800 NE 96 St (9)Date
Legal Description 41 \
Owner / Lessee
** * *
FEES: PERMIT
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 6 6d2 96 1' Tax Folio (1 4Vi 41 4A d
15 g
/ Tenant C; v y► e I o 4.17
Owner's Address Soo N . E . est60 �r�•��.�
Contractin Co. e.r► T' � �� *f C4 Address �(�� �. � /
Qualifier L to �? � b [ �o a. L'EX ;(Phone ev er ® 1 ;!:1a T
State #C ' QCS44nicipal # 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 4 ° fiLo144. E;Nt1 Ti o.JC9
Square Ft. Estimated Cost(value)
mo
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.
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
Mechanical
RADON
Zoning Building
otar/ as to
4
400 lim9rwklwienriPmikt
x , :' : .,°: No. CC197545
o tra or Owner- Builder
EPHINE CHURCH
Signatu e f
Date: .d //'
y Commission
PT
C
Master Permit # 5 9
Phone ®�
Electrical
Al
Plumbin �'
7./9 Engineering
g
**
C.C.F. *0 0--- NOTARY TOTAL DUE S'
Fire Other
�j J � /\ /ii '
DateO I ` '9' cg Job Address a)() fl & (RWv Tax Folio d 1 39 OoO 4 a Q9O 3
P
Legal Description L01 9 /0 5K it)aZ PP; \0
1 &CAW � Owner / Lessee / Tenan . 0 Master Permit #54 5 Ffl
Owner's Address 7 f ' //I Phone
Contracting Co -CO1)OYYtJZ 1 Address 4 e') L
Qualifier .B etllQS` Z SS4r Phone 0/ &
State # g .U SJ T Municipal # Competency 41 1 CE1 ns.Co. s' 1 7O(? \ Cl
Architect /Engineer Address
Bonding Company Address
Mortgagor
Notary as to Owner and /or Condo President
My Commission Expires:
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Zoning
Mechanical
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING) MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION - R•S. q� Da a J�j
Mau d r - S �` Q n A() ( ( ilptityln
Address
Square Ft. Estimated Cost(value) DO U C
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 regulatingons and zoning. Furthermore, I
authorize the above -named contractor to do the work st
Signature of owner and /or Condo President Signature of Contractgr or er- Builder
Date: Dateg401
otar: as to Cont
y Commission Ex
Plumbin
FEES: PERMIT 0 do11 RADON C.C.F. /' O0 NOTARY 00 TOTAL DUE ✓ 6'0
**
Fire Other
Buildin: Electrical
. ',7
Engineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank . [ ] Temporary /Experimental
riJ] Repair [ ] Abandonment
APPLICANT:
PROPERTY STREET Aim +RESS:
LOT: BLOCK:
PROPERTY ID #:
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R sou ] SQUARE FEET SYSTEM
A TYPE SYSTEM: ] STANDARD [ ]] FILLED
I CONFIGURATION: [ ] TRENCH [ BED
N
F LOCATION OF BENCHMARK:
L
H
E
R
Alt
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 10D -6, FAC
o 1
SUBDIVISION:
[ ] Other(Specify)
r - t(I
AGENT:
TITLE:
SPECIFICATIONS BY:
APPROVED BY: ' v TITLE:
DATE ISSUED: 5_4_13
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016 - 0)
nPPLOonmy
Woo r) - 9 Co
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
• o1
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
Y \. J -
T [0.>'] [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: [ )
[ ] MOUND [ ]
[ ]
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
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES 0 .� �n Q C, ici
EXPIRATION DATE:
w ` R
CPHU
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATI3N EO1:: Chock type of permit, if "Other specify type in blank.
Pi, yea) owner's full name.
:i„.EPHONE: Telephone uutrber for applicant or agent.
AGENT. r.c4y CV. c:.: 1. F I:, : .th e :L■_.a ..
MAILING ADDI:LSS: P.O. box ur Nive't mulling address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDI: 27 character id number for property. (CPHU may require properly appraiser ID 1/ or section/townsnip /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: 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 Rush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be scaled.
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.