DRAINFIELDBUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of - r r
Building .A' • • d . � ►
Architect
Contractor
or Builder
Legal Lot
Description II Bl
Address of r A
Building
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
Signed. L.A. INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance w all ordinan =. -• egulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In ac
cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
ref 4
MIAMI SHORES VILLAGE, FLORIDA
DATE 41) ° 19
❑ PERMIT N9 6404 Contractor's
License No.
D
CONTRACTOR OR BUILDER
Work to be performed under this Permit ~•-
t .
.Ci
Subdi-
vision
Value of
Project $
Amount of
Permit $
BY t `' AUTHORITY
A Y DOT
BUILDING ❑
ELECTRICAL El DATE 195'
PLUMBING d PERMIT N? 8 3 51 Contractor's h
License No r
ROOFING ❑
❑ Work to be performed under this Permit
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
MIAMI SHORES VILLAGE. FLORIDA
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the application
herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any plans,
drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked at any
time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this permit is
granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and regulations
pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes responsibility for work
done by his agents, servants or employees.
Signed • BY
INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I 'assume responsibility for all work done by either, myself, my agent, servant or employee.
Bl.
Subdi-
vision
Sq. Ft
Value of
Project $
Amt. of
Permit $
BY AUTHORITY
• MIAMI SHORES VILLAGE, FLA. N? 5711
JOB JeR...W0 4e
ADDRESS 3 3
INSPECTION =L-1
TIME READY
REMARKS:
'PECTOR % -' =� DATE 7
MIAMI SHORES VILLAGE, FLA.
INSPECTION r c_.
p 'rx .
JOB ?A ,J ill o S
ADDRESS .3 3 - E
N? 6231
_
TIME READY P - "-/ -s 7
•
REMARKS:
a+c
`
DATE
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
D a t e 5-40-99 J o b A d d r e s s 3 3 f ) 9 3 I Tax Folio /J 2 d /3 63
Legal Description Z078 2' 9 auf /IJ Historically Designated: Yes 2 No
Owner/Lessee / Tenant 74 T (J IL 7 Tl� �1// / Master Permit # 7 */ ✓'
Owner's Address 33.6 /CJE Q RZ 8 Phone 3 961? - 4
Contracting Co. L L CYD- /iDRT/t7FW �J4 ric Address Q t/v MJ -W /l/ var'
Qualifier J d 5-E SS# Phone — Rs — qq6-x
•
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING LDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
N
WORK DESCRIPTION / 5 414 " rA /AJF CV)
Square Ft. Estimated Cost (value) 4/R2).
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.
CLA/1_41- / KAANI pik 3/t) -99
Si afar of owner and/or Condo President Date
Notary as to 0 Date
My Commission Expires:
o'F P4 My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
11 Personally Known 1 Other 1.0
FEES: PERMIT / ✓ RADON
APPROVED:
Zoning Building
Mechanical Plumbing
5-v49
. �� ontracto • orl go
.:2_._: or' ._
Notary as to Contr
My Commission Expires:
wner- Builder Date
ct• • • ___ ' ...uu
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
11 Personally Known 1 1 Other 1 r)
Date
C.C.F. /* ( NOTARY BOND
Electrical
TOTAL DUE
Engineering
Notes:
Site Plan submitted by:
Plan Approved
DH 4015, 10/96 (Replaces HRS-H Forth 4015 which may be used)
(Stock Number: 5744 -0012- 4015.6)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERT
Permit Application Number ( 9Ge .0/ S
PART II - SITE PLAN
Scale: Each block,,represents 5 feet and 1 inch = 50 feet
l e 7 3 -L �•�r 4.t
I r d
_ _ u `� h - 1 -, 1
r1 , I ! T I
ti
j IJ
11+
�
. �
I I E —
01 N 006A- rl orori
• Signature
Not Approved
•
t' Ci
By �' County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Title
Date - /o -9i
Page 2 of 3
p F
I
0
T
H
E
R
DATE ISSUED:
STATE OF FLORIDA PERMIT # `P .01,''
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID:- F�
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $+ , J°`
CONSTRUCTION PERMIT RECEIPT # `q
Authority: Chapter 381, FS & Chapter 1OD -6, FAC 0
CONSTRUCTION PERM * T y R:
[L New System ,' fisting System
[ ] Repair ),/[ L] Abandonment
`� v� ,
APPLICANT: ' ,J � 1 1 AGENT:
PROPERTY STREET ADDRESS: cl.
LOT: ti p 7 K o(J BLOCK:
SUBDIVISION:
PROPERTY ID #: U �� _ s5 , [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
A �/ [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
T GPD] SE PTI C TA /AjaROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
A [ ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ^• GALL PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D ] SQUARE FEET PRIMARY DRAIN
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
3-
SYSTEM •
[ ] STANDARD [ ] FILLED [ ] MOUND [
[ ' ] TRENCH [ YED. [ ]
LOCATION OF BENCHMARK: »i 4 !/P.0 y / 7
ELEVATION OF PROPOSED SYSTEM SITE [ ] CHES FT]
BOTTOM OF DRAINFIELD TO BE 3 ] INCHES ]
E
L
D FILL REQUIRED: [ ] INCHES
LD
EXCAVATION REQUIRED: [ 3 3') INCHES
Ho -ding Tank ['emporary /Experimental
Other(Specify)
[ABOV BELO ENCHMARK /REFERENCE
[ABOV BELOW] ENCHMARK ERENCE POI
SPECIFICATIONS BY:
APPROVED BY: 2 ; TITLE:
EXPIRATION DATE: ,/' �,�
HRS -H Form 4016, Mar 92 (0bsoletes previous editions which may notjbe used)
(Stock Number: 5744- 001 - 4016 -0)
TITLE:
PPLICANT
CPHU
Page 1 of 2
'INSTRUCTIONS:
PEzEMrr NUMBER: r Permit tracking number assigned by CP }iU.
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: Properly owner's legally authorized representative.
MAILING, ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDN: 27 character id number for property. (CPHU may require property appraiser ID it or section /township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter IOD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter IOD -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 Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
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.