801 NE 96 StPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date i Job Address )3 N►_ q cb sr Tax Folio 1' — 32.06 ` 04- 2
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant Lour Si AS Master Permit 14
Owner's Address I E q() ; ; FT
Contracting Co. `k3 l F F PLUM 6` N 6
Square Ft.
Notary s to Own
My ission
FEES: PERMIT
Date
do President Date
otY p _ ° Term J. Felder
Notary S+
Public, ,te 01Florid:
Co
oFnA M Commission Mo. CC 480807
My Cossion Expires 07/16/90
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Nar ettoadies Co
RADON
APPROVED:
Zoning
Mechanical Plumbing
Building
C.C.F.
Phone 1Sg- I g5
Mows f /
SsS ' f'e 5) 4 4 67
Stile # A- r d o Ka /6 S•' Municipal # c C a f ,9'/e 3 Canvas:icy # Ins Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL LUM MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION � 5 l 1. Delki N FI
Estimated Cost (value)* 1 WO
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 Contractor or Owner - udder
NOTARY
Electrical
4te1P>
o Contract Ate - b uilder D ate
ssion E
1Y� - Teresa J. Felder
tAe Notary Public, St of Florida
M1'! Commission No. CC 480807
of FP My Commission Expires 07 /16/99
r-8oa9•NOTA1Y. P1.. t Hooding Ce.
etteef!Y!letteltteteeeet elQ eeeet eeeereK!
BOND
TOTAL DUE
q- �� - 9'7
Date
Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
CONS RUCTION PERMIT FO
[ /4' New System [ Existing System [ 1 Holding Tank [/d,Temporary /Experimental
[ J Repair [ , y bandonment [ /L}.- Qther(Specify)
AdPLICANT: AGENT:
L � ) / „�, .- f /u ho, 6'�*
PROPERTY STREET ADDRESS: /
LOT: /11A- BLOCK:
L
D FILL REQUIRED: [ ] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
SUBDIVISION:
PROPERTY ID #: 3 2 ' mss) [ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID 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 QTHER 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
MODIFICATYoNS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECI>i'I
T [ , ,C U] (GALLON GPD] EROBIC 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 DOW" D9 TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
,/ l2 A v / P
D [� G 7] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [
I CONFIGURATION: [ ] TRENCH [ }.►BErD [ ]
N
F LOCATION OF BENCHMARK: it- E • , 6' h -C-›,,
I ELEVATION OF PROPOSED SYSTEM SITE [ C. T] [ABOVE / BENCHMARK
E BOTTOM OF DRAINFIELD TO BE [ `'2... C ( ] [ABOV BELOW - BENCHMARK
[INCHES
TITLE:
HRS-H Form 4016, Mar 92 (0bsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
EXCAVATION REQUIRED: [ *INCHES
INSTALLER /CONTRACTOR
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
ii32
1
APPROVED BY: L TITLE:
DATE ISSUED:
EXPIRATION DATE: /A! -
Page 1 of 2
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Notes:
Site Plan submitted by:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION, FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION ERMIT
Permit Application Number Cf/ g 2 S 2
Scale: Each block represents 5 feet and 1 inch = 50 feet.
(
1
0
I 1 I
PART I1 - SITE PLAN
SIGNATURE
Plan Approved Not Approved
BY
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used
(Stock Number. 5744- 002- 4015-6)
1
FFE . 7 'vn : J
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) c r z' P,
fK U /( /UU-- 4 a 5
TITLE
Date
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Page 2 of 3