1245 NE 96 St (4)Date
Legal Description
Owner/Lessee / Tenant
Owner's Address
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address t'a yr /" t - %-SiL Tax Folio
Historically Designated: Yes No
Contracting Co. $' ef c p..3
Qualifier
State #
Architect/Engineer
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING: MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIP'T'ION P� 1 .// /,?'
Square Ft Estimated Cost (value) 1 S ®e) • 0 6
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 AN 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
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Notary as to Owner and/or Condo President Date
My Commission Expires:.
FEES: PERMIT
RADON
/ /J
Grp z 4/4
Municipal #
STEPHEN E COCKING
State of Florida
My Comm. Exp: 08/04/0
Comma: CC669180
APPROVED:
Zoning Building
Mechanical Plumbing
Master Permit # 406 6,5
Phone �,� ( 1 0
Address / 79c A !J.
ss# 4 J/' 7 ' S,
Competency #
Address
Address
Address
Si
Ins. Co.
Alrfr
/1
e o Co c or or Owner- Builder
-," r f £ i ' .t * C7rARYSEAI
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/ 11.v
/4
Date
/b`
Notary
ettStde. BeHaW:t ". •
EgpsitVPSION NO. CC714 i∎!3
y MYC(' \1 rc'•a" < ,,
6
C.C.F. 1 /.I U NOTARY s BOND .3 0
Electrical
2e)
TOTAL DUE
G
Date
Engineering
COTRUCTION PERMIT FO
[41 New System [fl Existing System [f' Holding Tank [r 3 Temporary /Experimental
[ •v] Repair [ 0 - bandonment [ i'}» Other(Specify)
APPLICANT:
AGENT:
PROPERTY STREET ADDRESS: 7 /
LOT: BLOCK: h/ SUBDIVISION: 1 .
PROPERTY ID #: „1J [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
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.
SYSTEM DESIGN AND SPECIFICATIONS
T [r).?)] GALLONS / GPD] SEPTIC /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:('']
A [ ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
SQUARE FEET EET PRIMARY DRAINFIELD SYSTEM
R [ FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [ ] TRENCH [ 8-.} BED
F LOCATION OF BENCHMARK: //. i /not.- C 41 r I, r r Ji, :k, rm _ �— Y )
I ELEVATION OF PROPOSED SYSTEM SITE [7",..S [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 2 _ ] [IN S /FT] [ABOVE? BELOW] BENCHMARK FERENCE POINT
L -
D [566) ]
0
T
H
E
R
D FILL REQUIRED: [
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
] INCHES EXCAVATION REQUIRED: [ ) INCHES
APPLICANT
TITLE:
TITLE:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4016-0)
PERMIT #
DATE PAID �o
FEE PAID $
RECEIPT #
EXPIRATION DATE:
CPHU
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOR Check i jpe of permit, if "Other" specify type in blank.
APPLICANT: Pr.pert, owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Prnp_riy aw;;ar's ietsiiy authuri /ed representative.
MA[LING ADDRESS: P.O. hox or ::treat r uiih g address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 ;.. r iu .•L;r; :b.■ tar propel (CPI-111 :ray require pr.,pe.rt; appraiser t i ,# or sec tion /towns rip /range /p; del number)
SYSTEM DESIGN AND
SPEC1FiCATIONSt
TANK Minimum specifications fiom Chapter IOD-6, FAC.
DRAIN FIELD. 1ir.icn' :n: spe:ilications faun Chapter 1CL) •f, FAC.
or. ER: Ut::. - i ,uu, st :..h n. o perating permit requircrner.:s, i i ' -v flume flush toilets, variance provisos.
SPLCIF1Ca11ONS BY: Nom: ... i w:.i, : ;ai r !ug sp ,; ,..s.a; if ue.igneu a registered engineer must he sealed.
f :P ?R
) BY: _ ownty f-'..t.i:: ;[calm Unit (CHILI) pc-tonne: reviewing 3:13 approving permit.
DATE ISSUED Date fermi: is ' <s,u ! h CPHU
EXPIR,S.TION DATE: Ode ea fro.,1 ,late is ..d it the . \ st::rn h ra r: i in, ,..,.i.::9. PL.rmita fur syq,,n repairs h:'cosre yoiil 90 days from the date
r
Lct
•
1
1
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes: /05o
Site Plan submitted by:
Plan Approved
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
i
IL 5,14 /L
f %# &L i
ALL CHANGESMUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744002. 4015 -61_
PART II - SITE PLAN
SIGNATURE
Not Approved
1
tte; 41.4
treia , -��d
` TITLES
r
Date r <. ' %?r
ilr County Public Unit
Page 2 of 3