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PLUMBINGA ' 1EkMIT APPLICATION FOR MIAMI SHORES VILLAGE Date �� 00 Job Address "f ( Q ') Tax Folio Legal Description Owner/Lessee / Tenant Cei ,L&)Co C c Owner's Address Contracting Co. Qualifier State # M unici Architect/Engineer Bonding Company Mortgagor � Address Square Ft. Signature of o Notary as to My Comm FEES: PE APPROVED: Zoning Mechanical )to5iu& p Permit Type (circle one): BUILDING ( ELECTRICAL UMBIN ECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION I n�I� 4 I I 11 (\eui d . 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 w . 11 be done in compliance with all applicable laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the wo ted. and/or Condo President ion Expires: ! Vc '-'); - lC ^Cit 12,2901-. • Presiedat r�• RADON Building Plumbing R.23-49 Historically Designated: Yes No SS# __ Phone J35 G`4-- ; (S co Competency # Address Address � \� Estimated Cost (value) 5 % cxD. C7C2 tractor or Owner - Builder Signa / No to My Commis Master Permit # Phone / \ Address 1 P • ■ Electrical C.C.F. 2 ' y' O NOTARY 5 4/79/ Ins. Co. stttttttttttt s: Anthony Louis Cappolino Notary Public, State of Florida a' Commission No. CC 577410 < r - 6 'or Fl.o My Conunission Exp. 09/22/2000 1. 800 - NOTARY • Fla Notary Service! Soutca Co. BOND 300 TOTAL DUE n(1 S — /g -o Structural Engineer • CLOSETS BATH Tuns "" alts LAVA. Toasts SINKS SLOP SINK[ LAUNDRY TUS• URINALS CATC SA FLOOR D DRINKING PiOUNT•N• TOTAL Putty' ES GcNTa. LIST * [ r / ®� CHICK I SEPTIC TANK SEWER CONN. DRAIN SOAKAOI r IaLD PIT G TRAP SOLAR HEATER DEEP WILL SPRKLR. SYSTEM SW IM•O POOL 6 0 0 Co#Ta. LIST O j4 v 9 p R ft I nJ I 01 CHICK Registered Architect and /or Engineer Employing Plumbers Name CA 5 71 N 5 5 $J MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Bkxk Location and Legal Description Lot Street and Number where work is to be performed —No State work to be performed and purpose of building (By Floors ) New Building..__._ _ .- Remodeling— _......_______ Size Septic Tank_._ Type of Tank__ Feet of Drain Tile _Dist. Feet of Tank or Drain Field from Well.. —_.�_ Nature of Water Supply: City—Well. (- L Size of Soakage Pit Amount of Permit $ 11a (Signed )_ (Signed) Subdivision Street '#._..._. Permit No a Application is hereby made for the approval of the detailed statement of the plans 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 specification must be kept at building during progress of work. Owners Name and Address. ► d • b a- 4 y .._.._. No ` o ( Street..! � 17 " ,.. Na ......•• e...�..�.. ••••••110....... $ SSt.IIM._..,,............ .., ....,. • No. of Stories... .... ... i 4 � M Commission Expires Notary Public, State of Florida l umbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5986, Compiled General Laws of Florida Permanent Supplement, and hur 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. STATE OF FLORIDA, } 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 be is the. -�.._ .._...... - -- of the above described construction, that he has carefully read the foregoing application, and that be did sign the same, and that all facts therein by him stated are true. NOTE: A re- inspection fee of $1.00 will be made when snob miaspaotba is soade'saoawry by bnproper notion for baspection, or fealty materials and /ar workmanship. ( i)A f et and Number where work is to be performed -No e work to be performed and purpose of building (By Building Remodeling Amount of Permit $ STATE OF FLORIDA, 1 COUNTY OF DADE. ss. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No 7 9 i. ___ I Date Application is hereby made for the approval of the detailed statement of the plans and specifications here submitted for the building or other structure herein described. This application is mad in compliance and conformity with the Building Ordin ce of Miami Shores Village, Florida, and all provisions of the Laws of the State of Flori , all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, w etherJerein specified or not. A copy of approved plans and specifications must be kept at i Lner's ldin during progress of work __ _ _ Name and Address ' _ _ No._ -_ Street login Plumber's Name g �Q - ? 7 -- -- �eg'stered Architect and /or En i r____ _ pnp g � „Sr � No. I � 4 � 0 Street `_ ation and Legal Description Lot Block Subdivision . ie Septic Tank Type of Tank Capacity Gals i et of Drain Tile Dist. Feet of Tank or Drain Field from Well [ Nature of Water Supply: City —Well Size of Soakage Pit L ...--) 7 f� r (Signe The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labo under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has co plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to e 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, or�. work to be perrforme J under this .permit, as are licensed by Miami Shores Village. ( Signed ) Repairs No. of Stories (/) Plumbi Before me, the undersigned authority, a notary pi blic, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath de oses 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 salve, and that all facts therein by him stated are true. 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 BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT'NS TOTAL FIXTURES i' / / 1 . : K � o� 7� SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL .K. / /P • ( i)A f et and Number where work is to be performed -No e work to be performed and purpose of building (By Building Remodeling Amount of Permit $ STATE OF FLORIDA, 1 COUNTY OF DADE. ss. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No 7 9 i. ___ I Date Application is hereby made for the approval of the detailed statement of the plans and specifications here submitted for the building or other structure herein described. This application is mad in compliance and conformity with the Building Ordin ce of Miami Shores Village, Florida, and all provisions of the Laws of the State of Flori , all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, w etherJerein specified or not. A copy of approved plans and specifications must be kept at i Lner's ldin during progress of work __ _ _ Name and Address ' _ _ No._ -_ Street login Plumber's Name g �Q - ? 7 -- -- �eg'stered Architect and /or En i r____ _ pnp g � „Sr � No. I � 4 � 0 Street `_ ation and Legal Description Lot Block Subdivision . ie Septic Tank Type of Tank Capacity Gals i et of Drain Tile Dist. Feet of Tank or Drain Field from Well [ Nature of Water Supply: City —Well Size of Soakage Pit L ...--) 7 f� r (Signe The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labo under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has co plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to e 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, or�. work to be perrforme J under this .permit, as are licensed by Miami Shores Village. ( Signed ) Repairs No. of Stories (/) Plumbi Before me, the undersigned authority, a notary pi blic, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath de oses 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 salve, and that all facts therein by him stated are true. 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. (r) % 40 BUILDING ELECTRICAL PLUMBING Owner of Building / /`, :tom f- r Lot Work to be performed under this Permit Contractor or Builder Legal Description Address of Building i CONTRACTOR OR BUILDER MIAMI SHORES VILLAGE, FLORIDA PERMIT N2 7963 1 ,. _,t, gb. Architect P '• Subdi- vision Value of Project 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 appli- cation herefor in strict compliance with all ordinances pertaining thereto and w th 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. ECT S OR In consideration of the issuance to me of this permit I agree to perform fKe 'ork covered hereunder in compliance with all or 'n Ices and regulatip s pertaining thereto and in strict conformity with the plans, drawings, statements specifications submitted to the proper autbppities df M iami 513:17 5111 e. In acce ti g this permit ssume responsibility for all work done by either myself, my agent, servant or employee. BY DATE 194 Ct refractor's License No. Amt. o Permit • - AUTHORITY Permit No teeLi Application is hereby made for the approval of the detailed statement of the plans 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. Owners Name and Address i ' ' ' a Z � C_L U . / No C i J 1 1v E Street 1. 4 • ... Registered Architect and /or Engineer Employing Plumber's Name \N `K q J _ - .- ... ... Na..r, ,.e... .d.. •••••........ StieSLI■..�,.... Location and Legal Description Lot. C _I Bloom Subdivon ‘ i S ; Street and Number where work Is to be performed —No - ' W�l�'_ "� Street. e. 7 . . - • State work to be performeii and purpose of - building (By Floors)._ — Repairs No. of Stories New Building.____ _— - - .... ....._ beg — ep� .:; ..... .r Size Septic Tank_ `,) Type of Tank L' ... __Capacity Gals._._.._... —_ Feet of Drain Tile rest- Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well. c'' ? y Size of Soakage Pit_ Amount of Permit 8 E3 STATE OF FLORIDA, sa COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts lsi£ obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, 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. (Signed) Mantes 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 ham carefully read the foregoing application, and that be did sign the same, and that all fads therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of 81.00 will be made when mob swlnspeodos 1 seade by improper notice for inspection, or faulty material and/or workmanship. CLOSRa BATH Tuns SHOWER[ LAVA. TOPICS SIN" SINK• LAUNDRY TUas URINALS CATCH BASIN FLOOR GRAIN - DRINKING FOUNT'N. TOTAL FIXTURE[ CONTR. LIST . CHECK SEPTIC TANK SEWtR CONN. DRAIN FIILD SOAKAGE PIT GREASE TRAP SOUR MIAMI D[[F WILL BPRKLR. SYSTEM SWIM POOL Comm LIST CHICK Permit No teeLi Application is hereby made for the approval of the detailed statement of the plans 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. Owners Name and Address i ' ' ' a Z � C_L U . / No C i J 1 1v E Street 1. 4 • ... Registered Architect and /or Engineer Employing Plumber's Name \N `K q J _ - .- ... ... Na..r, ,.e... .d.. •••••........ StieSLI■..�,.... Location and Legal Description Lot. C _I Bloom Subdivon ‘ i S ; Street and Number where work Is to be performed —No - ' W�l�'_ "� Street. e. 7 . . - • State work to be performeii and purpose of - building (By Floors)._ — Repairs No. of Stories New Building.____ _— - - .... ....._ beg — ep� .:; ..... .r Size Septic Tank_ `,) Type of Tank L' ... __Capacity Gals._._.._... —_ Feet of Drain Tile rest- Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well. c'' ? y Size of Soakage Pit_ Amount of Permit 8 E3 STATE OF FLORIDA, sa COUNTY OF DADE. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts lsi£ obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5988, 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. (Signed) Mantes 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 ham carefully read the foregoing application, and that be did sign the same, and that all fads therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of 81.00 will be made when mob swlnspeodos 1 seade by improper notice for inspection, or faulty material and/or workmanship. Lt BUILDING ELECTRICAL PLUMBING Owner of Building { CONTRACTOR OR BUILDER MIAMI PERMIT N? 1299 Work to be p ormed under this Permit { SHORES VILLAGE, FLORIDA _ ate. Subdi- vision Value of Project DATE 194-r Contractor's License N+l Architect Contractor os..B udder Legal Lot Description Address of Building ►f This permit is granted to the contractor or builder named above to construct the building or to install the equip application herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work with any plans, drawings, statements or specifications that may have been submitted to and roved by the proper munici be revoked at any time if the work is not done in com iance with such ordinances or if Ore ans are changed without au upon which this permit is granted is the understanding that the contractor or builder named above assumes the responsi the ordinances and regulations pertaining to the work vered hereby whether shown on the plans or drawings or in th that he assumes responsibility for work done by his agents, servants or employees. Signed • j''w pig INSPECTOR Amt. of Permit In consideration of the issuance to me of this permit I agree to perform the covered hereunder in complianet with tions pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the pfropr Village. In accepting this permit I assume responsibility for all work done by either myself, y agent, servant or empdyep. I' r _twice described in the _ in compliance This Permit may A further condition thorough knowledge of i. Off spccil cations and ordinances and regula- ties of Miami Shores MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No _ ��' = Date-- •- -- ____ - - ....... — - r - - -- �- � • - �• - - - - -- Application is hereby made for the approval of the detailed statement of the plans 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 Eng __ __ Employing Plumber's Name __w_: _ __ _— L."`^ `'v No. Street-- Location and Legal Description Lot --- _-__- _------________ -._-- ___.__.._.-_Block_ Subdivision. — .. Street and Number where work is to be performed —No 96. L Street.__. - 7 7 New Building Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. e No. / Street State work to be performed and purpose of building (By Floors) __ ___ -- -- ____ -- Remodeling___.__ __ ___ Addition_______.______ __.___ Repairs No. of Stories _ Size Septic Tank--- _ —__ -- --- �f — � — Type of Tank_ Feet of Drain Tile_ ./q ��'�"'°' - " - _Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City— Well._____ _ _ _ __ _ _ _ — Size of Soakage Pit _ _ (Signed) _ (Signed Capacity Gals. My Commission Expires Notary Public, State of Florida Master Plumber. G .. .� °'A Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under 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 th Ste of the wor such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, w9rk to 1 pe ormed under this permit, as are licensed by Miami Shores Village. 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. 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 BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY Tues URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT•NS TOTAL FIXTURES CONTR. LIST CHICK — SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SW IM•G POOL CONTR. LIST CHECK MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No _ ��' = Date-- •- -- ____ - - ....... — - r - - -- �- � • - �• - - - - -- Application is hereby made for the approval of the detailed statement of the plans 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 Eng __ __ Employing Plumber's Name __w_: _ __ _— L."`^ `'v No. Street-- Location and Legal Description Lot --- _-__- _------________ -._-- ___.__.._.-_Block_ Subdivision. — .. Street and Number where work is to be performed —No 96. L Street.__. - 7 7 New Building Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. e No. / Street State work to be performed and purpose of building (By Floors) __ ___ -- -- ____ -- Remodeling___.__ __ ___ Addition_______.______ __.___ Repairs No. of Stories _ Size Septic Tank--- _ —__ -- --- �f — � — Type of Tank_ Feet of Drain Tile_ ./q ��'�"'°' - " - _Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City— Well._____ _ _ _ __ _ _ _ — Size of Soakage Pit _ _ (Signed) _ (Signed Capacity Gals. My Commission Expires Notary Public, State of Florida Master Plumber. G .. .� °'A Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under 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 th Ste of the wor such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, w9rk to 1 pe ormed under this permit, as are licensed by Miami Shores Village. 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. 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. P LUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No.___ Date New Building _ Remodelin BATH TUBS SHoweas Size Septic Tank j Feet of Drain LAVA - TORIES Nature of Water Supply: STATE OF FLORIDA, as COUNTY OF DADE. Before me, the undersigned autho ' , a no appeared to me well known, and who, being by e - t dui of the above described construction, t :x has therein by him stated are true. My Commission Expires MI MI SHORES VILLAGE SLOP SINKS Addition Field from Well _.Size of Soakage Pit Notary Public, State of Fl Application is hereby made for the approval of the detailed statement of the plans and specifications herewith sub the building or other structure herein described. This application is spade in compliance and conformity with the Building Ordinance of loSslaktilinciss Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulatliisse the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and must be kept at building during progress of work. Owner's Name and Address _ _ _ I. 11 No. 4 1- 0 1 Stre Registered Architect and /or Engineer _____ I_ Employing Plumber's Name _____ r y . M I + ' - r No._ Location and Legal Description Lot -W.. •' Block y _______ -_ Subdiv Street and Number where work is to be perfo I d —No. a- Q__/ !! ..-__. _ ee State work to be performed and purpose of building (16I Floors) CONTR. LIST CHECK CONTR. LIST CHECK CLOSETS SEPTIC TANK SEWER CONN. DRAIN FIELD SINKS Disc eet of ank or LAUNDRY TUBS CATCH BASI FLOOR . RI 1 DRAIN O .. TOTAL FIXTURES Repairs_ ________w___ of Stories Capacity Gals • Amount of Permit $____ -_ i -12-00- I ____ _____ _-- ___-_. - -_ -_- (Signed) _- I The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligation,; M under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent S bas co plied with the provisions thereof, and will requir similar compliance from all contractors or sub - contractors employed i the work to be performed under this permit; and will post or cause to be po inspection on the site of the work such public shigli et notices ae are required by the Act. The under signed agrees t employ oply"'such s t ractors , on work to be p erformed omit iilk permit, as are licensed by Miami Shores Village. II s zed to administer oaths and take acknoludedgments, personally u� • s and says that be is the he foregoing application, and that he did sign iii that all facts NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice Etta . or faulty materials and /or workmanship. Permit No ______ _ ___ ` Owner's Name and Address Registered Architect and /or Engineer Employing Plumber's Name _ ;_LAP , Location and Legal Description Lot APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans 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. r Street and Number where work is to be performed —No t • r State work to be performed and purpose of building (Bp'-•loors) __S= 1E1/1_12 New Building Remodeling Addition Repairs _____ No. of Stories f Tank Size Septic Tank Feet of Drain Tile 75 t Dist. eet of I ank or Nature of Water Supply: City —iiAll Amount of Permit $___ a c2_ ___�_: My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT No (Signed) No._ Block ,A Date )L _ f� t Street__ )J `--.d C_ _.W Swot.__ ir- -1�'- Scree l' 1 iL 4V, .� Capacity Gals._ Field from Well �_ liki 1 '- VI or Size of Soakage Pit (Signed) - —'- --- Pl ibing Inspec r. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employe labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, an 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 under signed agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. .t- STATE OF FLORIDA, j ss. 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. Notary Public. State of Florida Maste lumber. 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 BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUN+RY TUBS UR ALS CATCH BASIf� FLOOR DRAINOU RIN I S TOTAL FI XTURES CONTR. LIST t CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE REASE PIT , TRAP 11F • A' ' EEP ELL SPRKLR. SYSTE WI G CONTR. LIST ,. •. CHECK h Permit No ______ _ ___ ` Owner's Name and Address Registered Architect and /or Engineer Employing Plumber's Name _ ;_LAP , Location and Legal Description Lot APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans 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. r Street and Number where work is to be performed —No t • r State work to be performed and purpose of building (Bp'-•loors) __S= 1E1/1_12 New Building Remodeling Addition Repairs _____ No. of Stories f Tank Size Septic Tank Feet of Drain Tile 75 t Dist. eet of I ank or Nature of Water Supply: City —iiAll Amount of Permit $___ a c2_ ___�_: My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT No (Signed) No._ Block ,A Date )L _ f� t Street__ )J `--.d C_ _.W Swot.__ ir- -1�'- Scree l' 1 iL 4V, .� Capacity Gals._ Field from Well �_ liki 1 '- VI or Size of Soakage Pit (Signed) - —'- --- Pl ibing Inspec r. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employe labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, an 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 under signed agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. .t- STATE OF FLORIDA, j ss. 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. Notary Public. State of Florida Maste lumber. NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. CONSTRUCTION PERMIT FOR: [0 ] New System [A] Existing System [NI] Repair [IN] Abandonment q- 6,01)(iid ( APPLICANT: PROPERTY ADDRESS: CIO t �I E'.. cf) 0 T H E R APPROVED BY: DATE ISSUED: 1 • 7 / fl-11 1 S OF FLORIDA ' .G DEPARTMENT OF HEALTH - : t d ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT [ Holding Tank [ Innovative ['V] Temporary [ LOT: l) 1 BLOCK: -- ) 1 K SUBDIVISION: 1 1 1 1 Q f. i' j L, U t, -- ES [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 01 N. Q U ...31(.) [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS 6: Ctit T [7 s 0 ] GALLO / GPD(SEPTIC TANK7AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES (, ] A [ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ] N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ] D (300] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET' SYSTEM A TYPE SYSTEM: [ ] STANARD [ ] FILLED [ ] MOUND I CONFIGURATION: [ ] TRENCH (%(] BED [ ] N F LOCATION OF BENCHMARK: /6;60 I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: ( ] INCHES • C .; r-. iv • [ 6, W] r f n u t t FT] [ABOVE BSL ti BENCHMARX F$ $ffCE"`P YIN [ 367 tf\? (INCHgS,/FT] (ABOVE FLOW ~ BENCBMARK B RENCE POI - NV EXCAVATION REQUIRED: [3 0 ] INCHES DH 4016, 12/99 (Page 1) (Previous Editions May Be Used) pt. I: Health Department pt. 2: Applicant pt. 3: Installer/Contractor pt. 4: Building Department [ '�•. •• VIM . p h O. .l`. EXPIRATION DATE: PERMIT NO. p/, art DATE PAID: FEE PAID: '1 .S , C7c, RECEIPT # : 5;(Q $,(,jp CGLI SPEC IFICATIONS BY: A/4 c��aJ -!2� y (]� Q Y - '-A C • TITLE: ( 151 kV / C if-1r l I TITLE: � ( It l / - d �!�! CHD J Page 1 of 3 INSTRUCTIONS: PERMIT NUMBER: Permit tracking number assigned by CPIiIU. CONSTRUCTION PERMIT 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. (CHD may require property appraiser ID # or section /township /range/parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 64E-6, FAC. DRAINFIELD: Minimum specifications from Chapter 64E -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 (CHD) personnel reviewing and approving permit. DATE ISSUED: Date permit is issued by CHD Ma 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. STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART II SITEPLAN • Scale: Each block retirbsents 10 feet 5 inch = 40 feet. 1 1 , F - I T i I 1 By 1 - - 4 L-, I ^tb- ."4 t • I / H • , I_ 1 1 1 ; 4 4 t 7 r fi 1 I I ----.1,--,-....... .1...........,-....,..,-- I I , , ! 1 1 , _ -.... _i_ -1-- - --4- • ,,. A 1 , , 4 .•.1 f ' .., 7 ! .■ _.1..___ ■ 1_ I. _ . k ; - ,_ 1 ■ 1 : - I ■ , - -" ' l 1- , , ■ . 1 , I , 1' - 1•- , 1 i . 1 1 , 1 7-47 2•44 47. Notes ' : ,. ' i - - --) . ' , r . ,• - - , ■ 6 t ' , : _> L ( ,. ••• , ,-1,," `fc (--)„, - 2t ,-,' ,t- r , '--,:.•:::- 1 t--,; ,. : -.(-, . r - < _ ,\., : ) - 4.,,e. , / -- .. -4 , 1 ,- . : _:" ,t, i ..t. ,,..--- &,...)../ . :‘,t ,,. .: 4 , /II .1-- , i\-\ i r -. „,_ ,. t i , 4-, , p, .. k • '-,'( ' --..c,- 4 • .„ 1/4.. , / ---, t cZ q - ...4 . . ' •- CI, i ■ . tr - : ‘.. , , :,...' ;••-- : l' -(1 , t. `',.., .•••••. . t ''' ',/it A c_4',: '' . '; • ,, ■ ..- I I ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT Site Plan submitted bY:, < Plan Approved_ `__L, Not Approved Date e County Health Department DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) Page 2 of 4 (Stock Number: 5744-002-4015-6) % TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: THE MINIMUM SETBAC WHICH SURFACE WATER: FT WELLS: PUBLIC: f . �l Vk- FT BUILDING FOUNDATIONS: SATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS APPLICANT: � ` L am` ^A L- LOT � BLOCK: -- )(7) SUB BENCHMARK /REFERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS C72.5 [INCHES/ CAN BE MAINTAINED FROM TH E DITCHES / S : LIMITED USE: (v 7k FT FT PROPERTY LINES: SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SOIL PROFILE INFORMATION SITE 1 w 1- 30 Depth (Pit . yr to to A, ( ice, to O to _ tao USDA SOIL SERIES: (,�,,\ -) Munse #/Cplor Texture r )t ")t.J { VMS 4 Li It SITE EVALUATED BY: DH 4015, 10/96 (Replaces HRS -H Form 4015 [Pape 3] which may be used) (Stock Number: 5744 -003 - 4015 -1) AGENT: 1 A 1 PERMIT # O D 4 ;l G;L'� . ;�1 ISION: ) �J Y1( c l), _ -.:� PROPERTY ID #: , v [Section /Township /Range /Parcel No. or Tax ID Number] 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. PROPERTY SIZE CONFORMS TO SITE PLAN: [[/ [ ] NO NET USABLE AREA AVAILABLE: 0 ° ?�. -� ACRES GALLONS PER DAY (RESIDENCES -TABLE 1 / OTHER -TABLE 2) C, GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] (c SQFT UNOBSTRUCTED AREA REQUIRED: . 6)(1 ; ) SQFT (p k T [ABOVE ENC PROPOSED T � ��jj 0RMALL SYSTEM TO THE FOLLOWING FEA F PRI ATE: [�]A FT NON - POTABLE: (0 FT POTABLE WATER LINES: SOIL PROFILE INFORMATION SITE 2 ERENCE POINT). A Y WET? [ ] YES TURF: [ NO FT FT 10 YEAR FLOODING? [ ] YES [ ] NO SITE ELEVATION: )O. k FT MSL /NGVD olor , Texture Depth .1\a .:. Munse • 'tl • 4 4 !- li dJ/ USDA SOIL SERIES :: (L IQ v\ to to to r. o fit, _ yet' OBSERVED WATER TABLE: E INCHES [ABOVE EXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ) YES NO MOTTLING: [ ] YES ej NO DEPTH: INCHES SOIL TEXTURE /LQADING RATE FOR SYSTEM SIZING: p DEPTH EXCAVATION : INCHES DRAINFIELD CONFIGURATION: [ ) TRENCH [ � J , O [ ] OTHER.4SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE : ' 1 (..(/- � IJ Page 3 of 3 INSTRUCTIONS: r PERMIT NUMBER: Permit tracking number by County Health Department. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number). PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. SEWAGE FLOW: UNOBSTRUCTED AREA: Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential), Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield. BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the proposed system site in relation (above or below) to the benchmark. MINIMUM SETBACKS: Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public drinking well within 200 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 flood elevation for site and actual site elevation. SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined. WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is 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 documents submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: BENCHMARK SITE 1 SITE 2 SITE 3 [ + ] SHOT H.1. H.I. H.1. H.1. [ - J SHOT [ - J SHOT [ - J SHOT APPLICATION FOR: W] New System [A] Existing System [,\] Holding Tank [to] Temporary /Experimental [ \] Repair [ 0] Abandonment [N] Other(Specify) APPLICANT: Ce)u/1 /'��j p TELEPHONE: AGENT: 4 / I � n � ;f ` CM1 r MAILING ADDRESS: f�� P- >C (rig .; — 73 - Y1 Lr . i y r' ,. - LOT: , BLOCK: BUILDING INFORMATION Unit Type of No Establishment 1 ( -) 2 3 4 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC APPLICANT'S SIGNATURE: DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1] which may be used) (Stock Number: 5744- 001- 4015 -1) RESIDENTIAL [ ] COMMERCIAL PERMIT # :1 DATE PAID � ' FEE PAID $ RECEIPT # L"` fL ' TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] SUBDIVISION: If\ 4ru 1 ! ..� I. A- t D ILL' 1-•-• _) SUBDIVISION: PROPERTY ID #: a' . [Section /Township /Range /Parcel No.] ZONING: PROPERTY SIZE: [ ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: ` ��" r / � 1. No. of Building # Persons Business Activity Bedrooms Area Soft Served For Commercial Only [�l Garbage Grinders /Disposals [ Spas /Hot Tubs [%d)] Floor /Equipment Drains 0j] Ultra -low Volume Flush Toilets 7 '[ ] Other (Specify) DATE: .-■ 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: I 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 lot 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 character number for property. (Health Department may require property appraiser LD# or section /township /range /parcel number.) Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions may be included in calculating lot area. WATER SUPPLY: Check private or public. PROPERTY ADDRESS: Street 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: List type of establishment from Table I1, Chapter 10D-6, FAC. Examples: single family, single wide mobile home, restaurant, doctor's office. NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for occupants. BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully screened patios or decks. Based on outside measurements for each story of structure. # PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are assumed. BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by Table II, Chapter IOD -6, FAC. FIXTURES: Mark each listed fixture with number installed or 'NA" if not applicable. SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees and attachments. ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, 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 wastewater. INV. DATE. 9/02/93 COST. ORD NO. 6834 DATE OF ORDER 3/11/93 DATE SHIPPED 9/02/93 SHIP VIA OMAR SALESMAN R.F./L.G. TERMS QUANTITY ORDERED QUANTITY SHIPPED BACK ORDERED DESCRIPTION UNIT PRICE TOTAL ALUMINUM CLIP -FAST STORM PANELS (INSTALLED) CONTRACT PRICE: $ 2,390. 00 LESS DEPOSIT: 800. 00 TOTAL: $ 1,590 @0 Pi (1 (>) 0 q \ \ p - V I' ..c:21 7JQ L fat �i li Tour r` u.:'�,, e.5 A.B. SOLD TO IMPORTANT P.O. Box 1492 • Hialeah, Florida 33011 n EDWARD COREY 901 N.E. 97th ST. MIAMI SHORES, FL. 33138 AWNING COMPAN INC. 5795 N.W. 36th AVENUE • MIAMI, FLORIDA 33142 PHONE: (305) 635 -0900 • 1- 800 - 327 -0905 • FAX (305) 634 -9078 r H T J O L SAME AS SOLD TO UNLESS NOTED 17937 J PAYMENTS MUST BE MADE IN ACCORDANCE WITH TERMS HEREIN STATED. CLAIMS FOR SHORTAGES MUST BE MADE WITHIN 10 DAYS AFTER RECEIPT. REFER TO OUR INVOICE NO. WHEN MAKING PAYMENT OR ON CQRRESPONDENCE. IF SHIPMENT IS RECEIVED IN BAD ORDER & GOODS ARE DAM. AGED OR MISSING, NOTIFY TRANSPORTATION COMPANY AND FILE CLAIM IMMEDIATELY. OUR RESPONSIBILITY CEASES AFTER SAFE DELIVERY TO THE TRANSPORTATION COMPANY. ITEMS LISTED IN "QUANTITY BACK ORDERED" COLUMN WILL FOLLOW AS SOON AS POSSIBLE. The intent of this form is solely for the application of shutter discounts. mitigation features or discounts. APPLICANT OR INSURED'S NAME: C.n ?F DATE DEVICE(S) INSTALLED: AGENT /APPLICANT: The property address shown in D.2 must match the property address on the Application for Coverage to which this document pertains. Shutter Requirements: A. All exterior wall and roof openings, such as doors (exterior and garage), windows, sky - lights and vents, of the insured building or unit, if a condominium unit, as described in the Declarations, is fully protected with STORM SHUTTERS of any style and material, or alternative as noted in Section B, designed and properly installed to meet one or more of the criteria requirements listed below. All shutters and/or alternative to shutters at the location shown in D.2 of this form are designed to meet one of more of the following: 1. withstand wind pressure that at a minimum meets the American Society of Civil Engineers, July 1988 standards (ASCE 7/88) and impact from wind -borne debris, adopted by Dade County, Florida in September 1994 or any local code that meets, at a minimum, September 1994 Dade County requirements for wind pressure and impact from wind borne debris or complies with SSTD -12 standards for wind pressure and impact from wind borne debris. 2. withstand wind pressure that at a minimum meets the standards set forth in the South Florida Building Code, adopted in Dade County, Florida in August'1988. NOTE: Roof ridge vents, soffit vents, and breakaway walls as defined and required by the National Flood Insurance Program (NFIP), and other non shutter openings as required by the Dade County building code, do not have to be protected by shutters. B. As an alternative to Storm Shutter(s): 1. The garage door(s) meets or is RETROi 1.1 1ED to meet the wind pressure and debris impact requirements noted in Al. 2. The exterior door meets both the wind pressure and debris impact requirements described in Al. Revised 3/14/00 1:35 PM WINDSTORM PROTEC1IVE DEVICES - (HURRICANE/ORDINARY) PROOF OF COMPLIANCE RESIDENTIAL FORM This form is not for use conjunction with any other APPLICATION/POLICY NO.6 4 6 / 3. Window or other wall, and roof opening(s) are covered by permanently installed glazing material that, along with respective window or other wall and roof opening structural components, meet both the wind pressure and debris impact requirements noted in Al. As the Insured, I certify the following: C. 1. I will close and secure my shutters in event of a tropical storm or hurricane affecting my premise(s); and 2. I have made arrangements to close and secure all shutters in my building or unit (if in a multi-unit building) when I am away from the premise. 3. The devices certified below are properly installed in compliance with the manufacturer's installation recommendation and aforementioned building codes. 4. "While your failure to comply with the above conditions will not result in denial of a claim for loss caused by the peril of Hurricane, Other Windstorm or Hail, we reserve the right to discontinue the benefits of this endorsement, including any related premium credit, in the event of such failure", and as stated in the policy conditions, " we may cancel immediately if there has been a material misstatement or misrepresentation or failure to comply with underwriting requirements - established by us." D. A signature of either a Registered Architect, Regulations and Code "Qualifier" for a Manufacturing Company, Engineer, or Building Code Compliance Official is required to verify section A and/or B. Notary Public to affirm. (Continued on Page 2) Ju c �- Signature of Applicant Date WPD-t R (7/00) Page 1 oft This certification is intended ONLY for the benefit of the Named Insured's receipt of a property insurance premium discount and for no other purpose. Unless otherwise specifically agreed in writing, other persons or entities, including assigns and successors of the building or unit owners, shall not be entitled to rely on this certification. 1. I hereby certify that I am a State of Florida registered Ai .bite ror an Engineer, proficient in structural d ie�gn, or a duly designated Regulations and Code "Qualifier" for a Manufacturing Company, or a Building Code Official (who is duly autorized by the State of Florida or it's county's municipalities, to verify building code compliance); and 2. In my professional opinion, based on my knowledge, information and belief I hereby certify that shutters, or alternatives t„ shutters, on the building or unit at the address indicated below, comply with one or more of the stipulations set forth in section A, and where applicable section B: (check one only) A.1 (Hurricane) A2 (Ordinary) (check all that apply) B.1 (Hurricane) 132 (Hurricane) B.3 (Hurricane) Signature of Registered Date Architect /Engineer /Qualifier (Notarize below) Print Name Below (check one only) A.1 (Hurricane) A.2 (Ordinary) Si ature of Building e Compliance Official (Notarize below) Print Name Below (check all that apply) B.1 (Hurricane) B.2 (Hurricane) B.3 (Hurricane) FRANCIS J. LUBIEN Address Title BUILDING OFFICIAL City/State/Zip Department BUILDING Registration Number Dept. Address 10050 N. E. 2nd AV. City/State/Zip MIAMI SHORES, FL. 33138 Phone Number 305 795 2204 Property Address: of IVY �S- State of Flori County of vJ . With respect to the above, / (� The above named signatory has sworn to and subscribed before me this f a day of by (name of person making the statem ) th information contained within and true. The above signatory is personally known to me 1 or produced identification) for identification. Revised 11/3/99 11:05 AM A.D., 2000, ocument is accurate (hPe of OT YS ErbeiPtS.j.VTLAR NOTARY PUBLIC STATE OF FLORIDA COMMISSION NO. CC714103 Print, Type or Stamp N d1brN'dt!atiySi0N EXP. MAR. ,,2002 Signature of Notary E. Hardship Acceptance when signature in Section D. above cannot be procured I have attached documentation proving that shutters, other devices, and doors without shutters meet the wind pressure and debris impact requirements stated in the rule and the devices are properly installed in compliance with the manufacturer's installation recommendation and aforementioned building codes. Such documentation must come from a Building Code and Compliance Official, the Regulation and Code "Qualifier" for the Manufacturing Company, a Florida Registered Architect, or Engineer proficient in structural design. Such documentation maybe waived if said individuals complete Section D of this document. Signature of Applicant Date FWUA reserves the right to confirm all information contained in this form via a survey of the risk. "Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree." WPD-1 R (7)00) Page of2