290 NE 95 St (10)CONSTRUCTION PERMIT FOR:
['''] Existing System
[.' .:) Abandonment
[ 1
. .•1
APPLICANT:
LOT:
T
A
N
K
D
R
A
I
N
F
1
E
L
D
0
T
H
E
R
[
New System
Repair
PROPERTY STREET ADDRESS:
7 n
PROPERTY ID #:
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.
SYSTEM DESIGN AND SPECIFICATIONS
[ ] [GALLONS / GPD] S ,ANK /►EROBIC UNIT CAPACITY
[ ) [GALLONS / GPD) CAPACITY MULTI- CHAMBERED /IN SERIES:[ 1
[ 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
GALLONS PER DOSE DOSING TANK CAPACITY DOSE .RATE [ ] PER 24 HRS NO. OF PUMPS: [ )
SQUARE
[ ] SQUARE
TYPE SYSTEM:
CONFIGURATION:
LOCATION OF BENCHMARK:
FILL REQUIRED: [ ( INCHES
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
{
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH DATE PAID !
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ ) _
CONSTRUCTION PERMIT RECEIPT 1
Authority: Chapter 381, FS &
BLOCK: SUBDIVISION: : / ,t
FEET PRIMARY DRAINFIELD SYSTEM
FEET SYSTEM
J STANDARD [ ] FILLED
1 TRENCH • (- ] BED
ii
L�r
DH 4016, 10196 (Replaces HRS -H Form 4016 (page 1) which may be used)
(Stock Number: 5744 -001- 4016 -0) Applicant
Chapter 10D -6, FAC
[� ) Holding Tank [° '] Temporary /Experimental
(#_„) Other(Specify)
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
AGENT:
MULTI- CHAMBERED /IN SERIES:[ )
[ 1 MOUND ( j'
4., f t s_
1.
ELEVATION OF PROPOSED SYSTEM SITE �
• ) [;II�CHO/FT] [ABOVE / Fy.L BENCHMARK /REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ „ '7, 1 [INCHES /FT] [ABOVE /4ELOW1> BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ,, ] INCHES
]NSTrI L S. MEW (111171F. S2ZD
TITLE:
TITLE:
[►' ".'xLL A:11 V y " JD
BCTT(''�i r i:in.it " C . l "''k' i'':b •�`� 4 4
T i.i -I_ST 2,0 F p Wti0E1 MD Lt". silk ::: Tilt
t r tj:3i: + i:.'ECR► T1014 EEO Oii ar,Atil YhEi1CH
i;
41.1
I
EXPIRATION DATE:,
I
I
CHD
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 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 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.
APPLICANT: , h A. 06-67-41:e5 AGENT:
LOT: l BLOCK: 2 SUBDIVISION:
/Al/ F
PROPERTY ID ,f' ` ... 4 !� . * EQ ' %ia [Section /Township/
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 SITEPLAN:
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH
SURFACE WATER: 4)
WELLS: PUBLIC:
BUILDING FOUNDATIO S:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [Pc NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION:
SOIL PROFILE INFORMATION SITE 1
USDA SOIL.SERIES3
SITE EVALUATED BY:
t
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
FZ'
FT
DH 4015, 10/96 (Replaces HRS -H Form 4015 (Page 3) which may be used)
(Stock Number: 5744- 003 - 4015 -1)
[I( YES ( ] NO NET USABLE AREA AVAILABLE: 46 ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2)
GALLONS PER DAY [1500 GPD /ACRE OR 2500GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED:
FT] [ABOVE
PERMIT #
46e.g.-re
Parcel No. or Tax ID Number]
SOIL PROFILE INFORMATION SITE 2
SQFT
:04
BENCHMARK /REFERENCE POINT
CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
DITCHES / SWALES: J /,; FT ORMALLY WET? [ ] YES (NO
LIMITED USE: dit„)j } FT PRI ATE: � FT NON- POTABLE: FT
FT PROPERTY LINES: Zfi FT POTABLE WATER LINES: c FT
10 YEAR FLOODINQ? , [ ] YES [k NO
FT MSL /NGVD
OBSERVED WATER TABLE: INCHES [ABOVE / BE OW] EXISTING GRADE. TYPE: PERCHED / APPARENT]
ESTIMATED WET SEASON WATTEE — TABLE ELEVATION: 9i INCHES [ ABOVE / ELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES M NO E MOTTLING: [ ] YES (l �.a,a/
DEPTH: ' INCHES
SOIL TEXTURE /LOAPING RATE FOR SYSTEM SIZING: 6ik DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGI.IRATION: [ ] TRENCH Of] : BED' [ ] OTHER, (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE: / d ;
Page 3 of 3
Date Job Address
cfrm,4
Legal Description ,.S
J C t-P ltrit,,, I1 .
Owner/Lessee / Tenant
Qualifier / - r p
State # 3
Square Ft. , 5-•16
y
mo t=
ure of own
A
Owner
Commission E
FEES: PERMIT
APPROVED:
Zoning
Mechanical
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Owner's Address Phone
Contracting Co. A.,,� � Atee,,e Address
SS# r ,_____- 7& one I a1z0
Municipal # Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION ./iMed 4 14%t1
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.
zo
o
SI,gtY Po,. OFFICIAL NOTARY SEAL
ANGELA M BECKER
2 , n COMPASSION NUMBER
4 4•'q�' • CC786697
71. 4 MY COMMISSION EXPIRES
NOV. 15 2002
RADON
t
OWNERS IPAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction an
g. Furthermore, I authorize the above -named contractor to do the work stated.
v\ 6
}
d/or Condo President Dae
5� "l9 L/O.00 7j
I. .
Building
Plumbing
Ld: S
0c
C.C.F.
Historically Designated: Yes No
Master Permit # 4 4O.3J
Estimated Cost (value)
.II
e
of Contract
r or Owner- Builder
Signs
Tax Folio
y Commission Expires:
- 3 . 06 - 0 /3 -37,0o
tary as to Contractor or Owner- Builder "pate
0 CIALN' 1'
GLAD VS ) VW-AR
OM ,ION NO. C
10 MY COMMISSIO "` ,2 2a?
00
NOTARY s: O t) BOND
Electrical
Ins. Co.
TOTAL DUE
Date
Structural Engineer
Permit No.______ -_` -. J / �a _
Registered Architect and /or Engineer_
Employing Plumber's Name!?1.M.13r'.__ -�._,t f
Location and Legal Description Lot_ ______ _______
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors)
New Building _._-- ------- ----- --_._ Remodeling
Size Septic Tank
Feet of Drain Tile___
Amount of Permit f ----------------------- - - - - -- -- ( Signed )_
STATE OF FLORIDA,
CCUNTY OF DADE.
MIAMI SHORES VIL:,AG
PLUMBING INSPECTION DEPARTMEi '
APPLICATION FOR PLUMBING r/ T
( Signed) ____
Block
`2_1' ® Street
Addition.______.__._ Repairs
Subdivision
My Commission Expires Notary Public, State of Florida
2 /'5 i
Application is hereby made for the approval of the detailed statement of thb plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and cm:for-:.;ty with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miam& Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified nrt. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address � lE _--'______ 1 C U l. L. No. 290 Street �" �/
E 9 cS X
No.. Street__ A/ OS _
2S ' --Le ef _�'
No. of Stories . . .......................
Type of Tank Capacity Gals
_Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well. -_ -.- _....... - _______ _______ ____ _- ._______- _____Size of Soakage Pit
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 : - public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractor` work to • pe •rmed under this permit, as are
licensed by Miami Shores Village.
Eafore me, the undersigned authority, a notary public, duly authorized to admini er 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
SINKS
SLOP
SINKS
LAUNDRY
TUBS
U RINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT'N&
TOTAL
FIXTURES
CONTR.
LIST
CHECK
^
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWIM'G
POOL
CONTR.
LIST
- ---
CHECK
Permit No.______ -_` -. J / �a _
Registered Architect and /or Engineer_
Employing Plumber's Name!?1.M.13r'.__ -�._,t f
Location and Legal Description Lot_ ______ _______
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors)
New Building _._-- ------- ----- --_._ Remodeling
Size Septic Tank
Feet of Drain Tile___
Amount of Permit f ----------------------- - - - - -- -- ( Signed )_
STATE OF FLORIDA,
CCUNTY OF DADE.
MIAMI SHORES VIL:,AG
PLUMBING INSPECTION DEPARTMEi '
APPLICATION FOR PLUMBING r/ T
( Signed) ____
Block
`2_1' ® Street
Addition.______.__._ Repairs
Subdivision
My Commission Expires Notary Public, State of Florida
2 /'5 i
Application is hereby made for the approval of the detailed statement of thb plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and cm:for-:.;ty with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miam& Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified nrt. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address � lE _--'______ 1 C U l. L. No. 290 Street �" �/
E 9 cS X
No.. Street__ A/ OS _
2S ' --Le ef _�'
No. of Stories . . .......................
Type of Tank Capacity Gals
_Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well. -_ -.- _....... - _______ _______ ____ _- ._______- _____Size of Soakage Pit
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 : - public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractor` work to • pe •rmed under this permit, as are
licensed by Miami Shores Village.
Eafore me, the undersigned authority, a notary public, duly authorized to admini er 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.
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building -
Architect
Contractor
or Builder C
Legal
Description
Lot
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
PERMIT N? 5215
4:\
t d1 { ( {
B1
Work to be performed under this Permit__
DATE 4 `f 19
Contractor's
License No. Li 1
Subdi-
vision
r .s
Address of Value of f! Amount of _ ---
Building 1' 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. 6- a INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in com once with all ordinances and regulations
pertaining thereto and fn strict conformity with the plans, drawings, statements or specifications submitted to the pro r, authorities of Miami Shores Village. In as
cepting this permit p
BY
assume responsibility for ell work done by either, myself, my agent, servant or employee. ,
Y S ) AUTHORITY ABBOT
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby le for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
stwucture herein desmibed. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and ail 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
....4d No.
Registered Architect and/or Engineer__________________
Amp tiELSQN SEPTIC TANK QPNTRACTO No.. 20
Employing Plumber's MEV° Stree
Location and Legal Description Lot___________. Block: Subdivision
Street and Number where work is to be performed—No
State work to be performed and purpose of building (By Floors)._ _
New Building_ Remodeling_____ Addition Repairs No. of Stories.
Size Septic Tank
--------------
My Commission Expires
( Signed)_
(Sign
Date
Street
Street
Type of Tank Capacity Gals
Feet of Drain Tile. Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City—Well Size of Soakage Pit
Amount of Permit $ r-o
2 67
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 n work to bperformed under this permit, as are
licensed by Miami Shores Village.
Notary Public, State of Florida
Plumbing Inspector.
MaeterFltietbas.—..
STATE OF FLORIDA, I
846
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
TUBS
URINALS
CATCH
emu,
FLOOR
DRAIN
DRINK I NG
FOUNT' NS
TOTAL
F I XTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW I PA' G
POOL
CONTR.
LIST
CHECK
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby le for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
stwucture herein desmibed. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and ail 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
....4d No.
Registered Architect and/or Engineer__________________
Amp tiELSQN SEPTIC TANK QPNTRACTO No.. 20
Employing Plumber's MEV° Stree
Location and Legal Description Lot___________. Block: Subdivision
Street and Number where work is to be performed—No
State work to be performed and purpose of building (By Floors)._ _
New Building_ Remodeling_____ Addition Repairs No. of Stories.
Size Septic Tank
--------------
My Commission Expires
( Signed)_
(Sign
Date
Street
Street
Type of Tank Capacity Gals
Feet of Drain Tile. Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City—Well Size of Soakage Pit
Amount of Permit $ r-o
2 67
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 n work to bperformed under this permit, as are
licensed by Miami Shores Village.
Notary Public, State of Florida
Plumbing Inspector.
MaeterFltietbas.—..
STATE OF FLORIDA, I
846
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.
Permit No
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF' DADE.
My Commission Expires
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Location and Legal Description Lot..- _..._. 8
Street and Number where work is to be performed - No._ : f 1 Street q &
State work to be performed and purpose of bdlding (By
(Signed) -42
(Signe)_ 0LC. M
/J
Date_ _./44
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. /� ® q / Q�
Owner's Name and Address U. yJ ( IDR t) Oki No ?O /V ' Street___J__ ? S'
Registered Architect and /or Engineer
/
Employing Plumber's Name // f'C /31- / i C /RN-C.76— Street
Size Septic Tank_ _Type of Tank___ Capacity Gals.
Feet of Drain Tile 3° \r 8A- ®C eiDist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City-Well. ________Size of Soakage Pit
Notary Public, State of Florida
Master Plumber.
New Building Remodeling Addition Repairs No. of Stories
Plumbing Inspector.
The undersigned applicant for this building penult does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5988, 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 work to be performed under this pennit, as are
licensed by Miami Shores Village.
cki -& )1
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 necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBE
SNOWLRR
LAVA.
TORIaf
KS
SINKS
SLOP
SINKS
LAUNDRY
Tuna
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NE
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
NEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'O
POOL
CoNTR•
LIST
CHECK
Permit No
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF' DADE.
My Commission Expires
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Location and Legal Description Lot..- _..._. 8
Street and Number where work is to be performed - No._ : f 1 Street q &
State work to be performed and purpose of bdlding (By
(Signed) -42
(Signe)_ 0LC. M
/J
Date_ _./44
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. /� ® q / Q�
Owner's Name and Address U. yJ ( IDR t) Oki No ?O /V ' Street___J__ ? S'
Registered Architect and /or Engineer
/
Employing Plumber's Name // f'C /31- / i C /RN-C.76— Street
Size Septic Tank_ _Type of Tank___ Capacity Gals.
Feet of Drain Tile 3° \r 8A- ®C eiDist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City-Well. ________Size of Soakage Pit
Notary Public, State of Florida
Master Plumber.
New Building Remodeling Addition Repairs No. of Stories
Plumbing Inspector.
The undersigned applicant for this building penult does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5988, 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 work to be performed under this pennit, as are
licensed by Miami Shores Village.
cki -& )1
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 necessary by improper notice for inspection, or faulty
materials and /or workmanship.