685 NE 97 St (7)�, ! PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date *D I �C�Job Address CJ C1 D ) A/ 13 ) 1 <S1 Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant k 1 / I I Yt WL - p G k Master Permit # 937) 7
Owner's Address 9 t 5 \ E • 9 ( St Phone 'S V5
Contracting Co. W L, \ LIG E N Address
SS# - Phone (C" '--- T
Qualifier o
S t a t e # c 1 5 5 7 9.3 Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION . <- l LC. l C 1 k el e _ V i �� i �. r Ql v —
Square Ft. Estimated Cost (value) ) D D ,- vy
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 stated.
6.,. ,.,,,,,,,,, j,,,,,, ,f„,,,,(,._____ /2 ___,. _g
Signature of owner and/or Condo President ate
a / OO - - 3 (0- i/ 1 7 2 df C /. ape
otary as t • ;IFV all • ri4!!►• .iA AAA?' • , .. • erit Date
My Commiss oiciNYMINALIC STATE OF FLORIDA
CO1`lMLSSION NO. CC714103
MY COMMISSION EXP.
FEES: PERMIT g.5 v � RADON
APPROVED:
Zoning Building
Mechanical Plumbing
C.C.F.
Vel C 7-11 fr i4 1 );:t4hrt
a s 7? • n OF FLORIDA
Pire6MMISSION NO. CC7ll4103
Sigma
N• :� as to Co
My Commission
Electrical
2 0 NOTARY BOND 300 r
Builder . / & te
Date
TOTAL DUE - 7 20
Engineering
LOT:
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
SPECIFICATIONS "BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA • J b L f J I
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK: SUBDIVISION:
[OR TAX ID NUMBER]
SYSTEM p
] STANDARD [ FILLED [ A MOUND
j] TRENCH [ ] BED [ /]
HRS-H Form 4016, Mar 92 (Obsoletes previous e•itions which may not be used)
(Stock Number: 5744- 001 - 4016 -0)
QPPdOMMIT
TITLE:
PERMIT # 96
DATE PAID 3 -- �' ?
FEE PAID $
RECEIPT # 7� r2 S.
C0 STRUCTION PERMIT FOR:
[M] New System [J] Existing System [] Holding Tank [ G4 Temporary /Experimental
) Repair [AJ] Abandonment [ ,J) Other(Specify)
APPLICANT: A � AGENT:
a Q.. /4
PROPERTY STREET ADDRESS:
a h
PROPERTY ID #: �1 [SECTION /TOWNSHIP /RANGE /PARCEL 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
Ed
T [ ® ® ] ` A�LL O S / GPD] - 'TIC T /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 [ a 0 ®] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
1
TITLE: , �� ,4
EXPIRATION DATE:
[A
I ELEVATION OF PROPOSED SYSTEM SITE ( 0 i] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ at ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ £J/ flfINCHES EXCAVATION REQUIRED: [ ] INCHES
ONSTA -oe 9A' OP L'
O UNDER BOTTOM 8r
T S! RFAIHNIt1°?K
H THIS PERMIT IS MOT FOR AO,',)!`!'c( N(yy
E
INVERT ELEVATION '^) �r `l ; j a-+ sit.
R 301110I!{J OF DRAINFIELD ELEM
kiti
CPHU
Page 1 of 2
'„ NS1 YUCTIONS:
'PERMIT NUMBER: ]Permit tracking number cosigned by CPHU.
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
PROPe RTY IDfl: 27 character id number for property. (CPHU may require property appraiser ID 11 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 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.