1260 NE 93 St (7)Page 2
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1°` Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
ST OF j L O • , COUNTY OF MIAMI -DADE
" "9 6 )
S ignature of Own
YYJ /C / EI 2 ?&bJ 22 &A)/ JE74Ai &,1&tJr
QQ Print Name
subscribed before me this c ri -tday of U Cl — R worn to nd subscribed before me this day of
Print Name
Signature of Notary
SEAL:
Personally known
LESTER E. CROCKE:
MY COMMISSION # DD 014r
EXPIRES: May 20, 20t;
Bonded Thru Budget Notary Se
OR, Produced Identification Personally known
Type of Identification Produced:
TATE OF
RID
A,
Signature of Contrac .r / Qualifier r
PERMIT APPLICATION
MIAMI -DADS
� -5 4te qlp�3dY M DECK., t
Signature
SEAL:
if
o. ~(' ' cowl NIAILIan
0 1 . » CCry ®6097'
u a Q
• "4:' 9 DAY CO:` ISSIOH
OR, Produced Identification
Type of Identification Produced:
CONTRACTOR
Name Lz S %C-k G • CyRoen
License No. iipb be/ ) /3 .`/..
`1 !J/'I
Address L_Lo Yl) etio.� / �/ q �
D� ji 7ci
m A mi , � D 3.3/
Telephone j , -4 , ^�� .96, r/ Fax �_ _/ Zs p . 7 O
Qualifier Name / iF- rz 02 � r O
PROPERTY OWNER
Name ^7 � ��/�
s4) CF)/11 . 7 L V V , 2-o AJ)
Address J ,k J G-176-411:
J/
424.oNL'93
m /1),(441 3313Y -i94t/
'i'O/2L i
Home Telephone 3 , c _ 4 _ j
Business Telephone /� _ t j 7 - O 1
`` �� ki4/0C-
Fax /7
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add 'l Attachment
Other
Add'I Detachment
Other
Master Permit No. SO ®
Subsidiary Permit No.
S - The ,follo∎1,tng<s j t r p .V%tst b�e.taken,
obtain a perml the
Step 1.
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
A PPL " ICATI;QN
Job Address:
Lot
Subdivision
9
Current Use of Property
Proposed Use of Property
Tenant Information
/�(vo A.,1[.= Q LCT 33/3
a Adddress Apt. City State ) Zip
Folio Number // .)„[.QS 0 .2-7 b, /D De of Work ?L?/q /72 � �" c iA 7
I y L l/PL PB 07 PG !off Zoning
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
v
Block Sz P//C TA
^ _ ' ,�,� Linear Feet
'C� /D1U % I it _. � d S tare Feet 400 Units Floors
/ Value of Work se0ekv. on Bldg Value
Ai' / Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
ENGINEER
Name
License No.
Address
Telephone
Fax
PERMIT APPLICATION
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 10 feet an
PART II - SITEPLAN
73
I ta)FP /Crzilusr
4,I TO EY CO7F
75k
op Pea ' -7)' Teo
R vM /A /&-
Mui
- ter - MiV$[4
Al E. . qARi
Notes:
zy 3.-72 1 rig '�,a.J - Dui::: To 1 ov �LDA2z /g 4U2)
Site Plan submitted by: ER CRC' CK4" - r/
Plan Approved
By
Date
DH 4015, 10/96 (Replaces HRS -H Form 401 which may be used)
(Stock Number: 5744 - 002 - 4015 -6)
Not Approved
ALL CHANGE MUST B APPROVED BY THE COUNTY HEALTH DEPARTMENT
T /C am/ 7,
t'
County Health Department
Page 2 of 4
APPLICANT:
LOT:
PROPERTY ID #:
STATE OF FLORIDA
,DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
rf :)
BLOCK:
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.
PROPERTY SIZE CONFORMS TO SITE PLAN: (i YES [ ]
TOTAL ESTIMATED SEWAGE FLOW: ',(: ) GALLONS
AUTHORIZED SEWAGE FLOW: �� GALLONS
UNOBSTRUCTED AREA AVAILABLE: (,( ) SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH
SURFACE WATER: 'Jig, FT
WELLS: PUBLIC: J;// FT
BUILDING FOUNDATIONS:
SOIL PROFILE INFORMATION SITE 1
CAN BE MAINTAINED FROM THE
DITCHES /SWALES:
LIMITED USE: /JAI FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES (,4 10 YEAR` - FLOODING? [ ] YES (4'NO
10 YEAR FLOOD ELEVATION FOR SITE: .� 1 er
(�) FT MS1;' NGVD � SITE ELEVATION: .�.� � rFT /NGVD
i SOIL P OFXLE'IN SITE 2
l
Texture Depth\
r);47Y)'4 . } »' i0 1. '•/
517it%> 'OP to
i )7-) to
to
/ 1 to
if 1' to
2 to - /,'
USDA SOIL SERIES: t )R Ps .t')A) =!/) 0
Munsell # /Color
/0 v
•,- "
1)
OBSERVED WATER TABLE: I INCHES [ABOVE / BELOW) EXISTING GRADE. TYP .PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATIO : -6 , INCHES[ ABOVE EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [11 NO MOTTLINGr rf YES (. NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:' r" 1. 0 DEPTH OF EXCAVATION :? INCHEE
DRAINFIELD CONFIGURATION: [ ] TRENCH [,:e] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITTERIA:
SITE EVALUATED BY:
-- -
r--1( • / /
DH 4015, 10196 (Replaces HRS -H Form 4015 (Pape 3) which may be used) -
(Stock Number: 5744 -003 - 4015 -1)
( / AGENT :
SUBDIVISION:
•
FT PROPERTY LINES:
[Section /Township /Range /Parcel No.
10 le ' KINCHESjFT] [ABO
PERMIT #
/ ,}t/f') A I . h : :.1 l i'� .. /'. I fr.
NO NET USABLE AREA AVAILABLE: • ACRES
PER DAY SIDEIeES -TABLE 11 OTHER -TABLE 2]
PER DAY \ [ 1500 opffixCat - 2500 GPD /ACRE]
UNOBSTRUCTED AREA REQUIRED: (7T' SQFT
or Tax ID Number]
Et04)-._BENCHMARK /REFERENCE POINT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
/ 4 FT NORMALLY WET? [ ] YES,& [ ] NO
PRIVATE: 4) 14 FT NON-POTABLE: S' fl FT
FT POTABLE WATER LINES: / FT
Mda e11' # / Color Texture Depth
/6 V c /.rte) ,0-r 7 V 0 : ; to
(%: i i4V :Sk ='r t) to /r-"
1 0 \T '. 1-2. •'4j7) Ito
r,. ill "7;e1.117) to
1 /; to
to
/f • . /; to
A to
/! /, to - /'
USDA SOIL SERIES: (,:Z • FlAtL, ?AJ/ )
DATE: ' /,
Page 3 of
C STRUCTION PERMIT FOR:
[71
APPLICANT:
PROPERTY ADDRESS:
LOT:
New System
Repair
STATE OF FLORIDA I ] f - '`
DEPARTMENT OF HEAL
ONSITE SEWAGE TREATMENT ,AND .DISPOSAL SYSTEM
CONSTRUCTION PERMIT
BLOCK:
ti Existing System
Abandonment
G qave6
/Ace, Me 9.3
SUBDIVISION:
PROPERTY ID # / i 4 S e ell ® f 0zo
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN
• y - ` . ,F •
T !..v GALLONS / GPD �` /AEROBIC UNIT
A [ ] GALLONS / GPD
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY
X [ ] GALLONS DOSING TANK CAPACITY [ ]
D (3® SQUARE
R [ ] SQUARE
A
I
N
F
I
E
L
D
0
T
H
E
R
STANARD
TRENCH
LOCATION OF BENCHMARK:
TYPE SYSTEM:
CONFIGURATION:
FEET PRIMARY DRAINFIELD SYSTEM
FEET SYSTEM
[ em FILLED
BED
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE'
[ INCHE
V MOBND
/FT] [ABO
/FT] [
FILL REQUIRED [Apr] INCHES EXCAVATION REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4016, 12/99 (P -ge 1
t INCHES
C?.1 STA
UN
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIP # •
/3-- 4.
EXPIRATION DATE:
fir~ oTX
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Instal ler /Contractor
pt. 4: Building Department
(914.040,5 g
2 5%00
T
Holding Tank [I4 Innovative
Temporary [ej
47a05cr
L4.A0Ce
[SECTION, TO SHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
OF LOAMY COARSE SAND
BO' 1 o ut4GCtttrtuLO
butiMrr BENCH: An 'r {SECT C
MOW tr
l � E:i ,� t 1 • : E
BI CHMARX /REFERENCE POINT
BENCHMARK /REFERENCE POINT
CAPACITY MULTI- CHAMBERED /IN- SERIES [
CAPACITY MULTI - CHAMBERED /IN- SERIES [
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLON ]
GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ]
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT 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
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 64E-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 (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by C :HD
EXPIRATION DATE:
PROPERTY 1D #: 27 character id number for property. (CHD may require property appraiser ID # or section /township /range/parcel number)
One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the date
issued.
; •
•
ELECTRICAL
TYPE
Minimum Fee
()Ty.
TYPE
Dryer
QTY.
TYPE
Outlet, Appliance
QTY.
TYPE
Service Repair
QTV.
A/C Central 1 -3 Ton
Cooling Tower
Fan
Outlet, Wall
Service, Temporary
A/C Central 4 -7 Ton
- Paint Booth
Fire Pump
Ventilation, Cost
Outlet, Switch
Air Handler, Tons
Signs
Ductwork, Cost of
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
Process/Pressure Piping
A/C Central 16-20 Ton
Fixture Light
Bath Fan - Vented, #
Parking Lot Lights
Fireplaces, Number of
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
"I'1'PE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTY TYPI.
Generator
Q . I ' V
. I'Y , PI;
Refrigeration, Tons .
QTY
A/C Central, Tons
Bath Tub
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
- Paint Booth
Filter Replace
Ventilation, Cost
Pool Piping
Air Handler, Tons
Sprinkler Repair
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Cap - Water
Gas - Appliance
Bath Fan - Vented, #
Pump, Domestic
Fireplaces, Number of
Pressure Vessel
Cap - Sewer
PLUMBING
TYPE
A/C Condensate
QTY.
'1'VPG
Drains, Roof
QTY.
TYPE.
Miscellaneous Fixture
QTY.
TYPE
Soakage Pit
Q'I'Y.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
1-DECNIJ ST'
CI OWNER - BUILDER FORM
(Attach)
CI FIRE DEPARTMENT
APPROVAL (Commercial /
multi - family)
CONCURRENCY
(New Construction)
CI OTHER
(Specify & Attach)
LJ PROOF OF OWNERSHIP
(Attach)
HRS / DERM APPROVAL
(Septic / Sewer)
GI IMPACT FEE
(New Construction)
CI OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.)
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
$ "0. O o
$ 3 a 0, 0 ,0
$
(I c?
(sq.ft. = x/ 1 000
x ¢.60)
$ (¢.005 /sq.ft.)
$ (¢.01 /sq.ft.)
REVIEWED AND PREPARED BY: DATE:
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
PERMIT APPLICATION
CI CONDO ASSOCIATION APPROVAL
(Attach)
BPR APPROVAL (Restaurants)
CI CONTRACTOR REGISTRATION
(On File)
TOTAL
a o
CONDITION OF APPROVAL i ,1
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL o (305) 795 -2207 FAX (305) 756 -8972 http : / /www.miamishoresvillage.com
APPLICANT:
AGENT:
PRoPERTY.ADDRESS:
TANK
[
(02]
[03]
.[04]
[05]
[06]
[07]
[08]
[09]
E
l LANATION OF VIOLATIONS
[ ]ate', {
[ .
[ ] •
[ 1
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND
CONSTRUCTION INSPECTION AND
:Teo ,
zcr,,
LfOLis d
/; t IQ
LOT: / BLOCK: 0- SUBDIVISION:
.CHECKED (X) ITEMS ARE NOT IN COMPLIANCE WITH STATUTE.OR RULE AND MUST BE CORRECTED.
INSTALLATION
TANK SIZE [1] Gi(; U [2]
( N
TANK MATERIAL
OUTLET DEVICE
MULTI - CHAMBERED. [ Y
'OUTLET FILTER
LEGEND •
WATERTIGHT
LEVEL,
DEPTH TO LID
•
DRAINFIELD INSTALLATION 3cu
[10] AREA [ 1 ] / f . ' [ 2 ] 2 5f`7 SQFT [ /,'! ]
[11] DISTRIBUTION BOX HEADER ✓ [ f]
[12]. NUMBER OF DRAIMLINES Li. [ l / '1 l
[13] DRAINLINE SEPARATION i�r, [ Y ]
[14] DRAINLINE SLOPE -.
[15] DEPTH OF COVER
[16] ELEVATION [ABOVE /BELOW] BM [ ]
[17] SYSTEM LOCATION [ .
[18] DOSING PUMPS
[ ]."' [19]
[ ] [
[• ] [21]
AGGREGATE SIZE r.J& ;167
AGGREGATE EXCESSIVi FINES
AGGREGATE DEPTH.
FILL./ EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE •
[24] EXCAVATION DEPTH
[ ]
t' I
[ .I
[ ] [ . AREA REPLACED
L [ .REPLACEMENT MATERIAL
CONSTRUCTION [APPROVED/ISAPPROVED OL
.FINALSYS [APPRO DISAPPROVED :
] 7.P,
DH 4016, 10/9 revious'Editions May
In / Contractor .
/N]
r
L f
1.4 r
DIPOSAL SYSTEM
FINAL APPROVAL
a !� ; . 1
U
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
PROPERTY ID 1: /1- 7 ).),1c - t; ) 7- ( ?IU
SETBACKS
[27] SURFACE WATER FT
(28] DITCHES FT
(29] PRIVATE WELLS FT
[30] PUBLIC WELLS ' FT
[31] IRRIGATION . WELLS 1/ re FT
[32] POTABLE WATER LINES nil FT
[33] BUILDING FOUNDATION ,�,4c FT
[34] PROPERTY LINES -S' FT
[35.] OTHER. FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
�,'_ (S
r
;(i -i -_iii
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS •
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE,PLAN
[46) FINAL SITE GRADING
[47) CONTRACTOR Li (50
[48] OTHER •
ABANDONMENT
[49] • TANK PUMPED /_ /_
[50] TANK CRUSHED & FILLED _ /
C
frviOc-
CED DATE: /c1— /5-4/
CHD . DATE: /0 ' % iC J7
Page. 2 of
•
ELECTRICAL
TYPE.
Minimum Fee
QTY.
TYPE
Dryer
Q'I'Y.
TypE
Outlet, Appliance
QTY.
TYPE
Service Repair
QTY.
A/C Central 1 -3 Ton
Fan
Outlet, Wall
Service, Temporary
A/C Central 4 -7 Ton
Fire Pump
Outlet, Switch
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Oven
Space Heater (kw)
A/C Central 16-20 Ton
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
-
Service, Number of Amps
Water Heater New
MECHANICAL
TYPE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTY.
'TY
Generator
QTY.
TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Supply, AC Well
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
Temporary Toilet
PLUMBING
'I'YI'E
A/C Condensate
()Ty.
'TYPE
Drains, Roof
QTY.
TYPE.
Miscellaneous Fixture
QTY.
'TYPE
Soakage Pit
QTY.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas - Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 2
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST 13E PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1 Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORIDA, COUNTY OF MIAMI -DADE
Signature of Owner
Print Name
Swom to and subscribed before me this day of
Signature of Notary Public - State of Florida
Type of Identification Produced:
Si
ORI
7OF MIAMI -DADE
gnature of No
PERMIT APPLICATION
ry Public - Sta
ame I �//
nd subscribed before me this 1(? day of )(I ,
av P OrRC'AL NOTARY S AL
SEAL: SEAL: o1P � 'Y� ANCELA M BECKER
ii ' ' �-.. ;j C, )2,C.' . 0i! HUMMER
li
�(-1.2',.:;:7>,—,--A; ` 7 Q CC786E 97
... Y CO, 'iss ou aXP1RES
Personally known OR, Produced Identification Personally known - " ` - -- OR, 'roduce �t . fi . "on
Type of Identification Produced:
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
SECTION
BY
DATE
AEI: /Z 2?S�.
1/ � !! 6R IJ FL .3/3 P/
Zoning
30^ _ q3"1/-,.„. /�11
Business Telephone
/7� { _ 449 it). // /
f 7
Electrical
4 E 7
Qualifier Name 1_15 OR iy /
Demolish
Mechanical
Relocation of Structure
Shell Only
Plumbing
Foundation Only
/D c?,(
Add'l Attachment
Fire
Other
Add'I Detachment
Public Works
Other
Structural
Building Official
PROPERTY OWNER
!� / , "
Name 44 / 'IACL t2 6 -U'[/e�� // J'fO C1/`/611,g
Address / o
nii /
AEI: /Z 2?S�.
1/ � !! 6R IJ FL .3/3 P/
Home Telephone
30^ _ q3"1/-,.„. /�11
Business Telephone
/7� { _ 449 it). // /
f 7
Fax
4 E 7
CONTRACTOR
New Construction
Name LL0 J c r,'-/ [3 #7 //G
Enclosure
License No. 19 ^ . 4 ,. 44 ,„
IJC
Alteration Exterior
Address . 9 r
.930 J 77,
rn /', .• 33/4
Repair
Telephone ".737_776 Fax A 2.J _,.7
/v'
Qualifier Name 1_15 OR iy /
Demolish
TYPE OF MANAGEMENT ('/ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'l Attachment
Other
Add'I Detachment
Other
Page 4
OFFICE USE ONLY
CGUNCOWqr
U OWNER - BUILDER FORM
(Attach)
• FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
• CONCURRENCY
(New Construction)
• OTHER
(Specify & Attach)
PERMIT -FEES
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) $
Inspector State Educational Fund
State DCA (Radon)
Code Enforcement Fine
Zoning Review
CI PROOF OF OWNERSHIP
(Attach)
HRS / DERM APPROVAL
(Septic / Sewer)
LI IMPACT FEE
(New Construction)
LI OTHER
(Specify & Attach)
$60
(sq.ft. = x/1000
x 0.60)
$ (0.005 /sq.ft.)
$ (0.01 /sq.ft.)
PERMIT APPLICATION
LI CONDO ASSOCIATION APPROVAL
(Attach)
BPR APPROVAL (Restaurants)
LI CONTRACTOR REGISTRATION
(On File)
ISSUINGOFFICIAL
REVIEWED AND PREPARED BY:
DATE:
co •
'!Di+ ON.A3FJ =PP' w it,
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL (305) 795 -2207 o FAX (305) 756 -8972 a http : / /www.miamishoresvillage.com
00
5-ac 7
Subsidiary Permit No. 50013
Master Permit No.
NSg RU,'CTo1®NS 1 7e4 - Wis; in g steps, must best ken_to obtairt,a.pe�rnut_ from the l\itamt�Sliores Village
Step 1.
Job Address:
Subdivision
Fax
PERMIT APPLICATION
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
PERMIT TYPE ( )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
i24 AJL 9 3 2 /ivmrn all-4;0;1 -F,4, 53/38'
Address
Lot `7 Block //
9 / L (J2L ``'' � PB �`7' 7' `` PG 63'
Current Use of Property RL /ZF k P L
Proposed Use of Property c52/f44L
Tenant Information N' , •
PERMIT CHANGE ( )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Apt. City State Zip
Folio Number // Description of Work PUMP / 4 A) A $tP
77
Zoning Linear Feet
Square Feet y � h Units Floors
Value of Work 0-2 70. o'D Bldg Value
Tax Assessed/Appraised Value
Flood Zone
ENGINEER
Name
License No.
Address
Telephone
Fax
Base Floor Elev.