261 NE 97 St (3)Date ' U - - q c 1 Job Address 6 ( N 5 1— Tax Folio
Legal Description H i Designated: Yes
Owner/Lessee / Tenant .1(5S el) k I 1 Z. (,a t..
Owner's Address 0- (e 1 Ar E- 9 S "T'
WORK DESCRIPTION
Square Ft.
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that a
construction and zo g. Furthermore, I authorize the above -named contractor to do
Signature LOK14
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Notary as to
My Commission !E l . °, van 7.°
i �w
FEES: PERMIT 6 RADON
APPROVED:
Zoning
Mechanical Plumbing
9
Address
C.C.F. I NOTARY
Master Permit # XSZ3 2
No
Phone 3 o 5 - ^ 7v f 1
Contracting Co. M 1‹.-, a 1 S
Qualifier ,c-11 io-r) . CcG/a& ss# - Phone 4 7., 4 / 1 trj - j
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
/elle te _, (et -
Estimated Cost (value) 2 a,.ro `.,•■
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 OF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER
OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
will be done in complian with all applicable laws regulating
ontractor o 'i : uilder
tary as to Contract or Owner- Builder
My Cotunp x 1m clA / NOTARYSEAL
* < e iJt *�Q11 1
'3 : ? y,< Q F. cc7pI 1
%Jr 1F � �4 MY CO 200
BOND 366
'cable). I certify that all work
required for ELECTRICAL
Building Electrical
Structural Engineer
ate
Date
CONSTRUCTION PERMIT FOR:
[ ] New System [ .] "Existing System [ _]Holding Tank [ ,] .Temporary /Experimental
[ ] Repair [ , %] Abandonment [ ] Other(Specify)
APPLICANT:
?ROPERTY STREET ADDRESS:
LOT: BLOCK:
PROPERTY ID #:
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 [', - / ] tGALLONS,/ GPD] SEPTIC TANK /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: [ ]
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
]
SQUARE
TYPE SYSTEM:
CONFIGURATION:
[
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
FEET PRIMARY DRAINFIELD SYSTEM`;
FEET SYSTEM
[ ] STANDARD [ ] FILLED
[ ] TRENCH [ %1 BED
LOCATION OF BENCHMARK: �
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED: [ ] INCHES
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
AGENT:
SUBDIVISION:
a
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4016 - 0)
[
[
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
] MOUND [ ]
]
']'[INCHES/FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
J'[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
TITLE: - CPHU
EXPIRATION DATE:
Page 1 of 2
iX
2 XV; • 37..CV: _7 • •
• 7
Scale: Each block represents 10 feet and 1 inch = 40 feet.
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITEPLAN
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744 - 002 -4015 -6)
Not Approved
Site Plan submitted by:
Plan Approved
By County Health Department
Date
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 4