485 NE 96 St (4)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
D a t e / / - - J o b A d d r e s s 47 e, e Tax Folio /) - 3 0 to • • -
Legal Description Historically Designated: Yes No
Owner/Lossee / Tenant r
Owner's Address y P,- y 6
Contracting Co. ^ _r a 6' ; r 4. 'Ps Address ) 3 0 .. 7 y
Qualifier ) a 19, a / is SS# - / Phone , OS - / /C - .It
Uk h < 113) 0 Aj4d
State # O C c. s 7- Municipal # ® (,..573 — Y Competency # D _ J - , Ins. Co. (4 1 .1
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL(PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
a
L7raq,w Ir� 2el t't.
WORK DESCRIPTION
Square Ft. Estimated Cost (value) 9 A, oco '00
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 zonin;. urthermore, I authorize the above -named contractor to do the work stated.
gnature of o / and/or Condo President Date Signature of C
ary and/o?C`. + • :�° j. Da
Not
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APPROVED:
Zoning Building
Mechanical Plumbing
FEES: PERMIT c(/ RADON C.C.F. 1 /
NOTARY
Master Permit # P ra i p £-
Phone 30,5— - yo- LI
tractor or Owner- Builder
q ,5/ z-eika
Notary to Contr actor or . li er - Date
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My Commission E Tres: C7 ISy ,may, If 7
STAIIYYfJ3L;C FL a a it
Electrical
ate
BOND 3e
TOTAL DU F3S S6
Engineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT: AGENT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
BLOCK: SUBDIVISION:
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 / 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 [ ]
Z CONFIGURATION: [ ] TRENCH [ ) BED [
N
F LOCATION OF BENCHMARK:
1 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
L
D FILL REQUIRED: [ ] INCHES
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
DH 4016, 10196 (Replaces HRS -H Form 4016 [page 11 which may be used)
(Stock Number: 5744- 001 - 4016 -0)
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
EXCAVATION REQUIRED: [ ] INCHES
0
T
H
E
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE: CHD
DATE ISSUED: EXPIRATION DATE:
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: Minimum specifications from Chapter 10D -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: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Permit Application Number
CH 4015. 10196 (Replaces HRS-H Form 4015 which may be used)
(Stock NurrCer: 5744.002- 4015 -6)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
PART II - SITE PLAN
Site Plan submitted by
Signature Title
Plan Approved Not Approved Date
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 3
BUILDING
ELECTRICAL
PLUMBING
Owner of
Building K
Architect
Contractor
or Builder
Legal Lot
Description
PERMIT N° 1325
Work to be performed under this Permit ti
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
DATE( 1 194
Contractor's
License No.
Bl.
Subdi-
vision
Address of r J / • q Value of Amt. of t
Building i t C,. j Project Permit
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the
application herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance
with any plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may
be revoked at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition
upon which this permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of
the ordinances and regulations pertaining to the work covered hereby whether shown oq.the plans or drawings or in the statements or specifications and
that he assumes responsibility for work done by his agents, servants or employees. < J i i
Signed: ' - -j By
INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in collCpliance with all ordinances and regula-
tions pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servant or employee.
BY AUTHORITY
BUILDING
ELECTRICAL
PLUMBING
ROOFING
0
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
PERMIT
Owner of
Building
Architect
Contractor
or Builder
Legal Lot
Description Bl
Work to be performed under this Permit
Address of Value of I! Amount of
Building If
Project $ 11 Permit $
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
Signed. INSPECTOR
In consideration of the issuance to me of this permit I. agree to perform the work covered hereunder in compliance with all ordinances aad regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In as
cepting this permit I assume responsibility for all work done by,either, myself, my agent, servant or employee.
N° 5757
DATE I9 --
Contractor's
License No.
Subdi-
vision
BY AUTHORITY