489 NE 95 St (8)Date Job Address I / f9 / +C 95
/ ,sr Tax Folio H 32-o ( 11" b( 4 D 1
Legal Description L-oT 2 2-1\- oc1G_ e6G 2_f6
�
0;;i› Lessee / Tenant ,1� .S , )69 ILIA Master Permit 4,` 3� 6
Owner's Address `7' 6 /v, , g � s Ft Phone 7.S ? ( 9 '9
Contracting Co. /2 4 S .S PT i @ se, 1)(2 Address / `,Q /&S ./1 ( / /(
Qualifier (;f c2 01(/j /rf - Phone 'A
State # Municipal # Competency it 1 '®6011 ins .Co .
Architect /Engineer NJ/ 4. Address
Bonding Company (1/•
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL P UMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION .2 0 .c Q , f' ee A / / .L //STALL - a,b
Square Ft. v / Estimated Cost(value) /AO Of t�
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 Condo President
Da
Notar
My Co
** *
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
T
s to Owner andjot Condo President
fission Expire ` COMM SSI N UNDE
EXP E LIC OF FLORIDA'
199S.
BONPEO THRU NOTARY PUBR WRITERS
* * *
* * * * * * **
FEES: PERMIT 3t fr0� RADON C.C.F. ) (46 NOTARY / 011 TOTAL DUE 3W
Fire Other
Zoning Buildin
Mechanical Plumbing
Signature 9f Contract • or Owner- Builder
Date* + 7/5 3
Notary as
My Commiss
ont*M'
II .1
riSSOMMISSION NUMBER
CC255237
® 4' MY COMMISSION EXP.
®��► 4 . , 1997± _
Electrical
(" 1 Engineering
Lder
sT'ATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[ Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS: 4 ,53 f% , / � (_
LOT:
PROPERTY ID #:
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DES GN AND SPECIFICATIONS
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 PUMPS: [ ]
D [ f SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [
I CONFIGURATION: [ ] TRENCH [ r BED [ [
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
BLOCK: SUBDIVISION:
HRS -H Form 4016, Mar 92 (0bsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016 - 0)
AGENT: LM +r < S
TITLE:
TITLE:
,
BUILDING DEPARTMENT
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
I
]
CPHU
(74 EXPIRATION DATE: 'j !i,
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOR: Check type of permit, if "Other" specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 character id number for property. (CPHU 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 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.
Y
MIAMI SHORES VILLAGE, FLA.
JOB 1-/ fr t C.
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ADDRESS f &' / A ' �__- - ! s fir
INSPECTION Z...).00- �� am C ,fit L
TIME READY P ! L "� r / 2
N9 6782
REMARKS'
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INSPECTOR DATE