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PLUMBINGCorrection ❑ Address Company / C-Ct 1 - L Phone # C . For Inspector: Approved — I MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date Time Type Inspjti L Re- Insp'n Fee cc Permit No. r Zc A .1:/1 4 2 � Name -)7 / 2.( t' Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Permit Number: PL2002 -100 Printed: 4/24/2002 Applicant: NORA TENNEY Owner: TENNEY NORA JOB ADDRESS: 1183 NE 99 ST Contractor Local Phone: Parcel # 1132050180090 Plumbing Permit Contractor's Address: Legal Description: REV PL MIAMI SHORES SEC 8 Page 1 of 1 PB 43 -69 LOT 20 Fees: Description Amount FEE2002 -2341 Budding Fee $65.00 FEE2002 -2342 CCF $3.00 FEE2002 -2343 Notary Fee $5.00 Total Fees: $73.00 Total Fees: $73.00 Total Receipts: $0.00 Permit Status: Approved Permit Expiration: 10/21/2002 Construction Value: $5,000.00 Work: SPRINKLER SYSTEM UPGRADE & RAIN SENSOR Signed: 1 /4? (INSPECTOR) BY: /r/ In consideration • f e , a ance to me of this permit, l agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, s • ements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either myself, my agent, servants or employes. BLK 178 If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection fee is $50.00, which must be paid in advance before calling for another inspection. 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 application herefor in strict compliance with all ordinances pertaining thereto and with 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 un• •rstanding 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 t e plans or drawings or in the statements or specifications and that he assumes responsibility for work done by his agents, servants or employees. Signed: (Contractor or Builder) BY: PROPERTY OWNER New Construction Name WI f1kHv i . T J (01'1"2 y 41 Address 11 P 3 IJ t? p sr M ; „TA U''er Home Telephone 3o S- 7 S y- 3 2 - ' 1 7 Business Telephone Sag 759- 0 9 6 Fax �`Z G a t o ✓-e--- TYPE OF MANAGEMENT (✓ ) New Construction Enclosure Alteration Exterior Repair Alteration Interior Demolish Relocation of Structure Shell Only Foundation Only Add'I Attachment Other Add'I Detachment Other INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village: Step 1. Job Address: Tenant Information Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted along with this permit application. Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the processing of your application, you may be asked to submit additional information. APPLICATION // 7 3 NE 99 ' 9t a_wt; SGtores Apt. City , Folio Number ►Description of Work sc e r 1 el ie I-e i— S vS" tp vr1 Lot Block g /2a.r S n er r Address Subdivision PB PG Zoning Linear Feet Current Use of Property Square Feet Units Floors Proposed Use of Property t a1'ue of Work As / G Bldg Value Tax Assessed/Appraised Value Flood Zone Base Floor Elev. PERMIT TYPE (✓ ) Building Electrical Mechanical Plumbing LPGX Roofing Fence Other J PERMIT CHANGE (✓ ) Chg. Contractor Renewal Revision Extension Supplement Reinspection ARCHITECT Name License No. Address Telephone Fax Master Permit No. PERMIT APPLICATION Subsidiary Permit No. - Pi/ ' ( 7 / 0 0 , : ' 1 State P 33/3? Zip ENGINEER Name License No. Address Telephone Fax CONTRACTOR Name License No. Address Telephone Fax Qualifier Name Iof i08 ra c(p Page 2 IMPORTANT NOTICES 1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m. to 5:00 p.m. No inspections will be conducted on weekends or holidays. 2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEA AND SANITARY CONDITION free from construction debris. 3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM IRT AND DEBRIS. 4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPME OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is required for work in or near the street/sidewalk. 5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer which requires a separate permit. 6. PORTABLE TOILETS for a construction site require a separate permit. 7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department. 8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the e(lge of pavement. 9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers. AFFIDAVIT - Please read carefully. Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR (DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY, ROOFING and SIGNS and there may be additional permits required from other governmental agencies. I, the OWNER of the property, have disclosed all information related I to any work at the property performed in the prior twelve months to the Building Official. Further, I am fully aware that if the cltmulative cost of work to my home or business under this and any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must conform to The current code requirements of the Building Code. WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for improvements to your property. If you are spending more than $2,590 or intend to obtain financing, you may wish to consult with your attorney or lender before recording your Notice of Comment ment. The Notice of Commencement must be recorded at: 22 N.W. 1st Street, P' Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and Choosing a Contractor. STATE OF FLORIDA, COUNT OF MIAMI -DADE Signature of Owner Print Name Swo d subscribed before me this SEAL: ature of No ry Publics = . , e of_ Flori ♦P PU B AP'C'LA M B L ig V co,r.7 GI i e CF rA. STATE OF FLORIDA, COUNTY OF MIAMI -DADE Signature of Contractor / Qualifier Print Name Sworn to and subscribed before me this day of Signature of Notary Public - State of Florida SEAL: PERMIT APPLICATION Personally known OR, Produced identification � — ') Personally known OR, Produced Identification Type of Identification Produced: 174 l J 4 �SDD 'q�� "/ OS /pe of Identification Produced: ELECTRICAL TYPE Minimum Fee QTY. TYPE Dryer QTY. TYPE. Outlet, Appliance QTY. TYPE Service Repair QTY. A/C Central 1 -3 Ton - Heating Strips, each Fan Outlet, Wall Service, Temporary - Paint Booth A/C Central 4 -7 Ton Fire Pump Outlet, Switch Piping, Flammable Liquid Signs A/C Central 8 -15 Ton Fixture - Fluorescent Process/Pressure Piping Oven Space Heater (kw) A/C Central 16 -20 Ton Pressure Vessel Fixture Light Parking Lot Lights Spas/Hot Tubs A/C Central 20+ Ton Flood Lights Plugmold/Strip Subfeeds, No. of Amps A/C Window FPL - Load Central Posts Swim Pool, Commercial Air Conditioners Garbage Disposal Range/Range Top Swim Pool, Residential Chiller Generators, etc. Receptacles Switchboards Clear Violations Heat Recovery Refrigerator, Comm. (p/PH) Temp Serv., Construction Compactor Low -volt, Burglar Refrigerator, Domestic Temp for Test - 30 days Deep Freezer Low -volt, Fire Renew - Temp Service Water Closet Demolition Low -volt, Intercom/Teleph. Repair Circuits Water Heater Dishwasher Low -volt, Television Service, Number of Amps Water Heater New MECHANICAL TYPE Minimum Fee QTY. TYPE Condensate Drain QTY. TYPE Generator QTY. TYPE. Refrigeration, Tons QTY. A/C Central, Tons QTY. Cooling Tower - Heating Strips, each Vent Hood, Cost A/C Wall/Win. Tons Dryer Vents, Number of - Paint Booth Ventilation, Cost Air Handler, Tons Ductwork, Cost of Piping, Flammable Liquid Periodic Inspections Barbecue Fire Sprinkler System Process/Pressure Piping Pump and Abandon Bath Fan - Vented, # Fireplaces, Number of Pressure Vessel Gas - Appliance PLUMBING TYPE A/C Condensate QTY. TYPE Drains, Roof QTY. TYPE Miscellaneous Fixture QTY. TYPE; Soakage Pit QTY. Bath Tub Drinking Fountain Miscellaneous Repairs Solar Water Heater Bidet Filter Replace Pool Piping Sprinkler Repair Cap - Fixture Fountain Pump and Abandon Sprinkler System Cap - Water Gas - Appliance Pump, Domestic Supply, AC Well Cap - Sewer Gas - Natural Pump, Fire Stand Temporary Toilet Catch Basin Gas - Propane Pump, Re- circulate Temporary Water Closet Clothes Washer Gas Piping Pump, Replace - Pool Urinal Dental Chair Grease Trap Pump, Sprinkler Utility - Sewer Discharge Well Ice Maker Pump, Sump Utility - Water Dishwasher Indirect Wastes Relay Repair Vacuum Pump Disposal Interceptor Roof Inlet Water Closet Domestic Well Laundry Tray Septic Connection Water Heater Drainfield, 4" Tile/Res. Lavatory Septic Tank Water Heater New Drains, Area Meter Set (Gas) Sewer Connection Water Re -pipe Drains, Floor Minimum Fee Shower Water Service Drains, French Miscellaneous Equipment Sink Well, Supply Page 3 ; PERMIT APPLICATION INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below. RECEIVED AND REVIEWED BY: DATE: Page 4 OFFICE USE ONLY CHECKLIST ❑ OWNER - BUILDER FORM (Attach) ❑ FIRE DEPARTMENT APPROVAL (Commercial / multi- family) ❑ CONCURRENCY (New Construction) ❑ OTHER (Specify & Attach) $3.00 per page (Scanning Fee) Miami Shores Village Bond Metropolitan Dade County (C.C.F.) Inspector State Educational Fund State DCA (Radon) Code Enforcement Fine Zoning Review ❑ PROOF OF OWNERSHIP (Attach) ❑ HRS / DERM APPROVAL (Septic / Sewer) ❑ IMPACT FEE (New Construction) ❑ OTHER SECTION Zoning Electrical Mechanical Plumbing Fire Public Works Structural Building Official BY DATE (Specify & Attach) $ 5: (sq.ft.l = x/1000 x0.60) $ (0.00 / sq.ft.) $ (¢.01 /sq.ft.) REVIEWED AND PREPARED BY: PERMIT APPLICATION ❑ CONDO ASSOCIATION APPROVAL (Attach) ❑ BPR APPROVAL (Restaurants) ❑ CONTRACTOR REGISTRATION (On File) PERMIT FEES / 7 TOTAL $ . v DATE: CONDITION OF APPROVAL 10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com Revised July 2001 :' a':ri�:� <t Permit No... -_ -.. L_ 3- 0 s?_ Owner's Name and Address Registered Architect and /or Engineer Amount of Permit $ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT 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 (Abel 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 Divisior 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. New Building `./ - -. Remodeling Addition__ -- (Signed)_ No. Street Employing Plumber's Name, _:__ G/2't�' / ' � No._ P � � . G/' � Street___ � _ Location and Legal Description Lot_____._ 0 I Block. _ .f __r Subdivision Street and Number where work is to be performed —No 1.1. c?‘ _. 'l -_ _ Street State work to be performed and purpose of building (By Floors) __ ( Signed -- ----_ Repairs No. of Stories Size Septic Tank Type of Tank___ Capacity Gals._ Feet of Drain Tile. p Dist. Feet of Tank or Drain Field from We1L Nature of Water Suppl City —' ell 0 Size of Soakage Pit Date Y ,9 1 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 corn - 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. Master Plumber. STATE OF FLORIDA, ss. COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare 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 fac therein by him stated are true. My Commission Expires 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 faul materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBS U R I NALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT•NS TOTAL FIXTURES -- CONTR. LIST / . / / CHECK V V 0 T 0 TANK TANK SEWER CONN. DRAIN FIELD PIEL SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL $E SYSTEM S O'G POOL � Q241:4; . rr�/,yC` 'CeV 7 Comm LIST £ l� p`.DO /� ,ry !� T /va CHECK Permit No... -_ -.. L_ 3- 0 s?_ Owner's Name and Address Registered Architect and /or Engineer Amount of Permit $ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT 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 (Abel 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 Divisior 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. New Building `./ - -. Remodeling Addition__ -- (Signed)_ No. Street Employing Plumber's Name, _:__ G/2't�' / ' � No._ P � � . G/' � Street___ � _ Location and Legal Description Lot_____._ 0 I Block. _ .f __r Subdivision Street and Number where work is to be performed —No 1.1. c?‘ _. 'l -_ _ Street State work to be performed and purpose of building (By Floors) __ ( Signed -- ----_ Repairs No. of Stories Size Septic Tank Type of Tank___ Capacity Gals._ Feet of Drain Tile. p Dist. Feet of Tank or Drain Field from We1L Nature of Water Suppl City —' ell 0 Size of Soakage Pit Date Y ,9 1 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 corn - 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. Master Plumber. STATE OF FLORIDA, ss. COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare 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 fac therein by him stated are true. My Commission Expires 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 faul materials and /or workmanship. 0 v c — 2 , , w o / 9, 2 a I3 1 lyv-44 ; Aruk, 2- 1 - N a- d- - rRrw - /— k-fri e Miami Shores Village BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): Building Electrical City hi / !q -!M/ .31ORE State rZ_0Rf73 1/ Tenant/Lessee Name ALA- a - $ Value of Work For this Permit T -00 Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Contractor's Company Name L LO . ff }j O'TF c 7)4 - Contractor's Address - 75t6 AV /a 3"1 ie 7 City 01(4 /14 / State � L Q u a l i f i e r L. L S ' - a : Z 0 C 7 7 Type of Work: ❑ � DAlteration ❑New Describe Work: 7f2L//CL= �7 �' l.t1ic/L7-.2) // P n.1 L= 'KIP/ err --r Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Is Building Historically Designated YES NO Squ Zip 3 a/ Phone # Phone Zip e Footage Of Work: epair/Replace RECEIVED APR li1114 Permit No. P J2- 00 - I' Master Permit No. Mechanical Roofing Owner's Name (Fee Simple Titleholders) A . 4 9 R , 4 1 h ( J L - Phone # 7 - a ( , - i i i — y - Owner's Address /7 ATC '777 grpc.br 3 5/3 / Zip 33 Iv Architect/Engineer's Name (if applicable) Phone 0 Demolition * * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ 1 1 • 00 CCF $ 1. Notary $ S vU Training/Education Fee $ • -1 0 Scanning $ 6 ` Radon $ Zoning Bond $ C Code Enforcement $ Structural Plan Review. $ Total Fee Now Due $ AgYcn. (Continued on opposite side) CO /CC Technology Fee $ • 32- Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC 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. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or Agent The fore oing instrument was acknowledged before me this ,,,,to, day of 2004', by atiRi 1 /9 T ,u&fL ( , who is per Tcno m to me\or who has produced s ign: Chc 12/15/03 As identi fic Print: L.: • er CeKCF - 7 - My Commission Expires: 71//y )g 56-US z eitz APPLICATION APPROVE r BY: A"; Contractor The foregoing instrument was // acknowledged before me this /t/ ,, day of �i�1f , 20 1 by L L iC -� IT �,0(7 -., -- r Toffs personally knowireior who has produced VP lgilwho « 1— —II * ISSIONODD0147x0 1 � I �J p o�tl s: X20, . il /� %� / awed r11fU( t, i DD ARY PUBLI Sign: Print: ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** (Certificate of Competency Holder) State Certificate or Registration No. Certificate of Competency No. * * * * * * * * * * * * * * * * * * * * * * * * *, * ** * * * * * * * * ** * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * ** s identification and who did take an oath. i ab 1 a U ' . ET I� nded Thru ic - nn rn o. nc My Commission Expires: Plans Examiner Engineer Zoning 1984 * * * ** * * * * * * * * * * * * * * * * * * * * * * ** CONSTRUCTION PERMIT FOR [ ]New System [ ] [ X ]Repair [ ] APPLICANT: Tenney, Nora PROPERTY STREET ADDRESS: 1183 NE 99 St Miami FL 33138 LOT: 20 BLOCK: 178 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT Existing System [ Abandonment AGENT: SR0001343, Crockett Lester SUBDIVISION: Miami Shores CENTRAX #: 13 -SG -20457 DATE PAID: FEE PAID : $ RECEIPT . ]Holding Tank [ ] Innovative Other ]Temporary [ NA ] [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3205 -018 -0090 [OR TAX ID NUMBER] OSTDSNBR : 04- 1407 - -R SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME PERIOD. 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 PROPERTY DEVELOPMENT. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ]Gallons SEPTIC TANK A [ 900 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ] N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 200 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED [ N ]MOUND [ N ] I CONFIGURATION: [ N ]TRENCH [ N ]BED [ N ] N F LOCATION TO BENCHMARK: Finished Floor Of Existing Res. Elev. 8.5' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 2.1 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT , E BOTTOM OF DRAINFIELD TO BE [ 3.6 ] [ FEET ] [ -1 BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ .18.:.0: ]• :'NCHES OTHER REMARKS: 1- Existing 900 gals. septic tank to be inspected for an'appropriate pump -out and a solid vertical deflector installed on the outlet device. The pump -out receipt shall be provided prior to the granting of the final approval. 2- Install 200 sq. ft. or available, but no less than 200 sq. ft. drainfield. 3- Invert elevation of drainfield to be no less than 5.40' NGVD. 4- Bottom of drainfield elevation to be no less than 4.90' NGVD. 5 -There are 2 systems on the property, this permit is for the system located on the west side. THIS PERMIT IS NOT FOR ADDITION. SPECIFICATIONS BY: Andre, Paul MULTI - CHAMBERED /IN SERIES: [Y ] TITLE: APPROVED BY: Andre, Paul , TITLE: Professional Engin Dade 1 SHALL BE PUMPED 1 DATE ISSUED: 4/14/04 DEFLECTIO D EVICE INSTALLED DN 1H �- ei �'�� I 0 DATE: 7/13/04 DH 4016, 03/97 (Obsoletes previous editions which may not be used) Y CHD STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other [ X ]Repair [ ]Abandonment [ ]Temporary [ NA ] APPLICANT: Tenney, Nora AGENT: SR0001343, Crockett Lester PROPERTY STREET ADDRESS: 1183 NE 99 St Miami FL 33138 LOT: 20 BLOCK: 178 SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3205 - 018 -0090 [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME PERIOD. 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 PROPERTY DEVELOPMENT. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ]Gallons SEPTIC TANK A [ 900 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ] N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 200 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED [ N ]MOUND [ N ] I CONFIGURATION: [ N ]TRENCH [ N ]BED [ N ] N F LOCATION TO BENCHMARK: Finished Floor Of Existing Res. Elev. 8.5' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 2.1 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 3.6 ] [ FEET ] [ ]BENCHMARK /REFERENCE POINT L D FILL REQUIRED:[ 0.0 ]INCHES EXCAVATION REQUIRED: [ 18.0 ] INCHES OTHER REMARKS: 1- Existing 900 gals. septic tank to be inspected for an appropriate pump -out and a solid vertical deflector installed on the outlet device. The pump -out receipt shall be provided prior to the granting of the final approval. 2- Install 200 sq. ft. or available, but no less than 200 sq. ft. drainfield. 3- Invert elevation of drainfield to be no less than 5.40' NGVD. 4- Bottom of drainfield elevation to be no less than 4.90' NGVD. 5 -There are 2 systems on the property, this permit is for the system located on the west side. THIS PERMIT IS NOT FOR ADDITION. SPECIFICATIONS BY: Andre, Paul TITLE: APPROVED BY: DH 4016, 03/97 (Obsoletes previous editions whic may not be used) CENTRAX #: 13 -SG -20457 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 04- 1407 - -R MULTI - CHAMBERED /IN SERIES: [Y ] . Andre, Paul A-' TITLE: Professional Engin Dade CHD / TH SEPT AHK ' SHALL E D , A . DATE ISSUED: 4/14/04 t nutuEn V : 7/13/04 Dm,. 1 ,f 0 APPLICANT: LOT: THE MINIMUM SETBACK WHICH SURFACE WATER: AJ ' FT WELLS: PUBLIC: /i 1!. FT BUILDING FOUNDATIONS: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: / AGENT: L L 0'/ ) / r7E ` ' ;L/ c >i °izzG= JLtA SUBDIVISION: cc PROPERTY ID #: 7/ G ,� � � "Grt:: ' [Section /Township /Range /Parcel No. 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: [ 0 1 YES [ ] NO NET USABLE AREA AVAILABLE: TOTAL ESTIMATED SEWAGE FLOW: ,2 GALLONS PER DAY [RESIDENCES -TABLE 1 AUTHORIZED SEWAGE FLOW: 1/ b GALLONS PER DAY [1500 GPD /ACRE OR UNOBSTRUCTED AREA AVAILABLE: (3(•} SQFT UNOBSTRUCTED AREA REQUIRED: BENCHMARK /REFERENCE POINT LOCATION: /-- / I % / -/ =)5 ELEVATION OF PROPOSED SYSTEM SITE IS FT] [ABOV !)/ P / I � --• / PERMIT # or Tax ID Number] (c? ACRES OT: -TABLE 2] 2500 GPD /ACRE SQFT BENCHMARK /REFERENCE POINT CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES: DITCHES /SWALES: /[,,.f /1 • FT NORMALLY WET? [ ] YES/C.4( ] NO LIMITED USE: /J•/ • FT PRIVATE: /V y) FT NON - POTABLE: 5 FT FT PROPERTY LINES: FT POTABLE WATER LINES: /f) FT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [•'] NO 10 YEAR FLOODING? [ ] YES [1 NO 10 YEAR FLOOD ELEVATION FOR SITE: . (FFT"PISL) NGVD SOIL PROFILE INFORMATION SITE 1 Munsell # /Color /0 V.R 3 /0 \.,e'' LS G`' Y /i t /P 1 to to to li to "'to - USDA SOIL SERIES: ! / 1 .� Depth 1 rte`I to to /o /00 to L to DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3] which may be used) (Stock Number: 5744 - 003 - 4015 -1) SITE ELEVATION: Ln.i -•/ (FT ESL -NGVD SOIL PROFILE INFORMATION SITE 2 Munsell # /Color Texture Depth L ay O" to t J2) T R1 s/ .5fati /T it USDA SOIL SERIES: to / ^' r /)' to to to /' to to to I/ to 77 07-1,U OBSERVED WATER TABLE: .,A. INCHES [ABOVE-C' BELOW EXISTING GRADE. [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION�:''r5 f� . > " INCHES [ ABOVE / BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES v% MQ T ING: ['j YES ['l NO DEPTH: N 4 INCHES SOIL TEXTURE /LOADING RATE FOR,SYSTEM SIZ LG: i ` /.4.) DEPTH OF EXCAVATION: /// INCHES DRAINFIELD CONFIGURATION: j't ; ', �//v //]� ' BED [ ] OTHER (SPECIFY) REMARKS/ADDITIONAL CRITERIA: ' % `...1,.:/ :J ((11.4f. .f!7,,,,L .4i2— ,' 449---"1 , t. ' ,.." .��r ` :` .a % d(74 ^1' /,r,, jot). . 2icy . l'. J'4./A ,„, (p7 , J '4'.2/ / 1/; 2 &' /I '/6i1'<<•i.•41.4f.1.4, ?)i /- V4Z-- , r 7 r �� SITE EVALUATED BY3 _>�: (/i • k•ZY - � DATE: L " ' Page 3 of 3 ,;. i •. — — — PART II - SITE PLAN Scale: Each block represents 5 feet and 1 inch = 50 feet. By Site Plan submitte by: Plan Approved STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION -1 F Permit Application Number Notes: (,VLk . ,_ .�tsa -1 �.....� 7 7 1- • /7 ,J.6: Cetk � ` /14, . 0-114A1-J. 3 /3r ALL CHANGES OH 4015, 10/58 (Replaces HRS-H Ram 4015 which may be used) (Stock Number: 5744. 002 - 1015.8) 4dPDC/aSigneture \, Not Approved UST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT -/ L a '7/C ab ` �f CI — Title Date County Health Department Page 2 of 3 Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Permit Number: PL2004 -118 Printed: 4/16/2004 Applicant: NORA TENNEY Owner: TENNEY NORA JOB ADDRESS: 1183 NE 99 ST Contractor LLOYD NORTH DADE SEPTIC TANK SERVIORINttactor's Address: 750 NW 107 ST Local Phone: 305 - 754 -3375 Parcel # 1132050180090 Signed: (INSPECTOR) Plumbing Permit Legal Description: REV PL MIAMI SHORES SEC 8 Permit Status: APPROVED Permit Expiration: 10/11/2004 Construction Value: $1,400.00 Work: REPLACE DRAINFIELD Page 1 of 1 PB 43-69 LOT 20 Fees: Description Amount FEE2004 -3978 Building Fee $175.00 FEE2004 -3979 CCF $1.20 FEE2004 -3980 Notary Fee $5.00 FEE2004 -3981 Training and Education Fee $0.40 FEE2004 -3982 Technology Fee $4.37 FEE2004 -3983 Scanning Fee $3.00 FEE2004 -3984 Builders Bond $300.00 Total Fees: $488.97 Total Fees: $488.97 Total Receipts: $488.97 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either myself, my agent, servants or employes. Signed: (Contractor or Builder) BY: BLK 178 LOT MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No 1'6"/ Date. 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' n Employing Plumber's Name �4 ldJL4(,. _ . Street_ Location and Legal Description Lot._._____ .... Bl Q __ -- Subdivision Street and Number where work is to be performed —No Jig '3 2i'&' ^_ M.. Street — State work to be performed and purpose of building (By Floors)_____ _______ ______ New Building ___ __. Remodeling_ _____ Addition..._____.______ ______ Repairs No. of Stories_ Amount of Permit $ STATE OF FLORIDA, ! COUNTY OF DADE. Size Septic Tank ..... - --- _________ - � � � of Tank __ Feet of Drain Tile.__ _________ ___ ________ __ Est et of Tank or Drain Field from Well Nature of Water Supply: City — Well....____ _ _____Size of Soakage Pit No. ( Signed)._ 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 the site of the work such public notice or notices as are required by tlie 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)._ Capacity Gals. 3/x Street. Master Plumber. 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. My Commission Expires Notary Public, State of Florida \L''‘ 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 TUBS TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBE URINAL! CATCH BASIN FLOOR DRAIN DRINKING FOUNT' NS TOTAL FIXTURES Comm. LIST - _- CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR H EATER DEEP WELL SPRKLR. SYSTEM SW IM'G POOL CONTR. LIST _ CHECK MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No 1'6"/ Date. 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' n Employing Plumber's Name �4 ldJL4(,. _ . Street_ Location and Legal Description Lot._._____ .... Bl Q __ -- Subdivision Street and Number where work is to be performed —No Jig '3 2i'&' ^_ M.. Street — State work to be performed and purpose of building (By Floors)_____ _______ ______ New Building ___ __. Remodeling_ _____ Addition..._____.______ ______ Repairs No. of Stories_ Amount of Permit $ STATE OF FLORIDA, ! COUNTY OF DADE. Size Septic Tank ..... - --- _________ - � � � of Tank __ Feet of Drain Tile.__ _________ ___ ________ __ Est et of Tank or Drain Field from Well Nature of Water Supply: City — Well....____ _ _____Size of Soakage Pit No. ( Signed)._ 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 the site of the work such public notice or notices as are required by tlie 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)._ Capacity Gals. 3/x Street. Master Plumber. 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. My Commission Expires Notary Public, State of Florida \L''‘ 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. root to tld luip of s eat $ It i of that do It Y A UTHORITY { CONTRACTOR OR BUILDER MIAMI SHOR PERMIT N9 7361 Work to b, perforated und.r 4 24 . BUILDING 0 ELECTRICAL [J PLUMBING 0 ROOFING 0 0 Owner of -'"'' Building . ' +' 440.E "4„ """. Architect Contractor or Builder " A . r Legal Lot Description Address of Building i k Y S ' t 1 This permit is granted to the contractor or builder naiad abevve w no tion herefor in Strict compliance with all ordinances pertaining thereto am. walk plans, drawings, statements or specifications that may have been subs es at any time if the work is not done in compliance with sea ordlponese Of *the permit is granted is the understanding that she oontranter or budder mpg tkkt ve regulations pertaining to the work covered hereby wiether sbewe on to er sibility for work done by his agents, servants or employe e* In consideration of the issuance to me of this permit i agree t Prima the work crewed holsonder pertaining thereto and in strict conformity with the plane, *cm/intik etatompinto or spec'lgtpolane et t.4 to OW prams au cepting this permit I assume responsibility for 'di wok do - by either, 11.114 my a or eisdoyae: Application is heremade for the approval of the detailed statement of the plans and specifications herewith ubmitted for the building or othlal structure herein de bed. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida and all provisions f the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Divisior of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept al building during progress of work. Owner's Name and Address.... .. .__.... Registered Architect and /or E gineer___._.- __.. /� "'�''.,� Employing Plumbei s Name. l� r. . a. - ,�- J J�'.te Location and Legal Description Lot.._... -._.._ __._ Street and Number where work is to be performed — 1 State work to be performed and purpose of building (By Ploora) New Building Remodeling Size Septic Tank Nature of Water Supply: City Well ............ ...__.. _..-- - --• - _ Amount of Permit $ STATE OF FLORIDA, l COUNTY OF DADE. se. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT • No. _ 1.1.._ ST Street.lJ. 9 ! l Block The undersigned applicant for this building permit does hereby certi under the Florida Workmen's Compensation Act, being Section 6988, plied with the provisions thereof, and will require similar compllaaoe from performed under this permit; and will post or cause to be posted for inspection required by the Act. The undersigned agrees to employ only such sub - contractors, licensed by Miami Shores Village. Date_ Street.... O bdivisio SI ..L9LAr-- dZ - Addition Repairs • (Signed nn Type of Tank- ._ - - -. -- Capacity Gals Feet of Drain Tile 1_ Dist. Feet of Tank or Drain Field from WeU. .__._. ..Size of So P1 ..ing Inspect ds and accepts his obligations as an employer of bor a of Florida Permanent Supplement, and has sub - contractors employed by him in the wo to be e of the work such public notice or notices as are on work to bs-. performed under this permit, as are Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare Master Plumber. to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the therein ab ee described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all far My Commission Expires NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or Paul materials and /or workmanship. Notary Public, State of Florida CLOSETS OATH TU!! SHOWER! LAVA• TORIES SINK! SLOP SINKS LAUNDRY TY!! URINA CATCH BASIN FLOOR DRAIN DRINKING FOUNT'N! TOTAL. FIXTURE* Corm. LIST -- CHICK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE FIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'O POOL CONTR. Lin CHECK 2.9' . I Application is heremade for the approval of the detailed statement of the plans and specifications herewith ubmitted for the building or othlal structure herein de bed. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida and all provisions f the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Divisior of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept al building during progress of work. Owner's Name and Address.... .. .__.... Registered Architect and /or E gineer___._.- __.. /� "'�''.,� Employing Plumbei s Name. l� r. . a. - ,�- J J�'.te Location and Legal Description Lot.._... -._.._ __._ Street and Number where work is to be performed — 1 State work to be performed and purpose of building (By Ploora) New Building Remodeling Size Septic Tank Nature of Water Supply: City Well ............ ...__.. _..-- - --• - _ Amount of Permit $ STATE OF FLORIDA, l COUNTY OF DADE. se. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT • No. _ 1.1.._ ST Street.lJ. 9 ! l Block The undersigned applicant for this building permit does hereby certi under the Florida Workmen's Compensation Act, being Section 6988, plied with the provisions thereof, and will require similar compllaaoe from performed under this permit; and will post or cause to be posted for inspection required by the Act. The undersigned agrees to employ only such sub - contractors, licensed by Miami Shores Village. Date_ Street.... O bdivisio SI ..L9LAr-- dZ - Addition Repairs • (Signed nn Type of Tank- ._ - - -. -- Capacity Gals Feet of Drain Tile 1_ Dist. Feet of Tank or Drain Field from WeU. .__._. ..Size of So P1 ..ing Inspect ds and accepts his obligations as an employer of bor a of Florida Permanent Supplement, and has sub - contractors employed by him in the wo to be e of the work such public notice or notices as are on work to bs-. performed under this permit, as are Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare Master Plumber. to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the therein ab ee described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all far My Commission Expires NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or Paul materials and /or workmanship. Notary Public, State of Florida