1092 NE 94 St (8)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date ( — n Job Address / 7) - E . / ' . Tax Folio
Legal Description
Historically Designated: Yes No
Master Permit # ( 4 /72 l
Owner's Address ' Phone . 2 Y o �^
Owner/Lessee / Tenant
Contracting Co.
Qualifier
Architect/Engineer
Bonding Company
Mortgagor
Signature of o
Notary as to Owner and/or Condo President
My Co
ti
FEES: PERMIT
.
`�` SUSAN J.NESE
MY COMMISSION, # CC 860763
OF F e EXPIRES: Aug 4.2003
1.8p0-3-NOTARY Fla Notary ce & Bonding Co.
(
bsr Bl ai SIC
State #C CG Municipal #
and/or Condo President Date
RADON C.C.F.
APPROVED:
Zoning Building
Mechanical Plumbing
Date
vOri
SS#
dress 5 7 S (Ai. (2 '1 _7o1_
( hone
Competency #C re 05‘-/ 8 . Co.
Address
Address
Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION /Pi .i L.,L S?°G77C 7i -A OP /A/F /kLl
Square Ft. Estimated Cost (value) 0237,0 'o
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.
e
f Contractor or
aQ ` µiF No SUSAN J. NESENMAN
uy MY COMMISSION # CC 860763
l i'Of Ftt' EXPIRES: Aug 4, 2003
l Fla Notary Service & Bonding Co.
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r i er -B '1
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NOTARY
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as to Contractor
Commission Expir e
Electrical
L1 31
i Dat
3
TOTAL DUE , £D
'i / /0
ate
Structural Engineer
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s"CONSTRUCTION PERMIT FO �
[/] New System [Existing System [d' 91ding Tank [1 Temporary /Experimental
[ 1Repair, [ a [ 11 Other(Specify)
eect4. -
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
a STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID U - 22 -`✓
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT . RECEIPT # ...57709(22"°
Authority: Chapter 381, FS & Chapter 10D -6, FAC
SYSTEM DESIGN AND SPECIFICATIONS
APPLICANT: ��Itr S oT c / 6 / AGENT:
PROPERTY STREET ADDRESS: / /504, -
PROPERTY ID #: 1 57
�� r [OR TAX ID NUMBER]
R [ ] SQUARE FEET
A .TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK: ' T G c(
I ELEVATION OF PROPOSED SYSTEM SITE 7 NCHES T] [ABOV E
E BOTTOM OF DRAINFIELD TO BE [ t g - r ] [INCHE /FT] [ABOV
L /
D FILL REQUIRED: [ ] INCHES
O 00 mil+ 3 CO ` t -
/Ail/ T /Ai >- '
HRS -H Form 4016, Mar 92 (Obsoletes previous ,s'ditions which may not be used)
(Stock Number: 5744 - 001- 4016
LOT: t._ BLOCK: SUBDIVISION: a 3 a.. <-,
[SECTION /TOWNSHIP /RANGE /PARCEL 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. 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.
T [ / CJ [GALLONS / GPD] MIZETANELBEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[
It
A [ ] [G'1M • S / GPD] CAPACITY . MULTI- CHAMBERED /IN SERIES:[
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ SQUARE FEET PRIMARY DRAINFIELD SYSTE
SYSTEM
[ ] STANDARD [ ] FILLED [ ] MOUND
( ] TRENCH [ ] BED [ ]
G A ( r 2_"]✓�'.
[
ggel S-&
i ^ c � , :•'h 0' /REFERENCE POINT
2 • 0j1•0 BENCHMARK/ FERENCE POINT
EXCAVATION REQUIRED: [ INCHES
EXPIRATION DATE:
Page 1 of 2
., ernit trsc:dnst numbc. a..: eed by
CA`s 7ON 70i1: Check type of permit, if 'Other" specify tyg:; in blank.
APPLICANT: Property owner's full name.
-ELEPHONE: 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, SUBDWISION or
PROPERTY IDI: 27 character id number for property. (CPHU may require property appraiser ID !1 or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 10D -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 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.
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