1257 NE 94 St (3)Date Job Address ick s� /1/6 9 s i
Legal Description
Owner / Lessee / Tenant g e S - /ice /24 r L ' '1 Master Permit # .34 7 7
Owner's Address /,\i-) /J�� r 9V U %- Phone ' ' j �
Contracting Co. /42 . �� J 6 l y %rC f - / " / :- * c Address
P Qualifier P, P C"j ` 6)c-e' r' .; SS# -, Phone 4S ` '7
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION
Signat
D
J
Square Ft. 3-D
My Commission Expires:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
v
4 :77C `4 GC:
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 he above -named contractor to do the work stated.
owner Co President
1_USI / 2 / q
Notary as to Owner and /or Co
Note/ tae Stet. f Fter4•y
'M!f tam. xxptra 1Msr 2?, t 9'
NI. CC3S$2 s
** * * * * * * * *
so
FEES: PERMIT
APPROVED:
Zoning
RADON
C.C.F.
Tax Folio
711 �/ r
V 6 f322 //,anni / -2326
,e),e. fa *.v i ! 0 i71/ -7c d ,
Estimated Cost(value) /
Signature of Co
Date:
tor or Owner- Builder
Notat7 is to Contractor or °`t`twA B OE
M Commission ;Expires :'
— Not/fl7aub11G,_Sure 'ripnla
My Comm. exerryr44 , ?9, f 2
*d*. CC z2S+
* * * * * * * **
c.' S NOTARY .� -- TOTAL DUE 2 L'
Fire Other
Buildin
Mechanical Plumbin
Electrical
Engineering
CONSTRUCTION PERMIT FOR:
[Al New System [ 11 Existing System [ ] Holding Tank [ ''] Temporary /Experimental
[ Li - Repair [ / Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
FILL REQUIRED: [
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
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 DESIGN AND SPECIFICATIONS
] INCHES EXCAVATION REQUIRED: [
TITLE:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
APPLICANT
AGENT:
;PERMIT #
DATE PAID
FEE PAID $
:R.ECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
be
/4
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.
] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
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: f ]
[ °] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] INCHES
i1,c: '.x ?. tom %.f: the c.'ra in
TITLE: _ CPHU
EXPIRATION DATE:
/_. -_
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: Properly owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDN: 27 character id number for property. (CPHU may require property appraiser ID N or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD-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.
Scale: Each block represents 5 feet and 1 inch = 50 feet
Notes:
{prC
;t �tStS"Y
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUC7kN PERMIT. �7
Permit Application Number / (7 /
R
fi� Irt �iQ r Lgts- 4 c
Site Plan submitted by:
By . -
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIb HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744- 002 - 4015 -6)
PART II - SITE PLAN
SIGNATURE
Not Approved
r Z tiA1 1st
TITLE �}
Date
qt Li i T 1
County Public Unit
Page 2 of 3
LOT:
PROPERTY ID #:
SOIL PROFILE INFORMATION SITE 1
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
TOTAL ESTIMATED SEWAGE FLOW: g e Ca GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2)
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: /00o SQFT UNOBSTRUCTED AREA REQUIRED: C0[1 SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE":
SURFACE WATER: 4, FT DITCHES /SWALES: CPO FT NORMALLY WET? [ ] YES mr NO
WELLS: PUBLIC: N FT LIMITED USE: f ;/ /Q FT PRIVATE: /r,/ /,a FT NON - POTABLE: tJ A . FT
BUILDING FOUNDATI NS: /l› FT PROPS TY LINES: 20 FT POTABLE WATER LINES: .- FT
SITE SUBJECT TO FREQUENT FLOODING: [ J YES [V1 NO
10 YEAR FLOOD ELEVATION FOR SITE: ' ( FT MSL /NGVD
Munse 1 # /Color Texture
USDA SOIL SERIES:
Depth
/� to
�� to
to
to
to
to
to
to
to
SITE EVALUATED BY:
AGENT:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1) l
PERMIT'#` —
1/
?' 7
[Section /Township /Range /Parcel No. or Tax ID Number]
10 YEAR FLOODING? [ ] YES [v4
SITE ELEVATION: - ' (2 FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color
USDA SOIL SERIES:
DATE:
Depth
/ R toil
to t t
29
to
to
to
to
to
to
OBSERVED WATER TABLE: C i v} L+ INCHES ABOVE /
9 BELO ,EXISTING GRADE,. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE E EVATION: r `'""'f l INCHES [ ABOVE BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES VINO MOTTLING: [ ] YES [ NO DEPTH:--- INCHES
} ¢,— r�
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: (' -N DEPTH OF EXCAVATION: c9 INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [`'] BED [ ) OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
Page 3 of 3
L4v., L..a,11C.. V .�..�NiS:
i'?R7 I 0: Permit tracking number assigned by C.?E-SJ.
Au PLICANT: Property owner's full name.
AGENT: Property owner'a legally cut'.'. ^.o:•', d rzprezr ta:i ✓ ;;
13i5OCK, SU3D;V1SiON: %tot bloc , and subdivision °b." :oI.
PROPERTY EDO: 27 character number for property. (prcpet ty appraise: M 0 or .polo J:cwrsh ip/ ma, /parse! number')
Check if property size at rite co"'.fo ins to cub ;fitted Bite pan. i ecoi -d net. ::able - �,',.. T
^CL. ;.! '�iSte ' :; CN ^: ;ot t „�... ' :FLei nl,wVe: of
all paves: areas and prepared roar: beds within public -of •:gay or caret :tents red exe'urive of e:. ecr. e, 'a!Sea,
nonnally wet e rainage ditches, marcher, or c such bodies e f wrier.
SEWAGE Fit -OW:
UNOBSTRUCTED AREA:
Record the estimated sewage Liow for the 'ec'..:b1iichrnent from Table 1 (residence) orisabie 2 (non-residential), C11..pter
10D-6, FAC. Record the aut. or:: ;d r„ -c fled fce Cie tot base::: on °':Y ua b!e .
per day per acre for private wine: cupp_ie; cart ^_ 2500 gpc per acre for ettblie wafter ru,T,p!ica). 1f cut: 'loci
does not equal or exceed i e ectir:tctecl siwcr;c r:cej, the application mart be
Record the square feet of unob tlttcted area available cost the c :_ic:ini
time an large re the drainfield absorption area and at !east 75 percent of tihc ^re3r:tra s: r:_-e :: sci .meat :`izz:m :1r:
setbacks ir.. Chapter IOD -b, iFAC. Tito trrcbri uctar_' area must be coniig::c: s .a C to drainfield.
7313i:C :MAIRK :NcO:itb1 ATM N: Record the location of the benchmark. Et %;:i:313 a surveyor c benchmark record the 7 :e;uai ciefmti on. Rena. -b tit;
elevation of the prop cccd system t,ite in ict =.'e 1 (hove or below) to ire b: _. :hank.
1V`- °N1IV: UiU;; SETBACKS:
Record minimum setback: which. can �a r.., :: to Eli listed fee:u:et% Act:::._ measure :.rents mtaft. be recorded or "NA”
for non apnticeJle featurue. 1:'cs.u;:ec on cite p.'ar.. o;• withir. 75 feet of the applic:: -t.: lot mast bn measured. The ?cwt lion
of any public drinking well within 209 feet of the applicant's lo: mast rlan he verifies;.
iCOD E1 NFOR.i',4ATION: Record information on tot s subject to flooding. For lots subject to flacdin3 record: 1.0 year 0=4 elevation for rile and
actual site elevation.
SOIL PROFILE 1NFORNLATIOP.: Two soil profiles within the proposed absorption urea to a minimum depth of 6 ''ea: c refute l.. are re €iuired. Soil
identification will use USDA Sot! Classification methodology (Muneell colors and 'USDA coil textures). E.ufuscic rr1^t
be clearly documented. Provicin USDA coil scrim if available, ;cord if the series cannot be determines;.
WATER T A3LI:: Record the depth of the observed water :able at the time of the evaluation. Mark "perched' o; "apporarn Cc
appropriate. Record the estimated wet cecson water table elevation based on site evaluation, USDA aoi! maps, and
historical information. Indicate if there is high water table vegetation present. Indicate if ,t ailing is prec3rt end depth.
SOIL 'TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH Or EXCAVATION: If applicable record depth of excavation required. Record "NA" if not cpplicable.
DRAIN - FIELD CONF:GURATION. Check drainfield configuration required. If other, specify type.
ADDEI'IONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
S1 E iEVALUATED BY: Signature of evaluator, title, and date of evaluation. Profeaaiona: engineers must seal all sic ar entation submittal.
L LEVAT1OR! WORKSHEET
RENCPc/MAREI
[+1 SHOT:
H.Y.
ELEVATION OF BENCHMA K / RE'FE1Ei`s!CI. O1RrT 5S:
SUE 1
H.1.
[ -] SHOT
SITE 2
[ -] SHOT,
SETE 3
H.11.
[ -] SHOT
APPLICATION FOR:
['r''_'`f New System
[V] Repair
}
APPLICANT:
AGENT:
MAILING ADDRESS:
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:
PROPERTY ID #:
PROPERTY SIZE:
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
[ 11 System [A/Bolding Tank [).4 Temporary /Experimental
[ y,'t,.` Abandonment [J Other (Specify)
SUBDIVISION:
BUILDING INFORMATION [ VV RESIDENTIAL
Unit Type of
No Establishment
1
2
3
4
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [WA PUBLIC
No. of
Bedrooms
[] Garbage Grinders /Disposals [.) Spas /Hot Tubs
;, #] Ultra -low Volume Flush Toilets [.,,] Other (Specify)
APPLICANT'S SIGNATURE:
•
_n.
HRS -H Form 4015, Mar 92 (Obsoietes previous editions which may not be used)
(Stock Number: 5744 - 001- 4015 -1)
] COMMERCIAL
Building # Persons
Area Saft Served
1PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TELEPHONE: f
DATE OF c �7
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
Business Activity
For Commercial Only
] Floor /Equipment Drains
DATE:
1
Page 1 of 3
Cr.: :ype of permit, if "Ofiern specify type bianft.
1?roo. 1y owner's full name.
'.7els: one number for applicant or ageni•
?rc y owner's :egni:y 21.1117'.10.712
DX or street, city, s:nt:: a1
C':hes• private or blie.
Stnc . .cldress for property. : lots whhout a.. assigned st o :and 7 fect:e ecuziy.
:3.: : ?rov• detailed ir,tructiono 'o lot or conch arcr. yap s"1. locr.tion.
Chn' c-: cominercial.
!Inc: laz (eect..ye. ::- 7 "., -. lc:
;Leff: ;E:C 0:7 deaf", - . 7 !1117i Cate..1..fi.
• date of sl.r.:1•"' 2 • "" •
: lel': two or "‘.•
2.7 n• flvm' fo:,• . .
bir area c<•• ;71 7;! ...)e •
.1.11; `. '"7.1.. "'" , ".12".. V12: r;.:.C.L 7 ' "7" •
.di —t of wat•";. unpr ;(
my ineludeci i.• arleuirtir7, .ct area
of esta.bliehmert from Tr:Ye E, wis:e
doctc i office.
NO. ;33'DROOMS: Cour' 11I rooms designed primarily for sleeping and 7hom areas expected to routinely provi4e accommodations or
0001/ 1 7,3AS.
SONS: Nurn '. of persons residing, .ising, or wor%ing in eLtablishment To 1.es:dentin! establist, 2 pe:.T.OnIS 90.7 be6.:c3rn
CS51./i:. 1.
1?..7JS7N:-.:33 'For e• Intercial applications only. n of employees, :17:f1.3, hou'.:n ref siperaf.on, c:sher cton
Chapter 10D-6, ir
Mark -eh listed fixture with number nll 0: "NA' if nal apolicable.
Signr of applicant or agent. :3 application orte riay to the, wit2-. Epp:op:Hate en and cnechn.
a floc: cibec. J C:r.f1 0CC:77 ' •
an,n.n.ne
.. . necessary to ci r:12.nn".i'..y of v.'nr.ewr.t..
3:1:::•.:37NC AREA: Total -',uare footage of cncloebd habitable cm:: of evening :rah, excluding gana cc.:port, c o:
scree • :d patios or decks. &zed on outside r.leasurentents fo: each story of stEc:cW•re.
A sl.tc . ..an draw:- to seria, showing climennir !cc: ::esirioces
ens. onsits scwst;c dinsosai s;, s"epe of 2:opee2y, any oz,in"linr; 3:: 2
filled ern, .• - .""•:faca
othe: ;rtinent facilities r fc: o Cf 1:16;j:11E.....coc.. i .1
pub: :Jell within 7CC :eat of lot.