357 NE 97 St (6)Date 'i ( i.) lc, 1 / Job Address 7 Tax Folio
Legal Description
Owner / Lessee / Tenant
Owner's Address
Contracting Co. C '_�
WORK DESCRIPTION 1 ),.t' -'tlti c �
Square Ft.
Notar
My C
** *
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
2 0
iri
�i - f s fe
Si nature of owner and /or Condo President
Date:
•
',p% BEFelt1eSN�TARY SEAL
I
0 - ,/i SANDRA M MONTIEL
4,4 ► * COMMISSION NUMBER
a ' : C r CC421261
177 ' Q - Ia COMMISSION •EXf.
e OF F\P AUG. 17 1998
FEES: PERMIT Wit- `'" RADON
Master Permit # ",�'�E`'
Qualifier `?�`t C )l = ( Gc�sL. C SS# ( Phone (( / '
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING) MECHANICAL ROOFING PAVING PENCE SIGN
%Z7 ±�.rir � / //' /• !/ ° /Y "�/��;'-
//-2-71
as to Owner an. • ±'• President
* *
Zoning Building
Mechanical Plumbing
Address cl L� �;\,;
Estimated Cost(value)
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 laws regulating construction and zoning. Furthermore, I
authorize the above -named contractor to do the work ated. 2
Signat
Date:
re of Contractor or Owner- Builder
,t \l Cit( // ���'� /
1!/i -, ,_ >. ` f 1 ' ) ' ' %r%/ ,/ - e--" <' //�/ .''. //
Notary as Owner Builder
My Co =1P SEAL
∎ SANDRA M
* * * i Q �OMMISSIwN MBAR * **
�...
ef t �Q. MY COM SS 0 A
61 � xp
....%�
FI AU U 1 �Q 9� D E �
C.C.F.
Fire Other
Phone
Electrical
Engineering
CONSTRUCTION PERMIT FOR:
t ] New System t" 1 Existing System
[`' ] Repair [ ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
0
T
H
E
R
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
L
D FILL REQUIRED: [ ] INCHES
BLOCK: SUBDIVISION:
] Holding Tank
] Other(Specify)
AGENT:
[ 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 [' ], [GALLONS / 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 [, ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED [
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
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 #
] Temporary /Experimental
TITLE: CPHU
EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION F'OR: Chec?: type of permit, if °Other° specify type in blank.
APPLICAN: Property owner's full name.
TELEPHONE: Teleplone number for applicant or agent.
AGENT: Prop:rty owner's legally authorized representative.
MAILING ADDRESS: P.O. :)ox or street mailing address for applicant or agent.
LOT, 3LOCIL, SUBDIVISION or
?ROB? RTY IDU: 27 chlracter id number for property. (C..' 'J may requir: property appraiser Iti 0 or sectionhownshie /rcnge /parcel ^_umber)
SYSTEM DESIGN AND
SPECIFICATIONS:
LANK: Minimum specifications from Chapter IOD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -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: Coun:y Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
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.
APPLICANT:
LOT:
PROPERTY ID #:
SOIL PROFILE INFORMATION SITE 1
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
PROPERTY SIZE CONFORMS TO SITE PLAN: [`']
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
AGENT:
BLOCK: SUBDIVISION:
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: �<,. FT DITCHES /SWALES: FT NORMALLY WET? [ ] YES ( ] NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON - POTABLE: FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: _, FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
Munsell # /Color Texture Depth
USDA SOIL SERIES:
to
to
to
to
to
to
to
to
to
.
SITE EVALUATED BY:
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015-1)
[Section /Township /Range /Parcel No. or Tax ID Number]
YES [ ] NO NET USABLE AREA AVAILABLE:
ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
SOIL PROFILE INFORMATION SITE 2
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
PERMIT #
10 YEAR FLOODING? [ ] YES [ ] NO
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [.] NO MOTTLING: [ ] YES [] NO DEPTH: INCHES
DEPTH OF EXCAVATION: INCHES
DATE:
Page 3 of 3
INSTRUCTIONS:
PERMIT 0: Permit tracking number assigned by CPI-1U.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized reprecentative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID/I: 27 character number for property. (property appraiser
PROP.3?3TY SIZE:
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MIN MUM SETBACKS:
lib
1/ or cection/township /range /parcel number)
Check if property size at site conforms to aubmitted cite plan. Record net usable area available - lot area exclusive of
all paved rreas Lad prepared road beds within public right -of -way ar eacementa and exclusive of atrecma, !Elmo,
normally wet drainage ditches, marshes, or other such bodies of water.
Record the estimated sews jc flow for the establishment from Table 1 (residences) or Table 2 (non- _ecidential), Cltcpte=
10D -6, FAC. Record the authorized cewage flow for the 1ct bacad on no usable area and water supply (1503 gal:one
per :lay per ccae for private water cuppliaa and 2303 gpd per acre for public water supplies). If authorized cewcgc flow
does not equal or exceed the estimated =wage flow, the application mur2 be denied.
Record the square feet of unobstructed arec available and the c. _:nu,:2 re,uirec. Uaoba:sacted area moot be et !scat 2
times as large as the drainfield absorption n:rea end et leant 75 percent of the unobstructed exec must meet minimum
setbacks in Chapter 10D -6, :SAC. The unobstructed area mutt be comiguoua to the drainfield.
BENCHMARK _ NFORMATION: Record the location of the benchmark. If using a surveyor's benchmark accrd she actual elevation. l.oco:ai the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements mutt be recorded or "NA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot must br measured. The location
of any public drinking well within 203 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year fond elevation for cite cre
actual site elevation.
SOX: ;?RO9C'.E INFORMATION: Two soil profiles within the proposed abcorption area to a minimum depth of 6 feet or refusal are required. ,roil
identification will use USDA Soil Classification methodology (Murrell colors and USDA toil textures). Refusals must
be clearly documented. Provide USDA soil series if available, record "UN!(" if the series cannot be determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mar's "perched" or "apparent' as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA coil mapo, and
historical information. Indicate if there is Leigh water table vegetation present. Indicate if mottling io present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[4] SHOT: H.I. H.I. H.1.
H.1. [ SHOT [ -] SHOT [ -] SHOT
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 5 feet and 1 inch = 50 feet.
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4015-6)
PART 1I - SITE PLAN
Notes:
,
Site Plan submitted by
SIGNATURE TITLE
Plan Approved , „, Not Approved Date
By ;. , "Jr _ .
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Page 2 of
APPLICATION FOR:
[ '] New System [; Existing System (, ] Holding Tank [ ] Temporary /Experimental
[< ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
AGENT:
MAILING ADDRESS:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT:
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK:
. "] Garbage Grinders /Disposals
SUBDIVISION:
Bedrooms Area Sqft Served
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TELEPHONE:
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
ACRES [Sqft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
] RESIDENTIAL [, ] COMMERCIAL
No. of Building # Persons Business Activity
For Commercial Only
[. -] Spas /Hot Tubs ['>] Floor /Equipment Drains
] Ultra -low Volume Flush Toilets [. -] Other (Specify)
APPLICANT'S SIGNATURE: DATE:
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4015-1)
Page 1 of 3
INSTRUCTIONS:
APPLICATION 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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
SUBDIVISION:
PROPERTY SIZE:
WATER SUPPLY: Cheek private or public.
:?ROPERTY ADDRESS: Stre :t address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT:
NO. BEDROOMS:
BUILDING AREA:
I/ PERSONS:
BUSINESS ACTIV1I'Y:
FIXTURES:
SCNAT U;,2E:
A 7u'AC} M ENTS:
Mart each listed fixture with number installed or 'NA" if not applicable.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
legal description or deed must be attached.
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lam originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID//: 27 caaracter number for property. (CPHU may require property appraiser ID Il or cection/township /range /parcel number.
Net usable area of property in acres' (square footage divided by 63,560 square feet) exclusive of all paved areas' and prepared road
beds within public rights -of way or easements and exclusive of atreem ra, lases', normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncomoected road rights-of-way end eaaementa with no subsurface obatructioan
may be included in calculating lot area.
List type of establishment from ?able E, Chapter 10D-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
Count all rooms designed primarily for sleeping end those areas expected to routinely provide sleeping accommodations for
occupants.
F otal square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screamed patios or decks. Based on outside measurements for each story of structure.
Number of persons residing, using, or working in establishment. For residential establishment, 2 persona per bedroom are
assumed.
For commercial applications only. List nurt:ber of employees, chills, and hours of operation, or other information required by
Table II, Chapter 1OD -6, FAC.
Signature of applicant or agent. Date application one day submitted to the CPI-IU with appropriate fees and attachments.
A sire plan drawn to scale, stowing boundaries with dimensions, locations of residences or buildings, swimming pools, recorder;
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
featares, filled areas, obstructed areas, and cur ace water. !Location of wells, one! sewage disposal ayaierna, surface waters, and
othe • pertinent facilities o; 1aatures on adjacent prope ty, of the fecturea are with 75 feet of the applicant 102. 1.4:cation of any
pubic well within 200 feet of lot.
For .- esidences, a floor plan (residences) showing number of bedrooms and building area of each unit. Fox nonresidential
estallishrnents, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of waatewater.
Ape iicason is hereby ralwi{.: for the approval of the detailed statement of the pans 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 during progress of work.
Owner's Name and Address
Registered Architect and /or En inee
New Building
Size Septic Tank_-----
Feet of Drain TileZ,!
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Employing Plumber's Name__r jj _ � ��--� No.�P�! Street
Subdivision_
— Block-
Street and Number where work is to be performed —No 3 2 X V Street X p
State work to be performed and purpose of building (By Floors
Remodeling__ - Addition_______ Repairs No. of Stories.
Location and Legal Description Lot _____.._____._.__.__- _-_- ----.-
No._ tf.2 ___./ __ Street. - __ --
Type of Tank..
t. Feet of Tank or Drain Field from Well
Nature of Water Sup;Iy: City— Well._----_-__ ____ ____ of Soakage Pit
� = ��
Amount of Permit $___ -- — 4a---- _._------- -___ -- _ - --- (Signed)_ t . G- :` ELF '
( Signed
Date °/ _ -6 e-
Capacity Gals.
Pluming Inspector.
The undersigned applicant for this building permit does hereby certify thst he understands and accepts his obligations as an employer of labor
Winder the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed 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
required 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.
4 00 Plumber.
S FATE OF FLORIDA, I sa.
COUNTY OF DADE.
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.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
TUBS
SHOWERf
LAVA.
TORIES
81NK5
SLOP
81NKS
LAUNDRY
Tulsa
U RINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FI %TURES
C OMM
LIGT
- --
-
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM•G
POOL
CONTR.
LIST
CNSCK
Ape iicason is hereby ralwi{.: for the approval of the detailed statement of the pans 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 during progress of work.
Owner's Name and Address
Registered Architect and /or En inee
New Building
Size Septic Tank_-----
Feet of Drain TileZ,!
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Employing Plumber's Name__r jj _ � ��--� No.�P�! Street
Subdivision_
— Block-
Street and Number where work is to be performed —No 3 2 X V Street X p
State work to be performed and purpose of building (By Floors
Remodeling__ - Addition_______ Repairs No. of Stories.
Location and Legal Description Lot _____.._____._.__.__- _-_- ----.-
No._ tf.2 ___./ __ Street. - __ --
Type of Tank..
t. Feet of Tank or Drain Field from Well
Nature of Water Sup;Iy: City— Well._----_-__ ____ ____ of Soakage Pit
� = ��
Amount of Permit $___ -- — 4a---- _._------- -___ -- _ - --- (Signed)_ t . G- :` ELF '
( Signed
Date °/ _ -6 e-
Capacity Gals.
Pluming Inspector.
The undersigned applicant for this building permit does hereby certify thst he understands and accepts his obligations as an employer of labor
Winder the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed 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
required 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.
4 00 Plumber.
S FATE OF FLORIDA, I sa.
COUNTY OF DADE.
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.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.