DRAINFIELDJob Address (where the work is being done)
City
Miami Shores Village
Is Building Historically Designated YES
State Certificate or Registration No.
$ Value of Work For this Permit
Type of Work: EAddition
Describe Work:
Submittal Fee $
Notary $ 5'00
Scanning $ A-60
Total Fee Now Due $
(Continued on opposite side)
Radon $
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (30)-79,S 2204 F--(O5 ) 756.8972
BUILDING /TP '
PERMIT APPLICATION
FBC 2001
Plumbing Mechanical Roofing
/136) 7/i7-
313
Permit Type (circle): Building ectrical
Owner's Name (Fee Simple Titleholder) -/ C 0 ,.... * $ � —
Owner's Address 6 � ` r f
City State 7 .-- 4 . _-- Zip
Tenant/L ssee Name
County Miami -Dade
NO
❑Alteration ❑New
Code Enforcement $ Structural Plan Review. $
Permit No. c
— I 1
aster Permit No.
Phone #
()--1;14
Zip
Contractor's Company Name Z5„,_ �� � Phone Q / 0
Contractor's Address / 00s, 0 /v n 1 .7 a Si
City A- State Zip 3 / 3(c
1
Qualifier jp> 0
Architect /Engineer's Name (if applicable) f(/ ) Phone #
(9 fi
Certificate of Competency No. Dili /t7.
Square Footage Of Work:
X 1 7 tepair/Replace ❑ Demolition
36I p/1u Jt /( ) vs7n2
* * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Permit Fee $ 1-75.00 �Jl�l CCF $ CO/CC
Training /Education Fee $ • CO o 0 Technology Fee $ / l • 00
Zoning Bond $
Bonding Company's Name (if applicable) 141/4
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) /
Mortgage Lender's Address !ll��� vvv
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. 1 understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: 1 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.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
h
•
Owner or Agent
is personally known to
Sign
The for . ing i is ument was acknowledged before r • this
NOTARY P
Si n:
nt:
My Commis o Ex Tres: - *. . ' Ex
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
APPLICATION APPROVED BY:
chc 05/13/03
or who has produced
s identification and who did take an oath.
Signature
day of
The foregoing instrument was acknowledged before me this
,20_,by
#/
ontra ctor
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
/ .r
• . • M { 2E) 2 My Commission Expires:
Gnnued Thrr
Sign:
Gm11y H. Gonei print:
• �. - : D32387(
** * ** * ***** * **** ** **** ** **** * ***** * *** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
)LC�(., o - v - / - c) 1 Plans Examiner
Engineer
Zoning
ITEM
BATH TLB
UNIT
FEE
ITEM
SWITCH CUTLETS
UNIT
FEE
ITEM
SPACE HEATERS
UNIT
FEE
BIDET
LIGHT OUTLETS
CENTRAL HEATING
DISHWASHER
RECEPTACLES
A/C (WIND)
DISPOSAL
SERVICE TEMPORARY
A/C (CENTRAL)
DRINKING FOUNTAIN
SERVICE SIZE IN AMPS
DUCT WORK
FLOOR DRAIN
SERVICE REPAIR/lkTER CHANGE
REFRIGERATION
GREASE TRAP
APPLIANCE OUTLETS
PROCESS AND PRESS PIPING
INTERCEPTOR
RANGE TOP
UNDERGROUND TANKS
LAVATORY
OVEN
ABOVE GROUND TANKS
LAUNDRY TRAY
WATER HEATER
U.F. PRESSURE VESSELS
CLOTHES WASHER
MOTORS 0- 1 If
STEAM BOILERS
SHOWER
MOTORS OVER 1- 3 HP
HOT WATER BOILERS
SINK, POT /3 COMP.
MOTORS OVER 3- 5 FP
MECHANICAL VENTILATION
SINK, RESIDENCE
MOTORS OVER 5- 8 HP
TRANSPORTING ASSEMBLIES
SINK, SLOP
MOTORS OVER 8- 10 HP
ELEVATORS/ESCALATORS
TEMPORARY WATER CLOSET
MOTORS OVER 10- 25 HP
FIRE SPRINKLER SYSTEM
URINAL
MOTORS OVER 25-100 HP
COOLING TOWERS
HATER CLOSET
(
MTCRS OVER 100 Ha
VIOLATION
INDIRECT WASTES- '
I
A/C WIDOW
REINSPECTION
WATER SUPPLY TO:
AIR CONDITIONERS
A/C UNIT
I
I STRIP HEATER
I
I
FIRE SPRINKLER
I
I GENERATORS TRANSFORMERS
I
I
I
'HEATER -NEW INST.
I
I GENERATORS TRANSFORMERS
I
I
HEATER - REPLACE
I
1 GENERATORS TRANSFORMERS
I
I
I
LAWN SPRINKLER -WELL
SPECIAL PURPOSE
I
I I
I
SW I W I NG POOL
OUTLETS COWERC I AL
WATER SERVICE
SIGN TUBES
SEWER CONNECTIONS
SIGN TRANSFORMERS
UTILITY -SEWER
SIGN TII€ CLOCK
UTILITY -WATER
FIXTLRES
SEPTIC TANK
ANTENNA
RELAY
I
TELEVISION OUTLETS
DRAINFIELD, S' TILE/RES.
VI
VIOLATION
I
I
PUMP & ABANDON SEPTIC TANK
REINSPECTION
SOAKAGE PIT CU. FT.
CATCH BASIN
DISCHARGE WELL
DOMESTIC WELL
AREA DRAIN
I
ROOF INLET
SOLAR WATER HEATER
FIRE STANDPIPE
POOL PIPING
LAWN SPRINKLER SYSTEM
GAS RANGE
METER SET (GAS)
GAS PIPING
ADDENDUM TO BUILDING PERMIT APPLICATION
,•
(AN APPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS E.
OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS.)
PLUMBING
ELECTRICAL
MECHANICAL
STATE OF FLORIDA
DEPARTMENT OF HEALTH
'ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other
[ X ]Repair [ ]Abandonment [ ]Temporary [ NA ]
APPLICANT: Lopez, Sheila AGENT: SR0921116, PARILLA ROBERT
PROPERTY STREET ADDRESS: 575 NE 95 St Miami FL 33138
LOT: 22
BLOCK: 54 SUBDIVISION: Miami Shores
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3206 - 014 -0760 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ]Gallons SEPTIC TANK MULTI - CHAMBERED /IN SERIES: [Y ]
A [ 0 ]Gallons MULTI- CHAMBERED /IN SERIES: [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ N4 ]STANDARD [ N ]FILLED
I CONFIGURATION: [ Nl ] TRENCH [ ] BED
N
F LOCATION TO BENCHMARK: FFE: 10.4 Ft NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 2.0 ] [ FEET ] [ BELOW BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 4.5 ] [ FEET ] [ BELOW BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 30.0 ] INCHES
OTHER REMARKS:
1. Install 300 sf of drainfield in bed configuration.
2. Existing 900 gal. septic tank has to remain.
3. Existing 900 gal. septic tank to be inspected for an appropriate pump -out and a solid
vertical deflector installed on the outlet device.
4. Invert elevation of drainfield to be no less than 6.40' NGVD.
5. Bottom of drainfield elevation to be no less than 5.90' NGVD.
THIS PERMIT IS NOT FOR ADDITION(s).
SPECIFICATIONS BY: Andre, Pau
APPROVED BY: Andre, P
DATE ISSUED: 4/5/05 EXPIRATION DATE: 7/4/05
DH 4016, 03/97 (Obsoletes previous editi.•• which may not be used)
(Stock Number: 5744- 001 - 4016 -0) [ostde cone 4016 -1J
TITLE:
CENTRAX #: 13 -SG -24526
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 05 -1113- -R
[ N ]MOUND [ N ]
[ N ]
TITLE: Professional Engin Dade CHD
Page 1 of 2
Scale: Each block represents 5 feet and 1 inch = 50 feet.
)- .
• <
-; •
STATE OF FLORIDA
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number .1 /d3
DEPARTMENT OF HEALTH
PART II - SITE PLAN-
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Site Plan submitt
Plan Approved
By
OH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-40154)
A /e2
' 7 1f r ),) )4.z.
• -,•••
by:
Signature
Not Approved
ALL CHAN S s BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
C)
Title
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County Health Department
Page 2 of 3
Date: `7
Please deli r these documents immediately to
To:
Of
Fax #
From: 0 '���-
Dade (305) 558 -5818 * Brow (954) 920 -5099 *
Fax (305) 893 -0270
# Of Pages Including Cover Sheet 3
MESSAGE:
BOB'
1 SEPTIC & DRAIN. INC
il • Septic Tanks • Grease Traps
Drain Fields • Sewer
Jet Cleaning
CC#000652 • State Certified • Septic Tank Contractor
P.O. Box 612333 • North Miami, Florida 33261.2333
Phone: (305) 558 -5818
FACSIMILE TRANSMISSION
oc
'67d ()0,,t)p
7i 0a),
"24 Hour Service • Licensed & Insured"
ev\o- \\
APPL ICANT: t"7`
r j
AGENT t _.>" ` C`) j' J / c: (! a-' .y
PROPERTY ADDRESSI
LOT:2
STATE OP FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
- 7r- N 4 . 7
1
BLOCK: i SUBDIVISIONN'
imememassessssasasstsrarr.s samara mwmwsgimm.. a ..a: :.aaswsssssssss=mmtm..m...
CHECKED [X] ITEMS -.ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BS CORRECTED.
= = ==== aswswaswwawssamxpemese —•� MllrO'tsassssae=assatss =T: === C31014ZfaYssasa wire =se
TANK INSTALLATION
[01] TANK SIZE [1] � FJC� [2]
[02 ] TANK MATERIAL
[03] OUTLET DEVICE
[04] MULTI- CHAMBERED [ Y /00]
(05) OUTLET FILTER
(06) LEGEND Jy l �-
[07 ] WATERTIGHT
[Oa ] lama, ---:.
[09] DEPTH TO LID 0 7'
[10]
[11]
[12]
[13]
[14]
(15]
[16]
[
(181
[
[
[21]
PILL / EXCAVATION MATERIAL
L22) FILL AMOUNT „ t
[33], FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
DRAINFIELD INSTALLATION
AREA (1] /.Z - Xx.7 1213 Q cam' sQFT `
DISTRIBUTION BOX HEADS
NUMBER OF DRAINLIIIE8
DRAINLINE SEPARATION
DRAINLINE SLOPE
DEPTH OF COVER) e
ELEVATION [ABOVE /BELOW] BM
SYSTEM LOCATION
DOSING PUMPS
AGGREGATE 5131 // )
AGGREGATE EXCESSIVE FINES
AGGREGATE DEPTH /#
DI 4016, 10/97 (Previous Editions May Be Used)
71-
a.• "� ( _ - A ,J G .C11"
l
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[ 1 [40]
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coNSTRUCTIO A PPROVEbISAPPROVED] : rte- -
1 /
FINAL SYST Q3t ti C, APP )ISAPPROVEDI t,rte R� -4:i C
INSTALLER / CONTRACTCIR
PROPERTY ID
SETBACES
[27] SURFACE WATER
[22] DITCEEs
[29] PRIVATE WELLS
[30]
[31]
(32]
[33]
[34]
[
PUBLIC WELLS J FT
IRRIGATION WELLS is/ ) L FT
POTABLE MATER LINES _3.,:, FT
BUILDING FOUNDATION t' - FT
PROPERTY LINES - FT
OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD.COVER
(37] SHOULDERS
(38] SLOPES
[39] STABILIZATIOIN
ADDITIONAL INPOIU0►TYON
UNOBSTRUCTED AREA
STORMWATIR RUNOFF
ALARMS
MAINTENANCE AGREEMENT
BUILDINGARIA
LOCATIONN CONFORMS WITH SITE PLAN
FINAL SITE INa f / J
CONTRACTOR -- .,' ,d cc/
OTHER
ABANDONMENT
[ 1 (49) TANK PUMPED _/ /r.3/ D
it 1 [SO) TANK CRUSHED & TILLED _ // r/,
EXPLANATION OF VIOLATIONS / REMARK8s
1
[ 1
[ 1
1
•.
L. CND DATE s / J / _ r? ✓
U C_ CND DATE :9 /3" — -f 3
Page 2 of 3
PT 1; Applicant
PT 2: Installw /Contractor
PT 3. BtilklIng Department
PT 4: Health Department
PERMIT MO. a - /l
DATE PAID:
FEE PAID,
RECEIPT O s .5() ( `fro
/1- 3 20 6 -0 //- 0 & ( ;
}- -}4 FT
FT
rr
• 4 / •
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 4/12/2005
Applicant: GUSTAVO & SHEILA LOPEZ
Owner: LOPEZ GUSTAVO & SHEILA
JOB ADDRESS: 575 NE 95 ST
Contractor BOBS SEPTIC & DRAIN INC
Local Phone: 305 - 558 - 5818
Parcel # 1132060140760
Signed: (INSPECTOR)
Plumbing Permit
Permit Number: PL2005 -115
Contractor's Address: 1020 NE 130 ST
Permit Status: APPROVED Permit Expiration: 10/5/2005 Construction Value: $2,500.00
Work: INSTALL NEW DRAINFIELD
Page 1 of 1
Legal Description: MIAMI SHORES SEC 2 PB 10 -37 LOT 22 & W1/2 OF 23 BLK 54 LOT SIZE 75.000
Fees: Description Amount
FEE2005 -4780 Building Fee $175.00
FEE2005 -4781 CCF $1.80
FEE2005 -4782 Notary Fee $5.00
FEE2005 -4783 Training and Education Fee $0.60
FEE2005 -4784 Technology Fee $4.38
FEE2005 -4785 Scanning Fee $3.00
FEE2005 -4786 Builders Bond $300.00
Total Fees: $489.78
Total Fees: $489.78
Total Receipts: $0.00
CCT 2 0 PAID
i 4 1
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Bu'lding Inspection Request 6 �'�
Date % 1d
Type lnsp' n �0 }U I S€ \ lc
Permit No. ' I 005- I S
Name LOPQ
Address , ) NC qS Sj-
Company
Phone #
Inspection Date
Approved
Correction
Re- Insp'n Fee
nc) -\-C1 • i r -\Ca
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Bu lding Inspection Request 16 �'�
Date ' -
Type Insp'n 1� C 6 SP' IC
Permit No. :- 1 0 0 S IS
Name LJ
Address tZ5 N C t5 54
Company
Phone #
Inspection Date
Approved
Correction
Re- Insp'n Fee
nil
cm1 ) 1 _ l cr\OiS'