1135 NE 99 StPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address /OS 11)47: `'7 %7, Q1 • Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant VL�� 2 ���" v v D/C.Pe' Master Permit #
Owner's Address CiMt/C
L - 0727,, .//a Address
Date
Contracting Co.
Qualifier /= , D0 AJd;
S
Notary as to Own
My Commission,o
1 1 '
Municipal #
State #
Architect/Engineer
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICA ' LUMBIN MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION 1 R(� Fly 1' 1 d IM Re
on o reside t Date
ires:
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
f I Personally Known 1 1 Mho. • ^
FEES: PERMIT J J RADON
APPROVED:
Zoning
Mechanical Plumbing
Building
Date
-9r
SS# Phone 2,.3 - r� " Z
Competency #
Address
Address
Address
4433 t{
Phone � .RS7 �7
J ?fib A/ / / /77/
Ins. Co.
Square Ft. 3 ® , Estimated Cost (value)
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.
Notary as to Contrac
My Commission xpires:
LESTER E. CROCKETT
I Q N(1T�u P My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
11 Personally Known I I Othe• "
C.C.F. NOTARY
Electrical
TOTAL DUE
BOND 3 OO
Engineering
At.
C PERMIT FOR:
[ ] New System [ ] Existing System ( Holding Tank 11/1 TeapOrity/Experimental
W 1 Otber(Specify)
AGENT:
( 9) Repair
APPLICANT:
PROPERTY STREET ADDRE :
LOT:
PROPERTY ID #: ISECTION/TOWNSHIPIRANGE/PARCEL.;111NRIORIV-::c..70'..K., •-t
fog:ggiir ,!.
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE W/TH SPECIFIMTIONS .AND STANDARDS OF CHAPTER 10D-6,
FAC. REPAIR PERMITS AND HOLDING. TANK PERMITS EXPIRE 80. DAYS PROM THE DATE OP. L3$3911-"::(47iWR
PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH APPROVAL 4311r-VNSTE34'
NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIKE. ANY maw MATERIAL
FACTS WHICH •SERVED AS A BASIS FOR ISSUANCE OF f:TRILS .M04.4,4140,44M THE.,AgigpICANT MOD M HE
PERMIT APPLICATION. SUCH. MODIFIC.AT/ONS MAY RESULT IN THIS RERM/T BEING MADE NULL,AND.
•
APPROVED BY:
STATE OF FLORIDA
DEPARTMENT or HEALS
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, PS & Chapter LOD RAC
( ) Abandonment
C r2 (2--,
BLOCK:
A
=IC
DATE ISSUED: 4 --qg
OH 4018, 10/96 (Replaces HRS-H Form 40.16 (page 1) which may be uallt0)
(Stock Number: 5744.001-4016-0)
AJ
q
SUBDIVISION) 4, .---, ''''' ' ' ' '
' ....`"■:.; ;,4.,... ,i
TITLE:
&k
APPLICANT
PERMIT # qg KZ/ 21
DATE PAID j4
RECEIPT
1 I •
FILL REQUIRED: [ ) INCHES EXCAVATION REQUIRED: 1 36] INCHES
EXPIRATION DATE:
SYSTEM DESIGN AND SPECIFICAT .
T '1 PX00 ) 6y. CPD) A UNIT CAPACITY NULTV.CHAMBEResini .seRzEsq 1
A , ( .- • ] toALL04p. / GITI _ i c,._ . .. ,, cAPAcTp' • /7, CIW413 En:AOC grpgiM34 " 1-
N ( ) GALLONS GREASE INTE ;CAPACITY ii4AXIiRR4 CAPAitTVSi :
-K ( ) GALLONS PER DOSE •DOSING TANK CAPACITY DOGE ( I PER 24 11RS NO. OF 1 1
zOo 34 e _ 4 , , , , ,,, : :- ,, , ,
D [ 4TW ) SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R ( J SQUARE FEET SYSTAtti •- '.- . . , .
A TYPE SYSTEM: [ ] STANDARD ( ) FILLED . 1 ] MOUND
I CDNFTG044TI9N: ( I' TRENC!J ( )(I B ( , 1 • '
N
F LOCATION OF BENCHMARK: FT /0 1
I ELEVATION OF PROPOSED SYSTEM SITE AOS ] Fll IABOV
E BOTTOM OF4DRAINFIELD TO BE [ 4 ] (IN SIFT)' fABove
L
D
INSTALL IMDF LOAMY COARSE SAND
T UPWEtt. tHYTTOM OF DRAINFIELD
BENCHMARK BUM AIMPECII014
THIF PERMIT 19 NOT FOR A J
R WER4 ELEVATION
BOTTOM OF DitAiNFIELD ELUATICN
SPECIFICATIONS BY: TITLE: r
CHD
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 IOD -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.
1
2
3
4
BUILDING INFORMATION
APPLICANT'S SIGNATURE:
LOT: rJ BLOCK: 10 V>
PROPERTY ID #:
ti
[IN] Garbage Grinders /Disposals
[N,]' Ultra -low Volume Flush Toilets
DH 4015, 10/96 (Replaces HRS -H Form 4015 (Rag 1] bleb may be pled)
(Stock Number: 5744- 001 - 4015 -1)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter '10D -6, FAC
[)(I RESIDENTIAL [ ] COMMERCIAL
/00
o 3 .
[ �-4 S) ' ?Hot Tubs
[ j Other (Specify)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
AVM
APPLICATION FOR:
[ ] New System [ ] Existing System ] Holding Tank [ ] Temporary /Experimental
010 Repair [ ] Abandonment ( j Other(Specify)
APPLICANT: Ceon° e GOD F Q r
AGENT: le 1 V� 1uoCr kfc' C'TIC Ti( - po
MAILING ADDRESS: goo t
OD I' m ( I 4
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH'BUILDXNG PLAN'AND'TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
TELEPHONE: ., S _ 757
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
SUBDIVISION: DATE OF
� SUBDIVISION: ���
[Section /Township /Range /Parcel No.] ZONING:
PROPERTY SIZE: Sqft /43560) PROPERTY WATER SUPPLY: [ ] PRIVATE [ )( PUBLIC
PROPERTY STREET ADDRESS: /0 N F "744 N S #404 1,1 1
DIRECTIONS TO PROPERTY:
sNoilPc r/x) -3�► ��-
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Sgft Served For Commercial Only
[ Floor /-quint Drains
DATE:
-Q
.Page 1 61 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:
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 ID# 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 lotor attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 1OD-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 1OD -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.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
6eoi\ce 6OD r Re
LOT: n / A_ BLOCK: k SUBDIVISION:
PROPERTY ID #:
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.
z
PROPERTY SIZE CONFORMS TO SITE PLAN: ('J YES [
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
SOIL PROFILE INFORMATION SITE 1
SITE EVALUATED BY:
HRS-H Form 4015, Mar 92 (
(Stock Number: 5744-003 -4
] NO NET USABLE AREA AVAILABLE: ( 0./ (e ACRES
[RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER Mitt. [1500 GPD /ACRE OR 2500 GPD ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: &∎ SQFT
BENCHMARK /REFERENCE POINT LOCATION: r • E7 - g? •
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABO BELO BENCHMARK
[Section /Township /Range /Parcel No. or Tax ID Number]
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: ____ FT DITCHES /SWALES: - 74' . FT NORMALLY WET? [ ] YES NO
WELLS: PUBLIC: �"�— FT LIMITED USE: FT PRIVATE: FT NON - POTABLE: FT
BUILDING FOUNDATIONS: _ FT PROPERTY LINES: FT POTABLE WATER LINES: /0, FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [Al NO 10 YEAR FLOODING? [ ] YES [x] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
MAnsell # /Color Texture
USDA SOIL SERIES: 6 N
Depth
0 to 7 ? '\
to
to
to
to
to
to
to
to
AGENT: 1/0 ( No(► H Du be_
IV A-
SOIL PROFILE INFORMATION SITE 2
PERMIT # Oie /��
OINT
EREN
Munsell # /Color Texture Depth
nOCU 1v SAN 4\ 0 to 72
to
to
to
to
to
to
to
USDA SOIL SERIES: C;57i7u7S
to
OBSERVED WATER TABLE: :7(( INCHES [ABOVE / ELO ] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [X} NO MOTTLING: [ ] YES [ NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [') BED
REMARKS /ADDITIONAL CRITERIA:
fetes previo editions which may not be used)
1)
[ ] OTHER (SPECIFY)
Page 3 of 3
DATE: g l'/ d
DEPTH OF EXCAVATION: 3� INCHES
7:0i\ tckirs immber nic y CL:-'J.
1. fAil 7'172.
. Property "^f:Ally
1.07, bloc, cad subdivitioa
)2O:' 27 character smites for p_opetty. (prope4 I')
C:tack if property at cit.; corfo:ras to mibrailuel Lite R.^^^.7: '2" • •
all paved ; enc pxpr..aci road beds within c: exelt:chxc:
normally wet drainage ditches, marshes, or other such 1ii ef V.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record th:: estimated smog() flow fo: the estabiichrnelt from Table I (residtc 'lr'ab:e. Cr.t Cf.:2%e:
10D-6, FAC. Record the authorized sewag,a ',low for Cle lot based or!, net usable r.rva wc:t4;: tzy (1$ CI317..tilorte
per day per acre for private , ..7Lter supplies and 2500 gpd per rem for public tntx.,g, T.:ow
does not equal or exceed the estimated sewage flow, the application :nun be denictl.
Record the square feet of unobstracted area available and the amettn: avquimd. Urtobstructee. C3 r.-..zzat be at lepzt 2
times as large as the drainfidd absorption area end et least 75 percent of:the ur2...11" OM: must rase': minimum
setbacks in Chapter 10D-6, FAC. The unobstructed area must be contiguous to the dminftehl.
BENCHMARK INFORMATION: Record the location of the benchmark. Iff using a surveyor benchmark record the actual elevation. Recorci
elevation of the proposed system site in relation (above or below) to the benclunark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "IXIA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot rnut:. L'Q 7:ensured. 'Irkto location
of any public drinking well within 200 feet of the applicant's /at must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 yea: flood elevation for cite and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or ream c.rc; requinti.
identification will use USDA Soil Classification methodology (Munsell colors and USDA coi! textures). Ilef..zsais must
be clearly documented. Provide USDA soil series if available, record "UNK" if the nries cannot in detemtirteri.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "cpparere
appropriate. Record the estimated wet season water table elevation based on cite evaitm:‘.tion, USDA JSJj coi aap3, and
historical information. Indicate if there is high water ',able vegetation present. cate 7:-.st!a a pmeem cl"...f. depth.
SOIL. TEXTURE: Record soil texture or loading rate for system sizittg.
DEPT E OF EXCAVATION: If applicable record depth of excavation mquired. Record 'NA" if not appiicCii
13RAIN:TIELD CONFIGURATION: Check drainfield configuration required. other, s type.
ADMTIONAL CRITERIA: Record any additional remarks pertinent to site or iatzliation. Ex. do
SEE 'EV A W A":"ED : Signature of evaluator, title, and dote ul cycluation. ?cfencr! gL ,:era
T
WOR.KStlEET ELEVATION OF BENCHMARK / LIEFER.ENCE
131ENCHM AA2C SITE 1 srrE 2
(+I SHOT' : N .1. N.R. L.7.
M.II. [-] SliCrir [-I s.7.-fiCir
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ]
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER jS.�� / ��
Permit Application Number (/ / //
N E . 9
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Site Plan Submitted by:
SIGNATURE
Plan Approved Not Approved
By
/(7 t qq-7 sr Miry (Al' S (4nhcs - /4. /-"ice
0/1 T Deal
ALL CHANGES MUST BE APPROVED BY E COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 002 - 4015 -6)
PART I1 - SITE PLAN
TITLE
Date 8-4-9g
County Public Unit
Page 2 of 3
blE
Permit No
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. !� 9
Owner's Name and Address ___ �..1 ci _�S__m A i No.__— N A 4 7
��__ � _ Street_
Registered Architect and /or Engineer____ —__.
Employing Plumber's Name_ 1_*At__ Q _� �►
Location and Legal Description Lot_ — _______________r� _� Block_ l
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors) - E L!'V _t RA/ At
New Building __ Remodeling__ —_____ Addition._______ Repairs_ No. of Stories.
Size Septic Tank
Feet of Drain Tile
Nature of Water Supply: City —Well.
STATE OF FLORIDA, ss,
COUNTY OF DADE.
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Type of Tank
_Dist. Feet of Tank or Drain Field from Well
_Size of Soakage Pit
4.
LCW!��'No
(Signed)
Date
Capacity Gals
6 Street__ —_ A/ 4 � s
Subdivision
My Commission Expires Notary Public, State of Florida
Plumb g Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an emp o 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 empl.. _ 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 su public otice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, . to be a forme • under this permit, as are
licensed by Miami Shores Village.
Master Plumber.
Before me, the undersigned authority, a notary public, duly authorized to administer o. ` s 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 i$LOO 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
TUNS
INAS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
_.
CHECK
blE
Permit No
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. !� 9
Owner's Name and Address ___ �..1 ci _�S__m A i No.__— N A 4 7
��__ � _ Street_
Registered Architect and /or Engineer____ —__.
Employing Plumber's Name_ 1_*At__ Q _� �►
Location and Legal Description Lot_ — _______________r� _� Block_ l
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors) - E L!'V _t RA/ At
New Building __ Remodeling__ —_____ Addition._______ Repairs_ No. of Stories.
Size Septic Tank
Feet of Drain Tile
Nature of Water Supply: City —Well.
STATE OF FLORIDA, ss,
COUNTY OF DADE.
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Type of Tank
_Dist. Feet of Tank or Drain Field from Well
_Size of Soakage Pit
4.
LCW!��'No
(Signed)
Date
Capacity Gals
6 Street__ —_ A/ 4 � s
Subdivision
My Commission Expires Notary Public, State of Florida
Plumb g Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an emp o 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 empl.. _ 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 su public otice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, . to be a forme • under this permit, as are
licensed by Miami Shores Village.
Master Plumber.
Before me, the undersigned authority, a notary public, duly authorized to administer o. ` s 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 i$LOO will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty
materials and /or workmanship.
'
is