485 NE 92 St (9)Square Ft.
OWNER'S
construction
Signature of
Date // 52? ?2 7Job Address 6 /1 /1/1 ^ 2,2 S✓ Tax Folio /7(12C) h" Cr yo.1
Legal DescnptioI,i-31 ' Shy?•
Owner/Lessee / Tenant J P t 0 `, 1 V7. � t 1
Owner's Address
Contracting Co.
Notary as to
My Commission
APPROVED:
Zoning
Mechanical
I/ ' `L 2 1 r"
4 , , k1 S ��fJ"�� J S � c
Qualifier . /4 4
State # ,S/4/:I'x0. j y J
Architect/Engineer 717 Address 4.../>%
Bonding Company �//!l Address
Mortgagor , , Address ,4 /?
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION / 4 VC:V
,EGA =• /V
PERMIT APPLICATION FOR MIAMI SHORES VILLAC
Municipal #
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.
AVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
zoning Furthermore, I authorize the above -named contractor to do the work stated.
and/or C : do ' esident
FEES: PERMIT (l RADON
Building
/
tiisA Sign atur f e Ownf
Date
:;10 /'1).--,2 ,2,470
/4 7,-,
or Condo President Date
Expires: ka Wm. MARK WOODARD
,1 ih C COMMISSin • Y (X .25712
io ,Q )(PIP,FS 0 s, 2001
+` G bONUEQ .NRU
OF ATLANTIC BONDI CO., INC.
Historically Designated: Yes (5i
Master Permit # GT( 3 % ,
Phone 7V /Jl
Address //c C�c. i ,�� Ccr•�t ...Zd`(
SS# „/
Competency # 5776 'Nf , ins. Co. . I. / /ec.�// iv j
7 ?5 Gi. �.
/'
Estimated Cost (value) Contracto )
or r- Builder
NotarY as to Contra
My' Commission E
Electrical
�t �}w 11,Q
A n n1_,*1,S 1 Cl'ATr. CI' 1-I .0!11"1:,.A 1
t..lr i_ i i� -tom
TOTAL DUE
8e') ` 2'65
tor or
C.C.F. NOTARY BOND
Date
Plumbing ) JJ N 1 ' Structural Engineer
1
APPLICANT: (
PROPERTY STREET
�`�::;, -' —cs', . • =. ,,- 71•
LOT , BLOCK:
PROPERTY ID #: )
t
STATE OF FLORIDA
DEPARTMENT OF' HEALTH
ONSITE SEWAGE DISPOSAL SYS
CONSTRUCTION PERMIT
Authority: Chapter 381, F
CONSTRUCTION PERMIT FQR:
[N] New System [hi) Existing System [/.4 Holding Tank ( # \4 Temporary /Experimeu
[s.. ) Repair [;.J) Abandonment [ fJi Other(Specify)
ADDRESS:
(.... AGENT: yC A
(1
SUBDIVISION:
7 ill CIO G C W i
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY
K [
] GALLONS PER DOSE DOSING TANK CAPACITY
D [c'{ .) SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ) SQUARE FEET SYSTEM
A TYPE SYSTEM: NI J STANDARD [ FILLED
I CONFIGURATION: V. TRENCH
F LOCATION OF BENCHMARK: 3 / l `5.
I ELEVATION OF PROPOSED SYSTEM SITE [ . J [ INSHEVFT
E BOTTOM OF DRAINFIELD TO BE [ c4. e ) [I,N ES / FT J
D FILL REQUIRED: (I„ 1) INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
1
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 1) which may be used)
(Stock Number: 5744- 001- 4016 -0)
Applicant
TITLE:
TITLE:
NA t i
[ /4 MOUND
[ ", BED
PERMIT 1 a
DATE PAID ,
FEE PAID $
RECEIPT 3�
[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_BEIt'G MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFI ATIQNS
Pe' „•, I <
T [ 0 -J [GALLONS / GPD] OPTIC T jAEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:( ]
A [ ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:( ]
[MAXIMUM CAPACITY SINGLE TANK:
DOSE •RATE [ ] PER 24 HRS NO.
[ABOVE /.
[ABOVE /; L•
EXCAVATION REQUIRED: [ ] INCHES
S
1
1250 GALLONS]
OF PUMPS: [ ]
[ /V
b : c , \/9
] BENCHMARK /REFERENCE POINT
] BENCHMARK /REFERENCE POINT
EXPIRATION DATE: j 1
l
CHD
Page 1 of 2
JCTIONS:
MIT NUMBER: Permit tracking number by County Health Department.
PPLICATION 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 1D# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter IOD -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.
APPLICATION FOR:
[ --] New System [ 1 Existing System [ -1 Holding Tank [ - , i' Temporary /Experimental
[ ] Repair [ `'] Abandonment G °'1 Other(Specify)
APPLICANT:
AGENT:
MAILING ADDRESS:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
1
2
3
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BUILDING INFORMATION C - -- RESIDENTIAL
OH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1] which may be used)
(Stock Number: 5744 - 001 - 4015 -1)
[
] COMMERCIAL
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TELEPHONE:
LOT: BLOCK: SUBDIVISION: DATE OF
SUBDIVISION:
PROPERTY ID #: [Section /Township /Range /Parcel No.] ZONING:
APPLICANT'S SIGNATURE: DATE:
/
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWIN6Ait{TL.!ENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
PROPERTY SIZE: ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [�] PUBLIC
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Soft Served For Commercial Only
Page 1 of 3
[ ] Garbage Grinders /Disposals [.' -`] Spas /Hot Tubs [ 1 Floor /Equipment Drains
( ] Ultra -low Volume Flush Toilets [ ' - 1 Other (Specify)
JCTIONS:
=PLICATION 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 SIZE:
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.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
# 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 1OD-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.
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.
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.
PROPERTY ID#: 27 character number for property. (Health Department may require property appraiser 1D11 or section/township /range /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.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 10D-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
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.
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.
By
C%
41
DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Plan Approved
t .
Site Plan submitted by:, I1 ,A
STATE OF FLORIDA
DEPARTMENT OF HEALTH
PART 11 SITE PLAN
tl•••••••• •
•
• ,-, • - •
„
,4
° -
<
Signature
Not Approved
•
Tine
•
ALL CHAN9ES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Date / </"--09'
County Health Department
•
Page 2 of 3