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935 NE 95 St (5)Date Type Insp'n Permit No. Name Address Company Phone # For Inspector: Approved Correction Re- Insp'n Fee MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Time MIAMI SHORES VILLAGE ( BUILDING DEPARTMENT 10) nn 305- 795 -2204 VI Building Inspection Request aut Tim-. Type Insp' Permit No. Name Address Comp Phone # For Inspector: Approved)) Correction Re- Insp'n Fee ate Record of inspection of permit covering the installation of: SEPTIC TANK WATER SUPPLY WELL DISCHARGE WELL INSTALLED BY: r t ADDRESS OF YORK: LOT :1 BLOCK t% Number of Plumbing Fixtures Nature of water supply: City Type of Septic Tank installed Capacity in Gallons Additional Information Ready for Inspection: DATE APPROVED BY: Remarks: PERMIT NO. DIVISION OF PLUMBING INSPECTION A SOAKAGE PIT SOLAR WATER HATER ADDRESS:( ADDRESS: Plumber SUBDIVISION CONDEMNED BY: DATE: NEW OLD STORY ADDITION REMODELED RES. STORE APT. HOTEL OFFICE BLDG. BUILDING HAS: BEDROOMS STORES APTS. HOTEL RMS. OFFICES OWNER OR AGENT: i (` Laundry Tubs Floor Drains Well Feet distant from all wells ivumber of feet of draintile /( Size of Soakage Pit Purpose of same Size of Solar Heater (Gallons) Size of Discharge Well (Inches) A.M. P.M. CONTRACTOR \ Name LLoyz) /vo,z 31z : - grp Li cense N1) * Sig ogot)(7tzbr Address 1 S - 0 / / 0 7p--/ c5",7 rav/9-av, Ft 33doe Telephone 3a-7.57-76A. Fax 303 7.31 Qualifier Name Li.." 0 I Cipeler 7 7--- ' PROPERTY OWNER lslanie R (Iva 7-b LL? Address q A jc.- . _0 Sp../ frn//97i/ / .5. FL_ 53/3k Home Telephone Business Telephone Fax TYPE OF MANAGEMENT ( i ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Addl Detachment Other INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores N'illage: Step I. X / Job Address: Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submit- ted along with this permit application. Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the processing of your application, you may be asked to submit additional information. APPLICATION PERMIT TYPE (/) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other 1/ q 33- 4 93 ir7 mievm siroz:z- / 33/3 Address Ap Folio Number 310/p-0/4-3i/ Lot Block 76 Subdivision Current Use of Property Proposed Use of Property Tenant Information PB PG Zoning PERMIT CHANGE (/) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax Master Permit No. Subsidiary Permit No. City PERMIT APPLICATION pL , State Zip Description of Work REP- /9-/ie vi-R"E"Pzie6:-- .3L-P7ic 774-4.)K Linear Feet Square Feet Units Floors kalue of Work )* •A b b 0 7 Bldg Value Tax Assessed/Appraised Value Flood Zone Base Floor Elev. ENGINEER Name License No. Address Telephone Fax IMPORTANT NOTICES AFFIDAVIT - Please read carefully. e of Owner ignature of C Print Name Sworn to and Public Page 2 1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT A the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Frid to 5:00 p.m. No inspections will be conducted on weekends or holidays. 2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITA 3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEB 4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES required for work in or near the street/sidewalk. 5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONS which requires a separate permit. 6. PORTABLE TOILETS for a construction site require a separate permit. 7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without appro 8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement. 9. Department of Health and Rehabilitative Services (HRS) approval is required for applications invol Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is re Application is hereby made to obtain a permit to do work and installation as indicat work will be performed to meet the standards of all laws regulating construction in th are required for ELECTRICAL, PLUMBING, POOL, EXTERIOR DOOR, ME ROOFING and SIGNS and there may be additional permits required from other gov I, the OWNER of the property, have disclosed all information related to any wor months to the Building Official. Further, I am fully aware that if the cumulative cos any other permit equals or exceeds fifty percent (50 %) of the fair market value of present federal flood criteria for finished floor elevation. I am also fully aware that under this and any other permit exceeds fifty percent (50 %) of the replacement co conform to the current code requirements of the Building Code. WARNING TO OWNER: Your failure to record a NOTICE OF COMMEN improvements to your property. If you are spending more than $2,500 or intend t your attorney or lender before recording your Notice of Commencement. The 22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Comme accordance with Section 713 -35 of Florida Statutes. Review the brochure a Choosing a Contractor. STA . ORIDA, C Print Name Signature o SEAL: YO Off COMMISSION#00 014762 EXPIRES May 20, 2005 Bonded nw, Budget Wotaq Betakes Personally known OR, Produced Identification ADE d subscribed before me this /6' day of / OCR Type of Identification Produced: ST SEAL: Personally kn Type of Identi PERMIT APPLICATION ERMIT CARD. Applying for a permit does not grant m 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m. )NDITION free from construction debris. D MAY NOT BE USED FOR STORAGE. A bond is TION SITES. Other construction may have a trailer an the Building, Planning and Zoning Department. septic tanks. Department of Environmental Resources for applications involving sewers. the OWNER of the property, certify that all isdiction. I understand that separate permits VICAL, WINDOW, FENCE, DRIVEWAY, rental agencies. the property performed in the prior twelve work to my home or business under this and structure, the entire structure must meet the ie total cost of work to my home or business the structure, then the entire structure must IENT may result in you paying twice for ain financing, you may wish to consult with of Commencement must be recorded at: Went must be POSTED AT THE JOB SITE in Ilage Hall on Construction Lien Law and A, CO E? 0420(-b vII bed before me this 1 7 day ( , tate of orida OR, Produced Identification on Produced: Page 4 OFFICE USE ONLY CHECKLIST ❑ OWNER - BUILDER FORM (Attach) ❑ FIRE DEPARTMENT APPROVAL (Commercial / multi- family) ❑ CONCURRENCY (New Construction) ❑ OTHER (Specify & Attach) $3.00 per page (Scanning Fee) Miami Shores Village Bond Metropolitan Dade County (C.C.F.) Inspector State Educational Fund State DCA (Radon) Code Enforcement Fine Zoning Review Notary ❑ PROOF OF OWNERSHIP (Attach) ❑ HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) ❑ OTHER (Specify & Attach) PER'SIIT FEES $ a $30 ©-, $ / e a 0 ( sq.ft. = x/1000 x ¢.60) $ (¢.005 /sq.ft.) $ (¢.01 /sq.ft.) ISSUING OFFICIAL REVIEWED AND PREPARED BY DATE: SECTION Zoning Electrical Mechanical Plumbing Fire Public Works Structural Building Official BY DATE, -. PERMIT APPLICATION ❑ CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) TOTAL $ 3 S Revised July 2001 10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com ELECTRICAL .1.1.),1, Minimum Fee Q.1.1 TYPl. Dryer Q.11 .11.1,1,- Outlet, Appliance Q.1.1 T1 Service Repair Q . I . V . A/C Central 1 -3 Ton Dryer Vents, Number of Fan Ventilation, Cost Outlet, Wall Ductwork, Cost of Service, Temporary Periodic Inspections A/C Central 4 -7 Ton Fire Sprinkler System Fire Pump Outlet, Switch Fireplaces, Number of Signs A/C Central 8 -15 Ton Fixture - Fluorescent Oven Space Heater (kw) A/C Central 16-20 Ton Fixture Light Parking Lot Lights Spas/Hot Tubs A/C Central 20+ Ton Flood Lights Plugmold/Strip Subfeeds, No. of Amps A/C Window FPL - Load Central Posts Swim Pool, Commercial Air Conditioners Garbage Disposal Range/Range Top Swim Pool, Residential Chiller Generators, etc. Receptacles Switchboards Clear Violations Heat Recovery Refrigerator, Comm. (p/PH) Temp Serv., Construction Compactor Low -volt, Burglar Refrigerator, Domestic Temp for Test - 30 days Deep Freezer Low -volt, Fire Renew - Temp Service . Water Closet:, Demolition Low -volt, Intercom/Teleph. Repair Circuits Water-Heater .. ' Dishwasher Low -volt, Television Service, Number of Amps :Water Heater New MECHANICAL TYPE QTY. Minimum Fee TYPE Q•I'Y. Condensate Drain TYPE; Generator QTY. TYPE, QT1'. Refrigeration, Tons A/C Central, Tons Cooling Tower Heating Strips, each Vent Hood, Cost A/C Wall/Win. Tons Dryer Vents, Number of Paint Booth Ventilation, Cost Air Handler, Tons Ductwork, Cost of Piping, Flammable Liquid Periodic Inspections Barbecue Fire Sprinkler System Process/Pressure Piping Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel PLUNIBING TYPE A/C Condensate QTY. TYI'I: Drains, Roof QTY. TYPE Miscellaneous Fixture QTY. TYPE; Soakage Pit Q' FY. Bath Tub Drinking Fountain Miscellaneous Repairs Solar Water Heater Bidet Filter Replace Pool Piping Sprinkler Repair Cap - Fixture Fountain Pump and Abandon Sprinkler System Cap - Water Gas - Appliance Pump, Domestic Supply, AC Well Cap - Sewer Gas - Natural Pump, Fire Stand Temporary Toilet Catch Basin Gas - Propane Pump, Re- circulate Temporary Water Closet Clothes Washer Gas Piping Pump, Replace - Pool Urinal Dental Chair Grease Trap Pump, Sprinkler Utility - Sewer Discharge Well Ice Maker Pump, Sump Utility - Water Dishwasher Indirect Wastes Relay Repair Vacuum Pump Disposal Interceptor Roof Inlet . Water Closet:, Domestic Well Laundry Tray Septic Connection Water-Heater .. ' Drainfield, 4" Tile/Res. Lavatory Septic Tank :Water Heater New Drains, Area Meter Set (Gas) Sewer Connection Water Re -pipe Drains, Floor Minimum Fee Shower Water Service Drains, French Miscellaneous Equipment Sink Well, Supply Page 3 PERMIT APPLICATION INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below. RECEIVED AND REVIEWED BY: DATE: < Applicant: RUTH POLLEY if a Owner: POLLEY RUTH - 0 JOB ADDRESS: 935 NE 95 ST 4 0 Miami Shores Village t 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 10/21/2002 Contractor LLOYD NORTH DADE SEPTIC TANK SERVIOt>vdNttactor's Address: 750 NW 107 ST Local Phone: 305 - 754 - 3375 Parcel # 1132060143110 Fees: Description Amount FEE2002 -5874 Building Fee $80.00 FEE2002 -5875 Builder's Bond $300.00 FEE2002 -5876 Notary Fee $5.00 FEE2002 -5915 CCF $1.20 Total Fees: $386.20 Total Fees: $386.20 Total Receipts: $0.00 Permit Status: Approved Permit Expiration: 3/31/2003 Work: REPLACE DRAINFIELD & SEPTIC TANK If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection fee is $50.00, which must be paid in advance before calling for another inspection. Plumbing Permit Permit Number: PL2002 -266 Legal Description: MIAMI SHORES SEC 3 PB 10 -37 LOTS 20 & 21 BLK 76 LOT SIZE 100.0C3 X Construction Value: $2,000.00 Page 1 of 1 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 application 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 responsibility for work done by his agent ervants or employees. INSPECTOR) BY: 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: 6 JIM WAHL & ASSOCIATES INC. 849 NF 9iND ST. MIAMI, FL 33138 I Order of Pay to the 11 Vivt 1 5 ' , -"�S ,✓ COLONIAL BANK. Miami. Florida 24 Hr Colonial Connection 1877- 502 -2265 Drzalw Wtelc P 9'33 For 1:067003 8032 438 ?3411 0 e Le American JIM WAHL & ASSOCIATES INC. 849 NE 92ND ST. MIAMI, FL 33138 Pay to the Order of OClarke American S Date 16 02 IT . L397 pc) cr--) Dollars 8 Date A2 63- 151/670 i ta-e c\C(1--geA ar C C OLOMAL BANK. Miami, Florida 24 Hr Colonial Connection 1-877- 502 -226 For 1 :06700 LSL8 80324 8 no L 3 1399 22 GUARDIANa SAFETY BLUE DEBL 63-151/670 22 $ 300 Dollars 8 T GUARDIAN® SAFETY BLUE DEE STATE OF FLORIDA DEPARTMENT OF HEALT.`i ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ )New System [ ]Existing System [ X ]Repair [ ]Abandonment APPLICANT: Polley, Ruth PROPERTY STREET ADDRESS: 935 NE 95 St Miami FL 33138 LOT: 20 BLOCK: 76 PROPERTY ID #: 11- 3206 - 014 -3110 CENTRAX #: 13 -SC -14389 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 02 -3000- -R ]Holding Tank [ ] Innovative Other ]Temporary ( NA ] AGENT: SR0001343, Crockett Lester SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] (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 A N K D R A I N F I E L D [_ [ [ [ 900 ]Gallons SEPTIC TANK MULTI- CHAMBERED /IN SERIES: [Y ] 0 ]Gallons MULTI- CHAMBERED /IN SERIES: [Y ] 0 ]GALLONS GREASE INTERCEPTOR CAPACITY 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM [ 0 ]SQUARE FEET SYSTEM TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED CONFIGURATION: [ N )TRENCH [ N ] BED LOCATION TO BENCHMARK: Top of Bottom Floor, 10.55' NGVD. ELEVATION OF PROPOSED SYSTEM SITE [ 0.2 ] [ FEET ] BOTTOM OF DRAINFIELD TO BE ( 2.7 ] [ FEET ] FILL REQUIRED:[ 0.0 )INCHES OTHER REMARKS: This permit is not for addition(s). *Replace existing septic tank by a new 900 gl. septic *Install 300 sq.ft. of drainfield. *Invert elevation to be no less than 8.35 *Bottom elevation to be no less than 7.85 T n + APPEC0 , . i:� at•. ; .� , , Aria SPECIFICATIONS BY: Icaza, Carlos APPROVED BY: Icaza, Carlos DATE ISSUED: 10/17/02 DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) [ostds cone_ao16 -1) EXCAVATION REQUIRED: [ 30.0 ] INCHES NGVD. NGVD. TITLE: [ N ]MOUND [ N ] [ N ) [ BELOW BENCHMARK /REFERENCE POINT [ BELOW BENCHMARK /REFERENCE POINT tank with its approved outlet filter. P FED:'.°::; .^ , , 5 ' "'� IN :.:' :•3 NG BOTC�A OF Os=:-,''s': .,_— w:�._ , , TITLE: Engineer I Dade EXPIRATION DATE: 1/15/03 CHD Page 1 of 2 ICANT: Rur jOyt BLOCK: ERTY ID #: //_ i5 1 O /_ O ! 25//t) (Section /Township /Range /Parcel No. or Tax ID Number] 1E COMPLETED BY ENGINEER, HEALTH UNIT /IDE REGISTRATION NUMBER AND SIGN AND 'ERTY SIZE CONFORMS TO SITE UL ESTIMATED SEWAGE FLOW: iORIZED SEWAGE FLOW: 3STRUCTED AREA AVAILABLE: :HMARK /REFERENCE POINT LOCATION: JATION OF PROPOSED SYSTEM SITE IS MINIMUM SETBACK WHICH FACE WATER: A). FT LS: PUBLIC: //- FT LDING FOUNDATIONS: E SUBJECT TO FREQUENT FLOODING: YEAR FLOOD ELEVATION FOR SITE: L PROFILE INFORMATION SITE 1 nsell # /Color Texture 0 5/iAJb ! D 14. 7/2 3/1 A )D G R4 / It / 11 if SDA SOIL SERIES: ( %?AJJLraAl) SERVED WATER TABLE: /U•A• INCHES [ABOVE / BELOW EXISTI.M GRADE. PIMATED WET SEASON WATER TABLE ELEVATIO . aF4).- INCHES ( ABOVE GH WATER TABLE VEGETATION: ( ] YES (I NO MOTTLINv: OYES [ DEPTH OF EXCAVATION :30 IL TEXTURE /LOADING RATE FOR SYSTEM SIZING: AINFIELD CONFIGURATION: [ ] TRENCH ( BED MARKS /ADDITIONAL CRITERIA: TE EVALUATED BY: STATE OF FLORIDA • j DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS Fora SUBDIVISION: rip 0 / /07?es �CC D » o CAN BE MAINTAINED FROM THE -I DITCHES/SWALES: _LIMITED USE: /)-,• FT FT PROPERTY LINES: [ ] YES Depth O to to /0" /Of' to to to to to to to 7 � // 14015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used) ock Number: 5744- 003 - 4015 -1) EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. YES [ ] NO NET USABLE AREA AVAILABLE: .35- ACRES GALLONS PER DAY SIDENCES -TABLE / OTHER -TABLE 2] GALLONS PER DAY (1 GPD /ACRE OR 2500 GPD ACRE] SQFT UNOBSTRUCTED AREA REQUIRED: SQFT NO AGENT: FT] [ABO PERMIT # sa 3/0o/e— L L o vD it) 0PTL SLP /G PROPOSED SYSTEM TO THE FOLLOWING FEATURES: A)./7- FT NORMALLY WET? [ ] YES A ] NO PRIVATE: ∎ A FT NON- POTABLE: VC FT J FT POTABLE WATER LINES: /fl FT 10 YEAR FLOODING? [ ] YES ■NO /.i:I'�1l• GVD NGVD SITE ELEVATION: SOIL PROFILE INFORMATION SITE 2 /• D TYPE: Munsell # /Color Texture )`1 • • /1) `/2 3%/ In '/P 7/? 5/14/ 5/-M)D Depth 0/ to to /O" to to to if / to !� /I to to to 7, /1 USDA SOIL SERIES: LA PERCHED / APPARENT] EXISTING GRADE. NO DEPTH: 1VJ2 • INCHES REFERENCE POINT INCHES ( ] OTHER (SPECIFY) DATE: /1)-4 1) � Page 3 of '3 Scale: Each block represents 10 feet and 1 inch = 40 feet. / STATE OF FLORIDA • DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number " �% ALE q5TH 5, cET DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used) (Stock Number: 5744 -002 - 4015 -6) PART II - SITEPLAN Date i ,Z GJ #UL ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT ice County Health Department Page 2 of 4 Notes: A .5P, iCC 017 fA)r/& L i/ 1 eV6'AJI9L Doc' ?Y / ti % ✓/' `' �l / ijR ' UL . r`/Y e-IL /x OVE7L®i42 ,�. z T y c 7;C 7;qfCie COAJCZZ-TE % / % / o t/ 0/ ,/ . -1 70 7 - Z 3- 4-`Ptr . $5 I L'' Q . 7k/ c:. , / /AM , � ! 1, , 55' Site Plan submitted y: ' \s2 L C'- ` 'I,�-' Plan A r ved ( F - -t� t Approved PP I By