1291 NE 94 St (12),. •
Square Ft.
PERMIT APPLICATION FOR MIAMI
Date Job Address / 62/9/ /6 9V , 9,ge7' . Tax Folio
Legal Description Lo f - 42 ifor c ' JtlDd� i e., ‘"" Hi n D s
Owner/Lessee / , a n t
Sr q d Y r f " 4 t f �9 / e
7°77/
Owner's Address
Contracting Co.
Qualifier ,14/4e--
State # 47X3
Municipal # Competency #
Architect/Engineer Address
Address
Bonding Com
Mortgagor ( a or
Permit Type (circle one): BUILDING ELECTRICAL
WORK DESCRIPTION
�A %fi e-
Estimated Cost (value) �(4d
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 perfonned 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 be done in compliance with all applicable laws regulating
orize e above -named contractor to do the work stated.
6,4 /ALE y 1. T ooe
RADON
Notary as to Owner and/or Condo President Date
My Commission Expires:
C.C.F. / - 0 NOTARY 6 - BOND3aC A/
APPROVED: TOTAL DUE J 5 -
FEES: PERMIT
Zoning Building
Mechanical Plumbing
en . Ca. 2,05 /7
Address
CC N0.00089 -0943 Real Estate Ins; action
WALLACE J. PONDER
SEPTIC TANK SERVICE
Commercial • Residential
Pump -Outs • Grease Trap • Parking Lots
New Drain Fields Installed
State Certified Septic Tank Contractor
Beeper:
(305) 824-7768
Office/Home: (905) 620 -8320
Phone WI f
Address /7 /s35ji 4j AI 'r
ss# c -5 � --� ,pgio Phone 494
94 - 7.7g
Ins. Co.
A//4, TA'
PLUMBING
MECHANICAL ROOFING PAVING
FENCE SIGN
Signature of Contractor or Owner - Builder Date
Electrical
otary as to Contrac Owner - Builder
My Commission Expires:
Date
FD G®c3 ,1 @3iJ 0
� r /Qr'
Free Estimates
Structural Engineer
ITEM
BATH TLB
UNIT
FEE
ITEM
SWITCH OUTLETS
UNIT
FEE
ITEM
SPACE HEATERS
UNIT
FEE
BICET
LIGHT CUTLETS
CENTRAL HEATING
DISHWASHER
RECEPTACLES
A/C (WIN))
DIAL
SERVICE TBPORARY
A/C (CENTRAL)
DRINKING FOUNTAIN
SERVICE SIZE IN AMPS
DUCT WORK
FLOCK CRAIN
SERVICE REPAIR/1ETER CHANGE
REFRIGERATION
GREASE TRAP
APPLIANCE OUTLETS
PROCESS AND PRESS PIPING
INTERCEPTOR
RANGE TOP
UNDERGROUND TANKS
LAVATORY
OVEN
ABOVE GROUND TANKS
ULNCRY TRAY
WATER HEATER
U.F. PRESSURE VESSELS
CLOTHES WASHER
MOTORS 0- 1 HP
STEAM BOILERS
SHOWER
MOTORS OVER 1- 3 HP
HOT WATER BOILERS
SINX, POT /3 COMP.
MOTCRS OVER 3- 5 HP
MECHANICAL VENTILATION
SINX. RESIDENCE
MOTCRS OVER 5- 8 If
TRANSPORTING ASSEMBLIES
SINK. SLCP
MOTCRS OVER 8- 10 HP
ELEVATORS/ESCALATORS
TEMPORARY WATER CLOSET
MOTCRS OVER 10- 25 !f
FIRE SPRINKLER SYSTEMS
URINAL
MOTORS OVER 25-100 fR
COOLING TOWERS
WATER CLOSET
MOTORS OVER 100 HP
VIOLATION
INDIRECT WASTES
A/C WINDOW
REINSPECTION
WATER SUPPLY T0:
AIR CONDITIONERS
A/C UNIT
STRIP HEATER
FIRE SPRINKLER
GENERATORS TRANSFORMERS
`EATER -NEW INST.
GENERATORS TRANSFORMERS
HEATER- REPLACE
GENERATORS TRANSFORMERS
AWN SPRINKLER -WELL
SPECIAL PURPOSE
SKIMMING POOL
OUTLETS C0M41ERCIAL
WATER SERVICE
SIGN TUBES
SEWER CONNECTIONS
SIGN TRANSPORWERS
UTILITY -SEWER
SIGN TIME CLOCK
UTILITY -WATER
FIXTURES
SEPTIC TANK
ANTENNA
RELAY
TELEVISION OUTLETS
DRAINFIELD, 4' TILE/RES.
✓
tL®
VIOLATION
PUMP b ABANDON SEPTIC TANK
REINSPECTION
SOAKAGE PIT CU. FT.
CATCH BASIN
D I SCGH,ARGE WELL
DOMESTIC WELL
AREA MAIN
ROOF INLET
SOLAR WATER HEATER
FIRE STANDPIPE
POOL PIPING
LAWN SPRINKLER SYSTEM
GAS RANGE
METER SET (GAS)
GAS PIPING
PLUMBING
ADDENDUM TO BUILDING PERMIT APPLICATION
( ?.N APPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS B.
OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS.)
ELECTRICAL
MECHANICAL
Notes:
Site Plan submitted by:
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITEPLAN
Scale: Each block represents 10 feet and 1 inch = 40 feet.
l
r
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744 -002 - 4015 -6)
Not Approved
Date
4
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 4
APPLICATION FOR:
[ n,] New System [. - -] Existing System [ /,] Holding Tank Temporary /Experimental
[;, ,°] Repair [ ] Abandonment [ ,,,] Other(Specify)
APPLICANT: it <
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 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT:
PROPERTY ID #:
PROPERTY SIZE: - °ACRES [Sqft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [,. PUBLIC
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
1
2
3
4
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 10D -6, FAC
APPLICANT'S SIGNATURE:
BLOCK: SUBDIVISION: /' OF
�._ . 5 �' ,r/ , • - /Y , ): //‘,;--,,' • f SUBDIVISION.
' [Section /Township /Range /Parcel No.] ZONING:
[A Garbage Grinders /Disposals
CM Ultra -low Volume Flush Toilets
,] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building # Persons Businees Activity
No Establishment Bedrooms Area Sqft Served Por Commercial Only
�i
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1] which may be used)
(Stock Number: 5744- 001 - 4015 -1)
TELEPHONE:
DATE:
[,,,] Spas /Hot Tubs [�;,) Floor /Equipment Drains
[� Other (Specify)
y
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:
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 LD# or section /township /range /parcel number.)
PROPERTY SIZE:
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved arena 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 I1, 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 deny
public well within 200 feet of lot.
For residences, a toor plan (residences) showing number of bedrooms and building area of each unit. For nonreaidential
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.
APPLICANT:
LOT: y
PROPERTY ID #:
1 /
' s '
BLOCK:
PROPERTY SIZE CONFORMS TO SITE PLAN: [,/J
TOTAL ESTIMATED SEWAGE FLOW: VA
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH
SURFACE WATER: / ; /! , 'T
WELLS: PUBLIC: T //' FT
BUILDING FOUNDATIONS:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
,u
SOIL PROFILE INFORMATION SITE 1
CAN BE MAINTAINED FROM T
DITCHES /SWALES:
LIMITED USE: ��''�', ° FT
FT PROPEINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES
10 YEAR FLOOD ELEVATION FOR SITE:
//9 »l
Munsell # /Color
USDA SOIL SERIES:
Texture Depth
� ' • 7 ; to ; r
to'
to
to
to
to
to
to
to
OBSERVED WATER TABLE: /;; INCHES [ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY: / /ff f/ /%
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3] which may be used)
(Stock Number: 5744- 003 - 4015 -1)
BED' [ ] OTHER (SPECIFY)
PERMIT #` /�' -%
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.
AGENT:
' SUBDIVISION: n // % 2
6
. / /J
/ 6 f J < -'_ \ )
[Section /Township /Range /Parcel No. or Tax ID Number)
YES [ ] NO NET USABLE AREA AVAILABLE: 2 / ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTH R- TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: ;% '/ -- SQFT
c
/ 2c
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
HE PROPOSED
77M TO THE FOLLOWING FEATURES:
"�'- FT RMALLY WET? [ ] YES [ f NO
PR I J TE : 9�'FT NON-POTABLE: , !,f, ' FT
FT POTABLE WATER LINES: I,- FT
v'
[ ,,if NO 10 YEAR FLOODING ? [ ] YES [t? ) . NO
FT MSL /NGVD SITE ELEVATION: /. FT MSL /NGVD
SOIL FROFILE INFORMATION SITE 2
Munsell # /Color
USDA SOIL SERIES:
Texture
Depth
to /1''
to
to
to
to
to
to
to
to
BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
INCHES [ ABOVE / BELOW ] EXISTING GRADE.
MOTTLING: [ ] YES [ ] NO DEPTH: / INCHES
DEPTH OF EXCAVATION: INCHES
( 9 ,
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area 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.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be der led.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter IOD -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For Tots subject to flooding record 10 year flood elevation'for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soi:
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparen:" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - ] SHOT [ - ] SHOT [ - ] SHOT
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System
[ ','] Repair [ ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
T
A [
N [
K [
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
BLOCK: SUBDIVISION:
SYSTEM DESIGN AND SPECIFICATIONS
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 1) which may be used)
(Stock Number: 5744- 001- 4016 -0)
i
Chapter 10D -6, FAC
] Holding Tank [ 1] Temporary /Experimental
Other(Specify)
AGENT:
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 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. DEPARTMENT OF HEALTH 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:[ ]
[GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:( )
GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE KATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND ( ]
I CONFIGURATION: [ ] TRENCH [ ] BED [ 1
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] (ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ j [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
TITLE:
TITLE: CHD
EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID #: 27 character ID number for property. (Health Department may require property appraiser ID# 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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address / �� [� 7(Z Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant ci �R:�� `'
Owners Address
Contracting Co.
My Commission Expires:
FEES: PERMIT
APPROVED:
Zoning
Mechanical
� fA
Qualifier 5 ip g >>< F
State #
SS#
Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION ��IL) d=)-‘2
Municipal #
Square Ft. .1 Estimated Cost (value) � /
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.
Signature of owner and/or bCondo President Date
Building
sof k
Ati .1e
Notary as to Owner and/or Condo Pre•ide ' Date Notary as to Contractor or Owner - Builder Date
My Commission Expires:
O .\PRY PC/ C.,7-7 • 'L •
ARA
.. �•. ,
J > �erdl:r
? ;ya_'S; z}
CO; ^ " ' .,i. ' -
.
o
RADON C.C.F.
Address
Master Permit #
Phone
Signature of Contractor or Owner- Builder Date
NOTARY BOND
Electrical
Phone � 05, 03
Ins. Co.
TOTAL DUE
Plumbing (�] ! } Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
_...IIII�V� � �� .el �i�� VIII
i iii �IIu n�mmu�
mum me n p @nespi ,
a � !s
II
eg�i�.�i ■Illfiiiiini's�iT
Notes:
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015-6)
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Site Plan submitted by:
SIGNATURE - TITLE
Plan Approved Not Approved Date;
By County Public Unit
Page 2 of 3
CONSTRUCTION PERMIT FOR:
,[ ] New System f J Existing System ..%] Holding Tank k ,'"] Temporary /Experimental
{ ' ] Repair [ %., /] Abandonment [,; j Other(Specify)
APPLICANT:
STATE OF FLORIDA PERMIT #
—DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 10D -6, FAC
PROPERTY STREET ADDRESS:
LOT: BLOCK: SUBDIVISION:
PROPERTY ID #:
AGENT:
SYSTEM DESIGN AND SPECIFICATIONS
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
/i "L"J
r7 .�r
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 [ ] [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 PITIIPS: [ ]
D t ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ 1 FILLED [ ] MOUND i ]
'_ CONFIGURATION: [ ] TRENCH [" ' BED [ ]
N
F LOCATION OF BENCHMARK: �.
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [ .;
L
D FILL REQUIRED: [ ] INCHES
0
T
H
E
R
] [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:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
Page 1 of 2
Y'Ca:
APPLICANT: ?roperty owner's full rtarna.
7E.I.:3P7ONE: numbe fo7 1:ppliceri or &lent.
Property owne;'.5 legaily au:horized reprecentativ:..
MAiLYNC.: ADDIU1SS: box 1..t. at:dr.:Ls fir cgetf..
sysi DE.S AN
SZIDil.r.S:ON
7.7 characier ourabc: for omperty. app7cLa: aactioni:own.b!p/r -11;c/2. 7 :."1'.7.
:,2et:ificatio-is from Chore::
Minimum specifIcations . fraT., Chapter 11.1D-, A.
Other r.,peelficatioti., !:.aeti oatin:s. .x,c1:217eroc. !oy!-"olti7r 1' 'oilcin, varir”co
3`!: Name of ir.tliviuJal nrovithng soecificoto_.a. regh.?:r..2.1 an :-
Couut-j Puolic In.eabh. 'Lida (C9.:-.1..LJ) peo.onre' a?pro
Date errnii is i.,sued by C?-1U.
X DA One d.te is,eLt.1 9C
/
MIA)v1II SHORES VIIJ..AGE, FLA.
N° 5939
JOB ,
ADDRESS / . - /
INSPECTION _
TIME READY
i/
(
REMARKS •
INSPECTOR DATE
Permit No -
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whe er herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work
Owner's Name and Address F,
Registered Architect and /or Engineer_..._
9
s
Employing Plumber's Name_ . ' •- No: -- — — - - -__ Street. Location and Legal Description Lot.._. _±_ Bl Subdivision _
Street and Number where work is to . be performed— No.___,L,� 9/ i( -- eet
State work to be performed and purpose of building (By Floors) _
New Building _ ___ Remodeling____ _ Addition._.____._.____ _____. Repairs No. of Stories.
Size Septic Tank
Feet of Drain Tile.
Nature of Water Supply: • —Well _____Size of Soakage Pit
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING r`-:k,MIT
Capaci
____Dist. Feet of Tank or Drain Field from Well
No._ Street
(Signed)____ �'` L _ _ ..... .._ -_
Plumbin nspector.
Date.
Gals. —
My Commission Expires Notary Public, State of Florida
7
The undersigned applicant for this building permit does hereby certify that he understands and accepts his ligation as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Pe nanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be pied under this permit, as
licensed by Miami Shores Village.
Master Plumber.
are
are
STATE OF FLORIDA, 1
COUNTY OF DADE.
3efore me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA.
TORIES
INK
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOU NT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
-
CHECK
Permit No -
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whe er herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work
Owner's Name and Address F,
Registered Architect and /or Engineer_..._
9
s
Employing Plumber's Name_ . ' •- No: -- — — - - -__ Street. Location and Legal Description Lot.._. _±_ Bl Subdivision _
Street and Number where work is to . be performed— No.___,L,� 9/ i( -- eet
State work to be performed and purpose of building (By Floors) _
New Building _ ___ Remodeling____ _ Addition._.____._.____ _____. Repairs No. of Stories.
Size Septic Tank
Feet of Drain Tile.
Nature of Water Supply: • —Well _____Size of Soakage Pit
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING r`-:k,MIT
Capaci
____Dist. Feet of Tank or Drain Field from Well
No._ Street
(Signed)____ �'` L _ _ ..... .._ -_
Plumbin nspector.
Date.
Gals. —
My Commission Expires Notary Public, State of Florida
7
The undersigned applicant for this building permit does hereby certify that he understands and accepts his ligation as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Pe nanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be pied under this permit, as
licensed by Miami Shores Village.
Master Plumber.
are
are
STATE OF FLORIDA, 1
COUNTY OF DADE.
3efore me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
Permit No. �_if
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address /�� A � �
Address_ •
- --- L_L 1_!___ -_ -- No._ -- -- ��_ -� -� Street- -- -- -�
Registered Architect and /or Engineer — /
Employing Plumber's Name_ .r� e 41 - 2 f -iL /'7 /
S C L
HA No._ - - - -_ _t_lt_ Street. Location and and Legal Description Lot _______._____— .___._ -___-- Block
Street and Number where work is to be performed —No I 9 ?/ AIL Y..y Street.
State work to be performed and purpose of building (By Floors)_
N Building — Remodeling_____ Addition__ ______________ ______ Repairs No. of Stories
Size Septic Tank _------ _ -__ -- Type of Tank__ Capacity Gals
Feet of Drain Til_r - -` -- ELI_Dist• Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well.______ _ _— ____Size of Soakage Pit
Amount of Permit $
---- --_ -- _ ____ ( Signed)_ _
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on w k to be performed under this permit, as are
licensed by Miami Shores Village.
( Signed
My Commission Expires Notary Public, State of Florida
Date ‘Al/IF
Subdivi
Master Plumber.
STATE OF FLORIDA, }
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
Twits
B
I NAS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
Comm.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWIM'G
POOL
CONTR.
LIST
-
CHECK
v
Permit No. �_if
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address /�� A � �
Address_ •
- --- L_L 1_!___ -_ -- No._ -- -- ��_ -� -� Street- -- -- -�
Registered Architect and /or Engineer — /
Employing Plumber's Name_ .r� e 41 - 2 f -iL /'7 /
S C L
HA No._ - - - -_ _t_lt_ Street. Location and and Legal Description Lot _______._____— .___._ -___-- Block
Street and Number where work is to be performed —No I 9 ?/ AIL Y..y Street.
State work to be performed and purpose of building (By Floors)_
N Building — Remodeling_____ Addition__ ______________ ______ Repairs No. of Stories
Size Septic Tank _------ _ -__ -- Type of Tank__ Capacity Gals
Feet of Drain Til_r - -` -- ELI_Dist• Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well.______ _ _— ____Size of Soakage Pit
Amount of Permit $
---- --_ -- _ ____ ( Signed)_ _
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on w k to be performed under this permit, as are
licensed by Miami Shores Village.
( Signed
My Commission Expires Notary Public, State of Florida
Date ‘Al/IF
Subdivi
Master Plumber.
STATE OF FLORIDA, }
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made by improper notice for inspection, or faulty
materials and /or workmanship.
BUILDING ❑ Date MIAMI SHORES VILLAGE, FLORIDA 2, 19 a
ELECTRICAL ❑ 10018
PLUMBING ❑ PER MIT N? Contractor's '
License No. (�
ROOFING ❑ r
`.1' 7 0 Work to be performed under this Permit
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
CONTRACTOR or BUILDER
Lot
II BI
/ fej
f
•
Subdi-
vision
Sq Ft.
Value of II Amount of
Project $ II Permit $
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion 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 respon-
sibility for work done by his agents, servants or employees.
Signed • ' - f✓ • ' ° u ,.'• (INSPECTOR) BY_,,..., '" r t. t, -R-
In consideration of the issuance to me of this perms I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, iarawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I assume responsibility for all work done by either, mys elf, my agent, servant or employee.
BY AUTHORITY