PLUMBINGBUILD G
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical
Owner's Name (Fee Simple Titleholder) Phone #
Owner's : ddress
City ' 1L State Zip
Tenant/Lessee Name ¢}' Phone #
Job Address (where the work is being done) 4 JL T / 5
City Miami Shores Village County Miami-Dade Zip 33 / 3
NO l/
Is Building Historically Designated YES
Contractor's Company Name o S ` G
Contracto 's Address /O, p
A ,ti C ► _
City ! dd / or,
State
Qualifier
Architect/Engineer's Name (if applicable)
$ Value of Work For this Permit
Type of Work: ❑Addition
Describe Work:
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
DAlteration
❑New
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $ 4 • r r] ' 0 G6 ,P9
Permit No. VI G Q00q - `fig
Master Permit No.
hone #
Zip
Phone #
Square Footage Of Work: 3
❑ Rep
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Mechanical Roofing
,(5 P
316 l
❑ Demolition
Submittal Fee $ Permit Fee $ 1 15 -00 CCF $ 1 • ISO CO /CC
Notary $ 5.O O Training/Education Fee $ . GC) Technology Fee $ LI . '3
Scanning $ - 6 • 06 Radon $ Zoning Bond $ s• 00
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
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. I 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: 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.
"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.
Signature
Owner or Agent
The foregoin anent was acknowledged before me this 1?
day of 1- rJ , 20 3 b )h fl F ,D l I IO n ,
who is personally known to or who has produce f z J1
As identification and who did take an oath.
argas
NOTARY LIC:
Sign:
Print:
My Commission Expires:
**************************************•********* *** ** *** ************* ****** ** * Y[M
* **MW I[�C]C'*** ** *****
"
, os AtartiC Bonding Co., tic
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * **
APPLICATION APPROVED BY:
Chc 12/15/03
Zip
`V. Commission #DD231984 NOTARY PUBL
ul , 2007
Sign:
Co �� ctor
The foregoing instrument was acknowledged before me this ).
,20a,by -f-QY RariI
day of
who is personally known to me or who has produced
as identification and who did take an oath.
Print:
My Commission
ZISA
"M I #DD '
*= Expires: Jul 13, 2007
as
************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
' Engineer
Zoning
CONSTRUCTION PERMIT FOR
[ ] New System [�] Existing System
[ f] Repair [fJ] Abandonment
APPLICANT: 0 (A 4. 1� 1 l ! U
PROPERTY ADDRESS: C 7 S
LOT: BLOCK:
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
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APPROVED BY:
DATE ISSUED: at . 5/01
DH 4016, 12/99 (Page 1) (Previous Editions May Be Used)
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer/Contractor
pt. 4: Building Department
[ 3O O ]
[ -- ]
SQUARE
SQUARE
TYPE SYSTEM:
CONFIGURATION:
LOCATION OF BENCHMARK:
S. TE OF FLORIDA _ -�
DEI "TMENT OF HEALTH
ONSI'.' SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
FEET PRIMARY
FEET,
[ STANARD
[ ] TRENCH
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED: [P ] INCHES
is
PERMIT NO. 6 'y ,-
DATE PAID:
FEE PAID:
RECEIPT #: 4L/1Z6360 /
13- 5c- r - 390
[N] Holding Tank [■] Innovative
[IJ] Temporary [ ]
Id , G. s t -, i .t-t;, s/ o e S F
P /A SUBDIVISION: ' l ” e ( -Ii i k e,
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
I (- X20 - 6020
- t>31 3e
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SPECIFICATIONS BY 13o
r. E A� TI u r, t . l(`�1
PROPO ABSORI
' BED OR
TITLE
,P,J� tRxa.w
EXPIRATION DATE:
[9 0 0] GALLONS _ / GPD SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI - CHAMBERED /IN- SERIES [ X]
[ _ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
[ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
[ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS ® [ ] DOSES PER 24 HRS # PUMPS [ ]
DRAINFIELD SYSTEM
SYSTEM
[ FILLED [ ] MOUND [ ] _
[ 4 BED [ ]
[i7 , (] [INCHES /FT] [ABOVE /BELOW] BENCHMARK/REFERENCE POINT
[(,7 [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ Lk Z ] INCHES
J o 4 / INST.�? 2 rip CT .T ^r' T] 5�' LIMITED SOS
J C C� C tJh � � L 1 p [ S a ) ] T _ ( ,t � jJN lPR BO 1`TOM OF Da INPI i T)
U R Cuts'? 0 t') ta Cc t C l c�
All\ /r 411�J l tva t l a:, , _ _ t rt ' vA• • 'Mar Z 0 r
R`L 1 .,n. :,.. _,- ,_ - -�. [ r`i 7 n
A A 1.1 BE
: ::JRAN THE
TRENCCH
s 1 `.1 a -.LCHD
Page l of 3
MUM ICTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT 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. (CHD may require property appraiser ID # or section /township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 64E-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 (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
o
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER 1IT ,'.��
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Scale: Each block represents 5 feet and 1 inch = 50,feet.
By
OH 4015, 1698 (Rspiaces HRS.H Fpm 4015 which may be used)
(Saadi ant.: 5744. 002.40154
PART II - SITE,PLAN
r
Permit Application Number
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Site Plan submitted by: � - — goAdr, Title /
Plan Approved Npt Approved = Date .3
E. "`� - ' �° " �' County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
-4
Page 2 of 3
S
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Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 2/18/2004
Contractor BOBS SEPTIC & DRAIN INC
Local Phone: 305 - 558 -5818
Parcel # 1132060350020
Nu
Applicant: JOHN DILLON
Owner: DILLON JOHN
JOB ADDRESS: 975 NE 94 ST
Permit Number: PL20044
Contractor's Address: 1020 NE 130 ST
Legal Description: MAGEE & HAWKINS SUB PB 51 -5 LOT 2 LOT SIZE 15361 SQUARE FEET OR
Fees: Description Amount
FEE2004 -1631 Building Fee $175.00
FEE2004 -1632 CCF $1.80
FEE2004 -1633 Notary Fee $5.00
FEE2004 -1634 Training and Education Fee $0.60
FEE2004 -1635 Technology Fee $4.37
FEE2004 -1636 Scanning Fee $3.00
FEE2004 -1637 Builders Bond $300.00
Total Fees: $489.77
Total Fees: $489.77
Total Receipts: $489.77
Permit Status: APPROVED Permit Expiration: 8/15/2004 Construction Value: $2,500.00
Work: REPLACE LEAKING SEPTIC TANK AND INSTALL 300 DRAINFIELD
er
it
Page 1 of 1
Signed: (INSPECTOR)
Pe' 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
Building Inspection Request
Si)
Type Insp'n scope T jca I
Permit No. P ��UIJ`7�`Iu
Name D 1 I
Address ` g s wt. r u S)-
Date
Compan & b
Phone #
43/c
Inspection Date
Approved
Correction
Re- Insp'n Fee
❑