 858 = =
❑ Restored ( ) (Date: )( )858= =
) (Date: )( )858= =
Building
)( )878= =
)( )878= =
)( )878= =
)( )878= _
Architecture
❑ Transportation(
❑
Fill( )(
❑ Dredge( )(
878= =
Date 8505
33138
lst Ave &
Structure is a fine example of Mediterranean Revival architecture
applied to a smaller, single -story home. Noteworthy features include
an arched French entry door on S facade, flanked by two arched
windows, all three with double -light transoms. Structure is in
scale and character with surrounding neighborhood.
911 ==
820= =
905= =
813= =
902= =
832= =
818= =
Original Use private resid.838= =
Present Use Private resid 850= =
Dates: Beginning + 1928 844 = =
Culture /Phase American 840= =
Period 20th Century 845= =
916= =
)( ) 878 = =
)( )878= =
)( )878= =
910= =
Township
Range
Section
812= =
53S
41E
1
8
'
ARCHITECT -- _-__ --__-- -
BUILDER
STYLE AND/OR PERIOD Mediterranean Revival
PLAN TYPE t-shape; irregular
EXTERIOR FABRIC(S) rough stucco
STRUCTURAL SYSSYSTEM(S) coocre±e block
PORCHES S entry; enclosed
942= =
FOUNDATION: concrete bloc
k �42 ==
ROOF TYPE: intersecting gables g42==
SECONDARY ROOF STRUCTURE(B: cross nable;bazreI tile g42==
CHIMNEY LOCATION: n/a S42= =
WINDOW TYPE: casement, aImn. awning A42==
CHIMNEY: n/a ' 882==
ROOF SURFACING: barrel tile 883==
ORNAMENT EXTERIOR: ceramic tile 882==
NO. OFCHIMNEYS none 952= = NO. {)FSTORIES 1 S50= =
none
NO. OFDORMERS 054==
K4apRofe,enoo(inc|.ana|e&date) Shores Village Plat 1980
809 = =
Latitude and Longitude:
Site Size (Approx. Acreage of Property):
LOCATION SKETCH OR MAP N
Contact Print
°
r* E 91 sr
le4:1=m4.
UTM Coordinates:
Photographic Records Numbers 1 2g/850103BG30
If
Zone zi"nng --- ���."o
872= =
874==
QS4= =
xvo= =
854= =
85R==
8OO= =
833= =
89O==
S ATE OF FLORIDA
DEPARTMENT OF STATE
Division of Archives. History
and Records Management
DS•HSP.3E 9 -74
Physical Description:
CONTINUATION SHEET
Site No,
Site Name 121 NE 92 Street
Miami Shores, FL
Structure is a one -story Mediterranean Revival cottage. Three -bay entry
on S has French kgs flanked by windows of similar proportion, all three
with double- liggtvtransoms. Entry screened door is excellent example of
wrought iron tropical scene with palm trees and birds. .Entry steps are
faced with decorative glazed tile. Stucco is extremely rough. Some
windows have solid wood hurricane awnings; all have wrought iron security
grills. Semi - detached single -story garage in rear is of similar style.
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MIAMI SHORE5
HEArriterARY
.5 CHOOL
APPLICANT: V r3 r o W AGENT: S 7`C Co,/ SW , 0 /-era.,..-5f
PROPERTY STREET ADDRESS: / 2 / w / C 7 2 9
LOT: / BLOCK: 2� SUBDIVISION: m ( p 1 ( S 40 V
PROPERTY ID #: J/ 3Zv/ — 0/3 ,/
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
TANK INSTALLATION
[01] TANK SIZE [1]
[02] TANK MATERIAL
[03] OUTLET DEVICE
[04] MULTI- CHAMBERS
[05] LEGEND
[06] WATERTIG Ty'
[07] LEVEL 1
[08] DEPTH OF LID t`
i e g4r. crA
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES RECEIPT # 895/.2/PD97
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID / ..7"/CF)
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
EXPLANATION OF VIOLATIONS:
( )
( )
( )
(
fi
�l9
DRAINFIELD INSTTION
[09] AREA (1)04O 2( fy (2] 1 SQFT
[10] DISTRIBUTION HEADER
(11) NUMBER OF DRA
[12] DRAINLINE SEPARATIOIJ3
[13] DRAINLINE SLOPE(2
[14] DEPTH OF COVER /4.
(15] SYSTEM ELEVATION
[16] SYSTEM LOCATION y [
[17] DOSING PUMPS
[18] AGGREGATE SIZE 0
[19] AGGREGATE SOURCE Bt
[20] AGGREGATE WASHED (91
[21] AGGREGATE DEPTH /2 fi
FILL /EXCAVATION MATERIAL
[22] FILL AMOUNT 9/r
4
[23] FILL TEXTURE
[24] EXCAVATION DEPTH . 76
[25] EXCAVATION AREA*
[26] REPLACEMENT MATERIAL
CONSTRUCTI% (APPROVED /DISAPPROVED]:h4 rnMr '/
FINAL SYST M [APPROVED DISAPPROVED]:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SETBACKS
[ ] (27] SURFACE WATER 4r/4
[ ] (28] DITCHES
[ ] (29] PRIVATE WELLS 4
( ] [30] PUBLIC WELLS r -/^
[ ] [31] IRRIGATION WELLS
[ ] [32) POTABLE WATER LINES /
( ] [33] BUILDING FOUNDATIONS
( ] [34] PROPERTY LINES7
( ] [35] OTHER
FILLED /MOUND SYSTEM
[ ] [36] DRAINFIELD COVER
[ ] [37] SHOULDERS
( ] [38] SLOPES
( ] (39] STABILIZATION MATERIAL
(
(
ABANDONMENT
[ ] [49] TANK PUMPED /( / 2
( ] (50] TANK CRUSHED AND FILLED /
12(.6979
APPLICANT
U CJ
ADDITIONAL INFORMATION
(40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
(42] ALARMS
[43] MAINTENANCE AGREEME
(44] BUILDING AREA Co G --42s
[45] PLUMBING FIXTURES I
[46] FINAL SITE GRADING" /�-
[47] CONTRACTOR C.�7 o '5.
(48] OTHER
CPHU DATE :SP-
2 4 d L ° CPHU DATE : / ;°-#1j 1
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) Page 2 of
(Stock Number: 5744- 002-4016-4)
i