125 NE 94 St (7)IP ERROT' AIIDP LIICATIION IFOIIS MIIAMII SEL tRIES VIIILILAGIE
Date Ib11 \ Job Address S Nz C+ .�
Owner's Address \ 7 S LJ cl ST
Tax Folio 1/ 1. ) G ( I
Legal Descriptiork /I' '» j /' 4 ; / / 1 ( / / / /
Owner / Lessee / Tenant V\ Master Permit #1
Contracting Co. ' W2o Zoo Address (42O7- SW TAS GI (i 1 ‹rim Ai(
330.3
Qualifier l 'k tCi \,4.„4L 'n'lj, 0,y ss# 2 o( - 77 - L /°/ Phone 9GC, Coq / S
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION RiA 1 vim, \JCX
Square Ft. -300 %'
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
?PROVED:
Estimated Cost(value) \ . CMG
Phone
WARNING TO OWNER: YOU DUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMIENTS 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
Signature of
Date: /2>4,
retractor or
as to Contractor or Owner- Builder
y Commission Expires:
** tr tr sc tz tr tr tr tr tr rr n **
FEES: PERMIT ej � / e RADON C.C.F. i b P NOTARY -5 ' Pi' TOTAL DUeU/ r
Fire Other
Zoning Buildin_ Electrical
Mechanical Plumbi._ � ''ngineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[(] Repair [ ] Abandonment [ ] Other(Specify)
pit -.14 sr,�
AGENT: )
APPLICANT:
PROPERTY STREET ADDRESS: /2 (°-- , & 1
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS Et Chapter 1OD -6, FAC
BLOCK: SUBDIVISION:
pose-==
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[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 [4� ] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY
MULTI-CHAMBERED/IN SERIES:( J
A [ ] [GALLONS / 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 SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [X] BED [ ]
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
f
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H
E
R
SPECIFICATIONS BY: TITLE:
APPROVED BY:
DATE ISSUED: {
1
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001- 4016 -0)
TITLE: �a 4
oNouALLmioom4nao - con
EXPIRATION DATE:
CPHU
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
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 mailing address for applicant or agent.
I .
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 character id number for property. (CPIiU may require property appraiser ID # 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, ow- 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.
r
th block represents 5 feet a t 1 inch = 50 feet.
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STATE OF FLORIDA
EPA TMENT OF 1EALTH —ND REHABILOTATDVE SERVICES
APPLOCATOON F•R ONSOTE SEWAGE DOSPOSAL SYSTEM CORISTRUCTOO PERIVOOT
Permit Application Number •
1111'
7
Site Plan submitted by:
Plan Approved Not Approv d
By f
ALL CHANGES MUST BE APP
PART H SOTE PLAN
10” JU c / V ST
FIRS-H Form 4015, Feb 85 (Obso)etes previous editions which may not be used)
(Stock Number 5744-002-4015-6)
72
SIGNATURE
OVIED 3' THE COUNTY PUfzLOC HEALTH UT
TITLE
.
Notes:
-
Date
(..,
County Public Unit
Page 2 of 3
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
MIAMI SHORES VILLAGE. FLORIDA
p DATE 195
p PERMIT N9 3891 Contractor's
License No.
Work to be performed under this Permit
Bl.
Subdi-
vision
Value of
Project $
Amount of
Permit $
This permit is granted to the contractor or builder named above to construc 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 ac-
cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
CONTRACTOR OR BUILDER
BY AUTHORITY
irlote of
JOB
ADDRESS
iami Shores
INSPECTION S / a.
INSPECTOR
f
TIME READY
REMARKS e-Q •
•
N° 4484
DATE 4- ,1 4,