1270 NE 95 St (10)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 9 Job Address 1 9d`7O ig.E 9 S S Tax Folio I I 3,2 0(9 —0/4 No 0
Legal Description LoT 5±( -1- 6 1% '7 Li ut.{L 15 Historically Designated: Yes No
Owner/Lessee / Tenant — OW) Kr 0 � 4 Cel
Owner's Address 19,670 14. C c q , D r—
Contracting Co. 56 t C. CO h A e- c Or 5 TttiC . Address I g$0 a 14, IV, 2._ Ave, Sdf 3,2 3
t `7'ti.o4„4 , 3 3 1 6 q
Qualifier TT,tz'So } o- c SS# Phone (3r6) GG 4 - 633
State # S•Pr09$'D@' 7 $ Municipal # Competency # Ins. Co. .A T 1
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL UMBiN MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION IN Tfr ,, TP,A PitY d rN1F) E
Square Ft. S OO Estimated Cost (value) # (:) 1133i. ®�
■
• 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.
OWNERS 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.
r�—
ature o
owner and/or C a ndo Pres (en
IA:
•'AA,S
er : • r 6• . condo President' -. ..
onums . o 4 !..A s TERESA J. SOLOMON
l MY COMMISSION # CC 854606
L%.fv7,7 EXPIRES: Jul 16, 2003
1.800-3- NOTARY Fla. Notary Service & Bonding Co.
otary :s to
2
APPROVED:
Zoning Building
Mechanical Plumbing
9' -
Date
Q
Date
t:
FEES: PERMIT '50 RADON C.C.F. / 2 0 NOTARY ,
Master Permit # 1/71175
Phone 3°57-76-9-- U 7
cits/D0
f Contractor er- Builder Date
Electrical
Notary as to Contractor or Owner - Builder Date
My Commission Expires:
BOND 3010
,�—•� Z4e,
TOTAL DUE3J �--
Structural Engineer
Scale: Each block represents 5 feet and 1 inch = 50 feet.
By
- I
Site Plan submitte
Plan Approved
DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Nurnber: 5744-002-4015-6)
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number 03 l`c 300
•
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ta”
PART II SITE PLAN
' I
1 I . , /1
1 '' i ''. ■ I i i . 11 , . ' i 1'
Notes: 112P \Cil 1210 qs s
• ," ; I ; I , • • i I - -
1_., . • ; : I I J i
p 1 Too C(..oZ To
M U -P\ t Si INC T ItQW1 NFINJ
af2.A fLD-
- AUL .II
Ignature
Not Approved
ws —6c le
Ig •
ALL HANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
County Health Department
Page 2 of 3
k.a
APPLICATION FOR:
CO) New System
[X] Repair
APPLICANT:
AGENT:
MAILING ADDRESS: g
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH'LEGAL DESCRIPTION OR DEED]
LOT: 6 f ( BLOCK: 08G, SUBDIVISION: m[I �S S 3
PROPERTY ID #: 11.32 01 4 [ Sectio /Township /Range /Parcel No.] ZONING: N A
PROPERTY SIZE: 11 ACRES [Sgft /43560 ] PROPERTY WATER SUPPLY: [ ] PRIVATE [) ] PUBLIC
1 i C IS HI COAA .S t o f L S 3, ■ 3'
IciS To v•I'Nk (3 )S fir T eCT i tt
N\ NO R:C (\ '( 0 Co 4(T ENT
To I'd SOuT lir TO Ne- °1 S EAST
To P—ILeSS
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
Unit Type of No. of
No Establishment Bedrooms
S“
Garbage Grinders /Disposals
Ultra -low Volume Flush Toilets
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
[N] Existing System
[N] Abandonment
DH 4015, 10/96 (Replaces HRS -H Form 4015 (Page 1] which may be used)
(Stock Number: 5744 - 001- 4015 -1)
IN ]
[N
S flc CoNWECT O
BUILDING INFORMATION( [( ] RESIDENTIAL
] Spas /Hot
[ ] Other (Specify)
Holding Tank
Other(Specify)
[ ]
22- vA Alit l 33
[ ] COMMERCIAL
, Building # Persons
Area Soft - Served
PERMIT #
DATE PAID
FEE PAID
RECEIPT 1
1 / - 7L/75 -
$ - 75• r
9Vr S901
Temporary /Experimental
TELEPHONE: 0)6( - 66, 3
DATE OF N■rj f
SUBDIVISION.
DATE: 91 /
Business Activity
For Commercial Onlv
[ ]Floor /Equipment Drains
Page 1 of 3
INSTRUCTIONS:
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 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 IDk 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.
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 10D-6, FAC. Examples: single family, single wide mobile home, restaurant,
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 shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
# 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 II, 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.
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.
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.
CONSTRUCTION PERMIT FOR:
[{J ] New System [N
[ )(] Repair [ N
SYSTEM DESIGN AND SPECIFICATIONS
D [ 2 0 O ] SQUARE FEET
R'[ ] SQUARE FEET
A TYPE SYSTEM: ( ]
I CONFIGURATION: [ ]
E BOTTOM OF DRAINFIELD TO BE
L.
D FILL REQUIRED: [JJCJ] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: / 1 <-/ GrID
DH 4016, 12/99 (Page 1)
�-„
• STATE OF FLORIDA
DEPARTMENT OF HEALTH u u u u
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Existing System [ Holding Tank [d] Innovative
Pi Traci [F"] Temporary [ ]
APPLICANT: 1 ra O`i J e 1 e 'i 5 e pf i6 Can 4eckf 0.1 , 1' c
PROPERTY ADDRESS: 127 0 /" ,E- 'is' S t' / /(4-1; S li,oye r TI. 331.3 Q
LOT: f 1 BLOCK: ES
PROPERTY ID #: I 32 0' c l 11 . `f d (D
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
T [ 900 ] Ga,ALLONSJ / GPD SEPTIC TANKL,EROBIC UNIT CAPACITY
A [ ] GALLONS / GPD
N'[ ] GALLONS GREASE INTERCEPTOR CAPACITY
K "' ] GALLONS DOSING TANK CAPACITY [
PRIMARY DRAINFIELD SYSTEM
SYSTEM
STANARD .( ) FILLED [ ] MOUND [ ] _
TRENCH [ 4 BED [ ]
F LOCATION OF .BENCHMARK:. / v , l 0 I' S L _ • t 1 .
I ELEVATION OF PROPOSED SYSTEM SITE [ ?►] 1 INCHES 'T] . [ABOVE/BELOW]) BENCHMARK
[(o/ 1] (INCHES FT] [ABOVE ELOW BENCHMARK
EXCAVATION REQUIRED: 3 o ] INCHES
,c�ei�w �rn�n<!nns-a IAASP C 1 IC[r
7,1 PEr.: °.fT IS NOT FOR AQCITrt(p)
Fl FQP�1TgGR{ t Q_
` OF DRA FIELD ELEVATEOM S
t TITLE: . DO'
C I 1. fM 14 (9 c i (hi 1 c ° C0�? T(a c
TITLE:
(Previous Editions May Be Used)
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer /Contractor
pt. 4: Building Department
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
oat -
S000'70:601
SUBDIVISION: P2 / 1 Shore S c . 3
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
T //k
MULTI - CHAMBERED /IN- SERIES [)(]
CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
[MAXIMUM CAPACITY SINGLE TANK:
]GALLONS 60 [ ] DOSES PER 24 HRS
NSTALL 10" OF LOAMY COARSE SAND)
EXPIRATION DATE:
1250 GALLONS]
# PUMPS [ ]
REFERENCE POINT)
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT 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. (CHD may require property appraiser ID # or section /township /range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 64E-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 (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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.