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500 NE 92 St (7)Date / — /o 1 ' Job Legal Description Owner / Lessee / Tenant Owner's Address Square OWNER'S AFFID IT: I be done in c. �,'• V ance authorize t Signature of o fl and Date: f.270/19.s a1 ary'as to Owner and Commission Expires: ** * * * FEES: PERMIT 31 0 f APPROVED: _ PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Address J 2 7 AdTZ Tax Folio// J .eJ r ,11/-46 SPhone State # Municipal # Ft. d©1 r/ft- Master Permit 4P L°r3Y 0 Estimated Cost(value A% ' d4i Contracting Co. a/i .. Address / 2 ..- ,/; Qualifier SS# Phone Competency # Ins.Co. Architect /Engineer Address Bonding Company Address Mortgagor Address Permit Type(circle one): BUILDING ELECTRICAL 'LUMBING MECHANICAL ROOFING PAVING PENCE SIGN WORK DESCRIPTION 9 /I;/i 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. certify that all the foregoing information is accurate and that all work will w h all applicable laws regulating construction and zoning. Furthermore, I ontractor to do the work stated. o' ►• ndo President RADON C.C.F. n aZaZf' 17°141412 Signature of Contractor or Owner- Builder Date: / /4/ otary as to y Commission * * * * * * ** NOTARY r Fire Other Zoning Building lectrical � i� t ) Mechanical PYumbing. ngineering TOTAL DUE---) -" 7e) £ 5 CONSTRUCTION PERMIT FOR: [ ] New System [ K:] Repair APPLICANT: PROPERTY STREET ADDRESS: LOT: PROPERTY ID #: ; r1 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC BLOCK: SUBDIVISION: 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. 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 0 T H E R AGENT: [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] PERMIT # DATE PAID FEE PAID $ 'C RECEIPT # [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental [ ] Abandonment [ ] Other(Specify) ] [GALLONS / GPD] 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: [ ] D [. ] SQUARE R [ ] SQUARE A TYPE SYSTEM: I CONFIGURATION: N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM E BOTTOM OF DRAINFIELD TO BE [ L D FILL REQUIRED: [ FEET PRIMARY DRAINFIELD SYSTEM FEET SYSTEM [ ] STANDARD [ ] TRENCH ] INCHES [ ] [ FILLED BED HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001 - 4016 -0) [ ] MOUND [ ] [ ] SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ ] INCHES SPECIFICATIONS BY: TITLE: APPROVED BY TITLE: ! CPHU DATE ISSUED: EXPIRATION DATE: Page 1 of 2 ..NST:11.ICTECNS: Pcrnnit traciting c!:sign.oe; by C:?;:-.;J. AlF:'.7.C.A7!3N FOR: Cheel; type of ,emit, if "Other" specify typo 1: owr_er's . fuli nurnbe- for sp;:lic;:r.:: or sgera. Froporty represnn." A:D.D112riSS: ?.C. bon 07 c cgcrt. SJ3D:.111SION 27 el-Li:Lane!: id ..13 :DEKON AND Minimum. specifications fron Chcpter AC. i\/..inirrum specifications from Chspter 10:(D-5, .AC. Other specifications, such ss operstin oer. requirements, !ccr-v: - ; Sl'EC:FIC_'AT;ONS 3Y: Nerve of individual providing specification:. :if desigr..ed Alr'?:::ZOVETD 3Y: County Fuid lie *jnit (C?7:.111) personn1 rovieviinq snci conrovir:! :DATE ISS'il.ED: Date permit it; issued by O?Hi..J. :5..."C?:.:ZA1.'ON DATE: One year from (int,: issued if the system no: been ins`xii;n:. 7:.; .71 1 2,0 r'• ';: issued. • - .e . I 1 1 1 l 1_! _�_� _ — I I i ' 1 1 1 I 1 II I 1 _ I I I —I 1 II 11 J I il II 1_1_ 3�'r' {+ l-1 > I. I I I I I jI '( J I 1 11 I -- ii 11 1 ,1 I 1i 11 11 - - I I 1 1 I_I .... I I III 1. l' III t II I II II l�� -- I - 1 i 1 I II 1r l I J I 11 I_1 1 I I 1 I 1 _. II 1Ii II Ili I II 1f 11 1I I II l' I I I 1! 11 1 1 I 1 1 III _ 1 1 11 I_i 1 1 I 11 111 11 11. 1 '1 11 11 II' 1i1 I 11 1_1 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE RMIT Permit Application Number / 'II 1_ 1 1 II 1 I 1 I '.....J [ - -- 11 I I I , I 1.. - .1 1 1 I II 11 II 11 1 11 i I '1 II II II I II i _. _1 1 _. _, 1 � 1 Notes Site Plan Submitted by SIGNATURE Plan Approved By ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT HRS-I-I Form 4015, Feb 85 (Obsoletes previous editions which may not be used) (Stock Number: 5744-002-4015-6) PART II - SITE PLAN Not Approved TITLE Date County Public Unit Page 2 of 3 APPLICATION FOR: [ ] New System [ Repair APPLICANT: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL,SYSTEM APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 1OD -6, FAC MAILING ADDRESS: B'ic tting System ] Abandonment 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 DESCRIPTION OR DEED] LOT: % BLOCK: PROPERTY ID #: PROPERTY SIZE: PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: 1 2 3 4 SUBDIVISION: BUILDING INFORMATION [;'] RESIDENTIAL Unit Type of No. of No Establishment Bedrooms ]'Holding T ank` [ ] Other(Specify) ].COMMERCIAL PERMIT # DATE PAID FEE PAID $ RECEIPT # ]'Temporary /Exp'eritental/ TELEPHONE: DATE OF SUBDIVISION: [Section /Township /Range /Parcel No.] ZONING: ACRES [Sqft /43560] PROPERTY WATER SUPPLY3 4 ); PRIVATE [p= %] PUBLIC Building # Persons Business Activity Area Soft Served For Commercial Only [ ] Garbage Grinders /Disposals [ ] Spas /Hot Tubs [ ] Floor /Equipment Drains [ ] Ultra -low Volume Flush Toilets [ ] Other (Specify) APPLICANT'S SIGNATURE: � � G .•/• , DATE: HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) Page 1 of 3 (Stock Number: 5744 - 001 - 4015-1) INSTRUC'T'IONS: 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 SIZE: Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If !ot io not in a recorded subdivision, a copy of the !et legal description or deed must be attached. DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /yeas) or date !ot originally recorded. Dividing on, approved lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot. PROPERTY MD: 27 character number for property. (CP} U may require property appraiser II1� 0 or section/township /range /parcel mumbo. Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paves] arena and peperc road beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, a ran't's°, 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 109)-6, FAC. 1Examptea: oing!e frmily, single wide mobile home, re°.aurant, 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 sued, or open or fully screened patios or decks. Based on outside measurements for each story of structure. fl PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 person 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 II, 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 one day submitted to the CI?} U with appropriate fees and cttachrnenA. ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of rc!dencea or building°, cvyimnting pool°, roco:'ded easements, onsite sewage disposal system components and !motion, slope of property, any existing or p;aposed we'? °, s:: r_7ga features, filled areas, obstructed areas, and surface water. Location or wo!!c, oni10 sewage dispom9 cyr:erno, mar :co wcto..r other pertinent facilities or features on cdjccent property, IT the f'cctterao c c with 75 ,'ect of' applicant fort :Loecfe.7.. public well within 200 feet of lot. " For residences, a floor plan (residences) stowing number of bedrooms cod a of each unit. For stet ealfat .!ci establishments, o floor plan showing the square footage of the ecCabliart onI, all p!1.1-1bing drains and forbm Cypec, cart ct tit features necessary to determine composition and quantity of wastewater.