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841 NE 95 St (10)STATE OF FLORIDA) COUNTY OF DARE) 7fliajn Sior� VLage AFFIDAVIT The undersigned Affiant, r c h fr-v c f , r, v 2 , does hereby attest that the (property owner) attached survey, performed by (name of surveyor's company) performed on is an accurate representation of the existing conditions and (date of survey) locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than six (6) months old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits.. Further, Affiant sayeth naught. it.1i w ate) Witness(sign and pr t SWORN TO AND SUBSCRIBED before me this S day of ®2Cewker 0,001 Affiant is personally known to me, )( produced Ft() IUer5 as identification. Li ceans -e2 1P 6 € tG V • r fi * 7... O • APPLICANT: AGENT: PROPERTY ADDRESS: LOTt =========================== EXPLANATION OF VIOLATIONS / REMARKS: CONSTRUCTION [APPROVED /DISAPPROVED] :' FINAL SYSTEM [APPROVED /DISAPPROVED]: DH 4016, 10/97 (Previous Editions May Be Used) M @3 C© C�.M'I ENIV PROPERTY ID #: CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. FILLED / MOUND SYSTEM [36] DRAINFIELD COVER (37] SHOULDERS (38] SLOPES (39] STABILIZATION SETBACKS [27] SURFACE WATER FT [28] DITCHES FT [29] PRIVATE WELLS FT [30] PUBLIC WELLS FT [31] IRRIGATION WELLS / FT (32] POTABLE WATER LINES FT [33] BUILDING FOUNDATION FT [34] PROPERTY LINES FT (35] OTHER FT ADDITIONAL INFORMATION (40] UNOBSTRUCTED AREA (41] STORMWATER RUNOFF [42] ALARMS [43] MAINTENANCE AGREEMENT [44] BUILDING AREA (45] LOCATION CONFORMS WITH SITE PLAN (46] FINAL SITE GRADING [47] CONTRACTOR [48] OTHER ABANDONMENT [49] TANK PUMPED % / / [50] TANK CRUSHED & FILLED CHD DATE: CHD DATE: ••s ,--- - - -tea Page 2 of 3 ?EPMIT NUMBER: Permit tracking ni ember assigned by CHD. APPLICANT: Property owner's `all narne. AGENT Property owner's legally authorized representative. MAILING ADDRESS: P.O. box or street mailing add for applicant or agent. T, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or P RGPER TY ID# 27 character number for property. (property appraiser ;D # or GIS location) CC:NT'r' HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS: TANK SIZE (gallons) TANK MATERIAL (concrete, fiberglass, etc) OUTLET FILTER (manufacturer, make, model) LEGEND (manufacturer code) DRAINFIELD AREA (square feet) DISTRIBUTION BOX / HEADER (check box) NUMBER OF DRAINLINES (number installed) SYSTEM ELEVATION (in relation to BM) DOSING PUMPS (number installed) SETBACKS (record actual setbacks in ft) SETBACKS OTHER (as required) STABILIZATION (date stabilized) CONTRACTOR (contractor installing system) ADDITIONAL INFORMATION (as required) ABANDONMENT TANK PUMPED (date) TANK CRUSHED AND FILLED (date) EXPLANATION OF VIOLATIONS: Record item number, explanation of violation, and required CONSTRUCTION APPROVAL: Circle approved or disapproved, CHD signature and date. AS BUILT INSTALLATION SKETCH FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval. Final approval shall not be granted unit the CHD has confirmed that building construction and lot grading are in substantial compliance with plans and specifications submitted with the permit application. ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT: EXISTING GROUND TOP OF AGGREGATE [+1 SHOT H.I. H.I. H.I. H.I. _ [ -] SHOT [ -] SHOT [ -] SHOT ELEVATION DEC -02 -20101 21:36 CONSTRUCTION PERMIT FOR: ]New System ` J Exis tang Sy:, j?m X )Repair. ! lAbandorment APPLICANT: Figura, Richard J. PROPERTY STREET ADDRESS: 896 NE 95 St Miami FL 13138 LOT: 1 BLOCK: N/A SUBDIVISION: Mari-1. n Heights SE /Tp,J :: t••i.E. /Rar.Je/ ?a=Ce1 No.] PROPERTY ID 4: 11- 3206 -002 -0010 .'0 AY. ID: N:N ER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SjE:.IPICATION :I N:) STANDARDS OF CHAPTER 64E -6,FAC DEPARTMENT APPROVAL OF SYS ^_'EN. DOES NCT GUARANTEE SAT:-=FACTORY PERFORMANCE FOR ANY SPECIFIC TIME t'ERIOD. ANY CHANGE, TN MATERIAL FACTS WHIC:I SERVED e?5 A. BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE IRE APPLICANT TO MODIFY . ::E PERMIT A?PLICATIC SU('a �10DIFI';ATIONS MAY RESULT ..I THIS PERMIT REINS MADE NULL AND VCID. ISSO NCL OF TEI3 ,ER Lx.,E. NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL STATE OR. LOCAL PERMITTING :REQTRED FOR PROPERTY DEVELOPMENT. SYSTEM DESIGN AND S ?ECIFICATIONTS T 1 ) hIJLTI- CHAMBERED %_N SERIES: ( J A i i MU:ZT- CHAMBERED /_N SERIES: ( 1 N ; )GALLONS GREASE INTERCEPTOR CAPACITY • ( ;GALLONS DOSING TANK CAPACITY ( );;;A(.;_ot :S 0 ( 1 00SES PER 24 HRS # PUMPS( ] O ( 1 SQUARE .ELT PR::t^.'}'f JRATNFTELD SYSTEM R i JSQUARE FEET SYS iIM F, 'YNE: SYSTr ^..tl: r 1 S' :'. Nr RU i i c (.., ._ ¶ ) �1 ^UKD I .ONE IGUR. Tr.0N: ( 1 '1•RENCH ( 1 3 E' ) N F LOCATION TO BENCHMARK: I ELEVATION OF PROPOSED SY3 :EX STIR ( 1 t FEE: ;BENCHMARK /REFERENCE POINT • BOTTOM OF DRAINFIELD TO BE I 1 FEET i J BENCHMARK /REFERENCE POINT I. C .'ILL REQUIRED: [ FINCHES E.XC2,':A•1'I ,. .i':, t.EQUIi'.t.C. : I INCEE:: OTHER REMARKS: I I A 0 lk (� '. C \'�Vav �S �4d , STATE OF FLOK' DA DEPARTMENT OF HEALTH ONSITE: SEWAGE TAEATL•i':.,fl' AND DIS PCSL :'[ t CONSTRUCTION PERMIT SPECIFI:;A:TC,NS BY: APPROVED BY: ; T 1 DATE ISS::ED: "'arik Innovative Other J 7 :ice ovary IN Infiltrator AGENT: SR093111g, COCKING MSTEPHEN CN 40:6, 03/97 (0b 01etes previous ec.irioas ai =h :1. +y usec:) A _ , b' 7 ' P.01 CENTRAN #: 13-SG-11111 DATE PAID: FEE PAID . $ RECEIPT OSTDSN °F, : 01 -3681- -R Dade CHD EXPI7AT'.0N DATE: P...., 7 c ') 12/03/2001 09:17 2056233E20 APPLICATION FOR: [ New System ( J Existing System [ 4 / ] Repair ( 1 Abandonment APPLICANT: ' iat d! OL, 1 U41, • AGENT; MAILING ADDRESS: ?. `j c 6A Z.7 444 tom(' 131Gei • as Mao= TO BE COMPLETED BY APPLICANT OR APPLICAN'T'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR PLATTED (b®4 /DD /YY) IF REQUESTING CONSIDERATION OF S'3'ATUTORY GRANDFATHER PROVISIONS. - = 111a6M asCa==- WMVMMBai Masi== = = HOMO '2aa=== =c =aa= 7aial=== PROPERTY INFORMATION OM LOT; 1 BLOCK; ' SUBDIVISION: 4 . ¢ PROPERTY ID 43; r( 7 `1:11) ' uo2 ~ Otto PROPERTY SIZE: P' AgR WATER SUPPLY: ( ] PRIVATE PUBLIC tV J <.20000PD [ a7 IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / N'J DISTANCE TO SEWER: _ FT PROPERTY ADDRESS; " q g / Is< i 1w( {� jc rl►-K gyp 4 /�►E` lo apa- owlI 4 r .;L &J$ — fie» DIRECTIONS TO PROPERTY: BUILDING INFORMATION Unit Type of No Establishment 1 2 3 4 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT J Pi 1 IG.s� 715,10==.....-40110= v a u a= a= 'J' as i lLep ( ] Floor /Equipment Drains [ J Other (Specify) SIGNATURE; ✓ r�— ` -- �—~s DATE : /1/ �/ d/ J Page 1 or 4 DH 4015, 10/97 (Previous Editions May Be Used) MDCHD ENV HLTH ( [ ZONING: ] Holding Tank Temporary ( 4 RESIDENTIAL [ ] COMMERCIAL N/A ' PAGE 01 PERMIT NO. DATE PAID: PEE PAID: RE EIP 40; CUSP v V 1 Innovative ( ) TELEPHONE 4 .. ;78,71 aa== =s+MMaaav_�--- MOUG=== =Mama■ -PLATTED: I I I( I f I/H OR EQUIVALENT: [ Y / N ] ] >2000GPD No. of Building Commercial /Institutional System Design Bedrooms Area Sgft Table 1, Chapter 64E -6, FAC I i v.« tzr.�i..:_ar mstv1 ,17m : .1* >, ∎.:�rr� .�� :7m�zr t.��.. .... �' ra» of - .,�_o PAY TO THE ORDER OF MR. C'S SEPTIC & DRAIN, INC. OPERATING ACCOUNT P.O. BOX 693239 MIAMI, FL 33269 -0239 Washington Mutual Washington Mutual Bank, FA Miami/199th Street Financial Center 1719 175 NW. 199th Street 1 goo-mg-700o Miami, FL 33169 24 hum Customer Service FOR � o0049700 ': 267084 i 3 11: 38 31110 308 4 2111011' t. 4970 63- 8413/2670 DATE 1 .Z 7/z L' 3830308420 DOLLARS el Date • g-- gip /c. 7s5 Job Address Legal I3escrip(ion Historically Designated: Yes N( 4& /Owner/Lessee/Tenet ' ,t JL C/ ' x Master Permit # 0 ?� r " 0 • 2 � . �(`- Phone � 7�� 3‘ 7., Owner's Address f � ho e " s Lork o� Contracting Co. ' ! wv-� ( Address r ?! 3 I- Qualifier 51,1 6 . a c -h- SS# Phone 34c- • a 1.- 7 es? State # Municipal # Competency # Ins. Co. IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY, THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE BEFORE CALLING FOR ANOTHER INSPECTION. Permit Type (circle one): BUILDING ELECTRICAL WORK DESCRIPTIO L v Ga C�— PERMIT APPLICATION FOR MIAMI SHORES VILLAGE 10050 N.E. 2nd Avenue • Miami Shores, Florida 33138.305- 795 -2204 Square Ft. II Estimated Cost (valu Tax Folio /1 3.2-0 £p .0(3' 0 / 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 ANY 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 pc rmits are required for all disciplines. OWNERS 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. 00 9�� b lure of owner an�.� ondo Pre �fi t..., 1 \ 1 7 �n Date � ignature of Contractor or Own uilde Date Si P . ) ____A-- : t W7I.11� #F li d v :.I , t0 of V,. 11-. I ON NUMBER : c CC786697 a P R 9V COPA�ISSIOPI EXPIRES 9r `�OF Os NOV. 15,2002 N.tary as to iwner an or rondo 'dent My Commission Expires RADON C.C.F otary as tv Con My Commission NOTARY 5:• 0 c MECHANICAL ROOFING 1 ate BOND 3 a c '7 FEES: PERMIT APPROVED: Zoning Building Electrical Mechanical Plumbing Structural Engineer TOTAL DUE 3 h 4,.»a