453 NE 99 St (14)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address S 3 /‘/ G . ( S ^ '( 'Tax Folio
Legal Description
Owner/Lessee / Tenant
Owner's Address
Contracting Co.
Qualifier fie Pfi< tit/ C.oc 1(1
State #
Architect/Engineer
Bonding Company Address
WORK DESCRIPTION
Square Ft. c�
S3 /16. ??
e few/9c
FEES: PERMIT 1 S RADON
APPROVED:
Zoning
Mechanical
Municipal #
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMB ! G MECHANICAL ROOFING PAVING FENCE SIGN
`41 ✓.� `e /we
Notary as to Owner and/or Condo President Date
My Commission Expires:
'!
Historically Designated: Yes No
(q7 �) y/a80
Master Permit #
Phone
Address / / 3 2 d Amtit.4.4
SS# - Phone (7is 57 71
Competency #
Address
Ins. Co.
Estimated Cost (value)
/52s6'
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.
Sign: ture of owner and/or Condo President Date l Signature of Contractor or Owner- Builder D to
zfz_zA_e3P.)
j 7'7 - 12 ? 0/4- 7 / r/
Notary as to Contractor or Owner-Builder _ :._;, Date
My Commission Expires : c::
lja(' 5c_.
C.C.F. / NOTARY
BOND __ y
TOTAL DUE 3 (a
77
Building Electrical
Plumbing Engineering
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA PERMIT # W9 &CP
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
CONRUCTION PERMIT FO
[ 4 1 New System [Al xisting System
[Si] Repair [ 6 Abandonment
APPLICANT:
MR. — s- / c4F AGENT: es , � S 4
PROPERTY S R ET ADDRESS: jE: ? (2 4
LOT:&& BLOCK: SUBDIVISION: ,*frc. Aw
PROPERTY ID #: // 061 [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
7 0 o [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 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 D IFICATIONS
T [O] [ O:03/ EPTIC TAN 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: [ ]
D [ '& DARE FEET RIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED
I CONFIGURATION: [ ] TRENCH [D
N
F LOCATION OF BENCHMARK: R 95- 4 cYc," 4-„. ( el) e
E
-lding Tank [ /temporary /Experimental
Other(Specify)
[ ] MOUND [ ]
[ ]
I ELEVATION OF PROPOSED SYSTEM SITE [ [INCHES /FT [ABOVE /BELOW] BENCHMARK /REFERENCE Pth
E BOTTOM OF DRAINFIELD TO BE [ 4e g t iorapult-T] [ABOVE FL OW] B NCHMARK REFERENCE POINT
D FILL REQUIRED [ ] .T CHE$ r n,fi ,EXCAVATION REQUIRED: [' INCHES
Cw3V',ter _ „ ,v, .7e „al .i' . a u-r.
O ” ° "3'1VJ,.. 1 "� !'.:s� "emu;'. :rl` °;��. il�u`.
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4016 -0)
TITLE:
• TITLE: CPHU
' 1
EXPIRATION DATE:
Page 1 of 2
:5'_CN AND
S ?: Ci ::CAT7,ONS:
owner's ieJS'.ily r.L Luri%cd rapre. ntn",: ./.:.
. f[ •: fur applicnn:
SJ,:7ivi.S:;ON ur
c.',., racier id number for p - ups :ty. (C? . J t:[ uirr. :y _. praise: i C or L'ection /tov/ :lip /rrnpe /parcel number)
ANr :e;inir.r ! specificetimr: fro:-i C?apte: 10D -6,
_LAi1T'_ -I >:q N inim.im specifications from Chapter 1OD -6,
�ILe::,necifcations, such r.s operating ocrnii , nL ir.m ^:urs,'::ci -veil, e flush toilets, variance provisos.
SPEC/ %CA a i0 YS 3Y: Nan of individual p! oviding specifications. ;:f designed by r c bterzd engineer must be sealed.
A6 " :D 3` : Count' :?ublic Health Unit (C.THU) personnel reviewing and c.pp-oving permit.
.':ATE ISSUED: Date permit is issued by C'.'- U.
One yet!r from date issued if the system has nn> been instalied. ;?ermits for system repairs become void 90 days from the date
issued.
STATE OF FLORIDA
, k.DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 5 feet and 1 inch = 50 feet.
II
1 11IIIIIHIIUIHIIIIIHHIIIIIIIIIIIIIIIHIH1HIIIII 1 � NAME IIIIIIIIIIIIIIIIIIIIII
Notes:
,70 lat
w-41e- TR-4Ig- 444 91 / CM'
/ha. (te,f et 3 42
Site Plan submttgd:
Plan Approved t!/
By
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4015-6)
PART II - SITE PLAN
SIGNATURE'
of Approved
r _ P4
"`
• � .. _ P � o
)47179e-0---
TITLE
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
County Public Unit
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