10782MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
I1ermit No /Q it z•• Date / 2- - ®�
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the. Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building
Owner's
I'
Employing
Location
during- progress of work.
Name and Address i. / 0 . 1iti ' 4 / ICeAl No street__ vt
egistered Architect and/or Engineer
's Name e t~ a eo to Sri- s air i e p tr,sl No Street i t
41
and Legal Description Lot Block Subdivision
Street and Number where work is to be performed —No. 5 _ Street
State work to be performed and purpose of building (By Floors) if w N 5 r 1 au / ('/e a S y .f !e,+"1
New Building Remodeling Addition Repairs No. of Stories
.CLOSETS
BATH
Tulle
SHOWERS
LAVA-
`TORIES
SINKS
-SLOP
SINKS
'LAUNDRY
TUBS
URINALS.
CATCH
BASIN
FLOOR
-DRAIN -
DRINKING
FOUNT'NS
-
-,
-
TOTAL
FIXTURES
LIST
CHECK
SEPTIC
TANK -
SEWER
CONN. -
- DRAIN
FIELD.'
SOAKAGE
PIT
GREASE
TRAP
. SOLAR
HEATER
DEEP
. WELL
SPRKLR.
SYSTEM
SWIM'Ci
POOL.
1.
CON TR.
LIST
CHECK
-
-
--
e
Size Septic Tank Type of Tank -
Feet of Drain Tile Tim' Feet of Tank or Drain Field from Well"
Mature of Water Supply: City—Well. W 1 p Size of Soakage Pity
Amount of Permit (Signed)
Ph nibing Inspector.
Capacity Gals
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as airs employer of labor
cinder the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplenient, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub- contractors employed by hiul in the work to be
ormed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
uired by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
(signed) ) nN le
r ®u/ p Co
Master Plumber.
f
oTATE OF FLORIDA, i �.
COUNTY OF DADE. s
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, 'personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same; and that all facts
therein by him stated are true.
I ,
My Commission Expires Notary Public, State of Florida
1`'
NOTE: 'A re- inspection' fee of $1.00 will be made when such re- inspection is made necessary by improper notice for j#ispecUon, or faulty
materials and /or workmanship.