390 NE 97 St (3)Date /4 % 17
Legal Description
Owner/Lessee / Tenant
Owner's Address
1;
Contracting Co. j7 y 60 lCi�
Qualifier (/
State # Municipal # F
Architect/Engineer
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION , L -, , a', 1 S
Square Ft.
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 cone in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
otary as to O
My Commission xpires:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 37f, , `�, /ST, Tax Folio
r and/or Condo President. Date
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APPROVED:
Zoning
Mechanical Plumbing
Building
C.C.F.
Historically Designated: Yes No
Address
Competency #
Address
Address
Address
Estimated Cost (value
Master Permit # C5 s(/ :cm : j
4eij
v6 <W_ , , t t (�(���. ( Jl
SS# / Phone
Ins. Co.
Signature of Contractor or Owner - Builder Date
.if/ f iy t
( I
Notary as to Contractor or Owner - Builder
My Commission Expires:
4 ,0V 1 P45, Wm. MAKK WOODARD
COMMISSION # CC 625712
EXPIRES MAR 2, 2001
BONDED TWILL
OF F\. ATLANTIC BONDING CO., INC.
,
1111
Electrical
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NOTARY BOND (I
G 6 ,ar�
D ate
Engineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System
[ ] Repair ( ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT: BLOCK: SUBDIVISION:
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. DEPARTMENT OF HEALTH 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 / GPDk "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 KATE [ ] 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 [; t.. ] (INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 1-1 [ABO /sfLOW] BENCHMARK /REFERENCE POIN
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ .% ] INCHES
0
T
H
E
R
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE: CHD
DATE ISSUED: EXPIRATION DATE:
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1) which may be used)
(Stock Number: 5744 - 001 - 4016 -0)
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 10D -6, FAC
] Holding Tank [ ] Temporary /Experimental
] Other(Specify)
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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 mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID #: 27 character ID number for property. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
DRAINFIELD:
OTHER:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXPIRATION DATE:
Minimum specifications from Chapter 10D -6, FAC.
Minimum specifications from Chapter 10D -6, FAC.
Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
Name of individual providing specifications. If designed by a registered engineer must be sealed.
County Health Department personnel reviewing and approving permit.
Date permit is issued by County Health Department.
If
One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.