1183 NE 99 St (2)APPLICANT:
AGENT:
PROPERTY ADDRESS: J
LOT: :?L BLOCK: /-,7 SUBDIVISION: ,V? I c >M^
= asssa � sa=s=s ssss:aa:asz
zss sssassssssasssssszsssssssssssss CO
BE RRF+CTED
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST ST B E ===== = = =
zxz= == �� ss
xsxxssssssxxssassxz SETBACKS TANK INSTALLATION 17 SURFACE WATER
[ l [01] TANK BIZS [1] r [ � � � �Zg] DITCHES FT
FT
03 TANK MATERIAL Co ,,s 1', l [29] DRICAEE WELLS FT
( ) [03] OUTLET DEVICE I. 19] FT
[ l (04] MULTI- CHAMBERED [ Y /:.>) ] ( ] (31] PUBLIC WEL WELLS FT
[ ] [05] LEGEND �� ' OUTLET FILTER g '. [il [33] POTABLE WATER LINES 4 '7 FT
[ ] [0 [07) ( '] [33] BUILDING FOUNDATION K_ FT
[ ] [ 8]
[ l WATERTIGHT [ !] (34] PROPERTY LINES FT
OS EPTE FT
l L �
[ l [09] DEPTH TO LID '; � [ l [ 35 l OTHER
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT
CONSTRUCTION INSPECTION
DRAINFIELD INSTALLA FT
[10 ] AREA [ 1 ] �?'1`J [ ]
[11] DISTRIBUTION BOX HEADER
[12) NUMBER OF DRAINLINES a te _
[13] DRAINLINE SEPARATION 21,
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER
[16] ELEVATION [ABOVE /BELOW] BM
[17] SYSTEM LOCATION
[18] DOSING PUMPS r! 0
[191 AGGREGATE SIZE plc,. r j
[20] AGGREGATE EXCESSIVE FINES
(21] AGGREGATE DEPTH
FILL / EXCAVATION MATERIAL
[221 FILL AMOUNT !
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL.
EXPLANATION OF VIOLATIONS / REMARKS:
[ l
'70-(.1%
l
l
l
l
l
CONSTRUCTION [APPROVED /DI PROVED] : c 6L
FINAL SYSTEM [ APPROVED /DISAPPROVED] : , I t It
DH 4016, 10/97 (Previous Editions May Be Used)
Installer / Contractor
i1-
PERMIT NO.
DATE PAID: c ( 4 c J
AND DIPOSAL SYSTEM FEE PAID:
AND FINAL APPROVAL RECEIPT #_
PROPERTY ID #: /- ^ ?Cii -(
FILLED / MOUND SYSTEM
(36] DRAINFIELD COVER
(37] SHOULDERS
[38] SLOPES
(39] STABILIZATION
ADDITIONAL INFORMATION
[40) UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
(43] MAINTENANCE AGREEMENT
(44] BUILDING AREA
[45) LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRAD r w' 1 1,n
[47] CONTRACTOR -- L . ,
[48] OTHER
ABANDONMENT
[49] TANK PUMPED / /
[S0] TANK CRUSHED & FILLED
CND DATE : _4
.1� C`_. CHD DATE :'?
Page 2 of 3
/ -/
Kind of Insurance
Policy No.
Expiration Date
Limits of Liability
Workmen's Compensation
Employer's Liability
WC
10/1/52
Statutory
Manufacturer's Public L iability Con-
tractors
Liability Bodily Injuries
MPL-51812
10/1/5. 2
$10,000. one person
$20,000. one accident
Manufacturer's or Con-
tractor's Property Damage
MPL -51812
10/1/52
$ 1,000. one accident
$10,000. aggregate
Owner's or Contractor's
Contingent Liability
Bodily Injuries
$ one person
$ one accident
Owner's or Contractor's
Contingent Property
Damage
$ one accident
$ aggregate
This is to Certify Mat the following described Policies, subject to their terms, conditions and
exclusions, have been issued to the .fissured named herein by either the BITUMINOUS CIISUZILTY COR-
POR14TION or the BITUMINOUS FIRE FIND MtIRINE INSUR1INCE COMP/1NY, of Rock Island,
Illinois, and are now in full fore and effect.
Descriptive Sehedule
Assured ROBERT MILLER
Address of Assured 1183 N. E. 99th Street, Miami, Florida
Locations Covered Same and elsewhere in the State of Florida
Description of Work Carpentry
This Certificate is issued to
whose address is
Certificate of Insurance
Date March 28, 1952
Director of Finance
Miami Shores Village
Miami Shores, Florida
In the event of cancellation of any of the above Policies the insuring company will notify the party to whom
/his certificate is issued by giving ten (ro) days prior notice of such cancellationximt CJS tariJCtlpex Qxxxx
BITUMINOUS CASUALTY CORPORATION
or
BITUMINOUS FIR 1 MAR N 4.i0 ' AN E OMPANY
By Ile#
Authorized Re tentative
360 Alhambra Circle, Coral Gables, Florida
Location
P- 120d -9 -50
Certificate of Insurance
BITUMINOUS CASUALTY
CORPORATION.
OR
BITUMINOUS FIRE AND MARINE
INSURANCE COMPANY
ROCK ISLAND, ILLINOIS
H. H. CLEAVELAND, Jr., President
ISSUED TO
SPECIALIZING IN
WORKMEN'S COMPENSATION
AND ALL LINES,,
OF
LIABILITY COVERAGE
"Sec 444 with Se ice„
STATE OF FLORIDA) SS"
COUNTY OF DATE )
NN‘x b 'of the Village of "Mama Shores.
County of Dade and State of Florida,, being duly sworn, doth depose apt say,
that under the provisions of Ordinance No 185,, dated Tune 15, 1948. amendp
ing paragraph (d) of S'eetion x.368 of Ordinance No.. 97 of the Building Oode
of Miami Shores Village, he desires to build a
on Lot
a o Blocs 1 r7 o S Subdivision,
that he is the owner of said property, and will be the owner of said
1 l Q 3�'E • ' .that he will do the work personally , and that
1, at such times as are required by the Zoning axed BuildingDirectar-
1. File plans and specifications and obtain approval of the
Planning Board and the Building Inspector.
2. Apply for and secure a Permit.
3. Pay the required fees.
4. Execute the work in accordance with the provisions of this
Code.
5. Apply for inspections,
6. File with the Building inspector certificates that provisi,a
has been made to carry the necessary Workmen's Compensation,
Public Liability and Property Damage Insurance.
7. File with the Building Inspector as the job progresses eerti-
ficates showing the payment required by the Federal Social
Security Act to the State of Florida or the United States of
America.
8,
A F F I D A V I T
Assume the responsibility of not employing other than properly
licensed contractors by Mimi Shores Village for any part or
portion of the work.
9. Not set himself up as a "contractor ".
10. Sign an affidavit before commencing work to the effect that
he has read this Article and will do the work personally and
observe all of the requirements of the Building, Electrical,,
Plumbing and Zoning Codes of Miami Shores Village. Such
affidavit to be properly notarized upon blanks to be supplied
by the Building Inspector.
11. In order to. prevent abuses and subterfuge tin right of such
owner-builder as herein. provided, " is limited to but one
owner...builder omit each 2 years, and where an owneri.builder
has once exercized the privilege herein conferred no second
application for owner-builder permit shall be granted._: in less
than. 2 years, unless the applicant is qualified as a licensed
•General Contractor under the applicable Ordinances of said
Village.
And Further this Deponent says not:
SUBSCRIBM AND mEP'OR'l.M this <l day of
19 S`� .
BP LICr
N+te, Public State -of FI6tida at Large.
My CdrfunissitIn Expiree Noy. 26, 1952,