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PLUMBING
BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): Building Electrical Owner's Address Contractor's Company Name Contractor's Address Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 71131-- " City 4 / State /• /1 Qualifier Le-.) 4-4 $ Value of Work For this Permit /j V 2sl) Master Permit No. Owner's Name (Fee Simple Titleholder) Phone # 345 - 7J -777O City /Ku'.5 Zip 33/34 Tenant/Lessee Name ldto �'' - Phone # L L Z Phone # Permit No. ? I OL) .-311 ! Job Address (where the work is being done) f‘ /1 / L_ • Le S �"1" -( City - , Miami Shores Village County Miami -Dade Zip Is Building Historically Designated YES NO * * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Total Fee Now Due $ pU lC' 0 `-'1 1 .1 ! 1 ` — I (Continued on opposite side) RECEOVED NOV 0 4 2004 N56 Mechanical Roofing Zip 3 3 /may State Certificate or Registration No. SC. 4 31 Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Square Footage Of Work: 2.5D Type of Work: ❑Addition ❑ yteration New 1:24 air/Replace ❑ Demolition Describe Work: to /)/f "/"' Z..5 44 .,,.. , � `rf 7 7 7„ , Submittal Fee $ Permit Fee $ 11 S Ov CCF $ ` • V0 CO /CC Notary $ . W Training/Education Fee $ • (pc) Technology Fee $ (I . 34- Scanning $ 3 .00 Radon $ Zoning Bond $ 3O0 , o0 ' Code Enforcement $ Structural Plan Review. $ ft ...rnnu Cmmnanv'c Name (if applicable) Signatur Chc 05/13/03 T v E 0 Z < U a promise in good faith that a copy of the notice of commencement and construction lien law brochure will be aeuverea ro me 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 inspe which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will of b approved and a reinspection fee will be charged. NOTARY PUBLIC: Sign: Print: My Commission Expires: gent * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPLICATION APPROVED BY: PHEN E. COCKING MY COMMISSION # DD 031747 NfuO, 2005 s ;1 u 2005 Nas Contractor The foregoing instrument was acknowledged before re me this 7 The foregoing instrument was acknowledged before me this day of _5 � 20 , by 4 J li014 , day of , 20 by who is personally known to me or who had produced t who is personally known to me or who has produced As identification and who did take an oath. My Commission Expires: as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: **************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ***************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ******************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** U 5'e/if Plans Examiner Engineer Zoning as ►g S, ill IF rst STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT L D FILL REQUIRED: [ 0.0 ]INCHES SPECIFICATIONS BY: Icaza, Carlos APPROVED BY: Icaza, Carlos DATE ISSUED: 9/Z0/04 CONSTRUCTION PERMIT FOR: [ ; ]New System [ ]Existing System [ { ]Repair [ ]Abandonment APPLICANT: Dorney, Geoffrey AGENT: SRO931119, COCKING NSTEPHBN PROPERTY STREET ADDRESS: 90 NE 98 St Miami FL 33138 GOT: 1 BLOCK: 7 SUBDIVISION: n Shores /Township /Range /Parcel No.] PROPERTY ID #: 11- 3206 - 013 -0890 [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 [ 1050 ]Gallons SEPTIC TANK A [ 0 ]Gallons N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK ]Holding Tank [ ) Innovative Other )Temporary [ NO ] Modified CAPACITY [ 0 ]GALLONS ® [0 ]DOSES PER 24 D [ 400 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 400 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED I CONFIGURATION: [ N ]TRENCH [ N (BED N F LOCATION TO BENCHMARK: CL NH 1st.. 11.86' NGVD. I ELEVATION OF PROPOSED SYSTEM SITE [ 1.3 1 [ FE ST E BOTTOM OF DRAINFIELD TO BE [ 3.8 ] ( FENT EXCAVATION REQUIRED: [ 30.0 ] INCHES CENTRAX #: 13 -SG -22076 DATE PAID: FEE PAID : $ RECEIPT : OSTDSNBR : 04-3026-18 MULTI- CHAMBERED /IN SERIES: [Y ] MULTI- CHAMBERED /IN SERIES: [Y ] HRS # PUMPS[ 0 ] [ N (MOUND [ N [ N ] ] [ BELOW 3 BENCHMARK/REFERENCE POINT ] [ BELOW]BENCHMARK /REFERENCE POINT OTHER REMARKS: *Xxisting 1050 gl. septic tank to remain. *Install an approved outlet filter. * nstall additional 400 sq.ft of drainfield to existing 400 aq.ft.of drainfield. *invert elevation to be no less than 8.60' NGVD. *Bottom elevation to be no less than 8.10' NOVD. TITLE: © 2 f ° ■;-1( TITLE: Engineer I Dade EXPIRATION DATE: 3/2 CHD APPLICATION FOR: [ ] New System [ ] Existing System ( ( ) , Repair [ ] Abandonment - �+ • [ APPLICAi aE AGENT: C J l�'�! c- t• 11 v NAILING ADDRESS: PROPERY SIZE: 1 9.1 PROPER'T'Y ADDRESS: DIRECTIONS TO PROPERTY: BUILDING INFORMATION Unit Type of No Establishment SI 1 �. 2 3 4 TAE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT PERMIT N'. DATE PAID: FEE PAID: RECEIPT #: laS E <'t 44huctf ac( - 1? Bolding Tani: ( ] Imno a Ave Temporary [of] M4 i c 1 X00 TEIZPEOIOI: '5 e { rgs T am=ass, -_mss= TO BE COMPLETED. BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 469.105(3)(m) OR 489.552, FLORIDA STATUTES. PROPERTY INFORMATION +� LOT; Ill BLOC[: ! SUBDIVISIOX$ 6/144 f/4%1A, 5 1 PROPERTY ID #: l l -320t *" ' g 90 ZONING: IS SEWER AVAILABLE AS PER 381.0065, FS? (T / $ ] DISTANCE TO SEWER: 1 floor /Equipment Drains ( 1 Other (Specify) DATE: a /)075 DH 4015, 10/97 — Page 1 (Previous editions may be used) Stock Number: 5744- 001 - 4015 -1 ni ittm Ate Au_ f r iAz$ (X RESIDENTIAL [ ] COMMERCIAL No. of Bedrooms Area sgft Table 1, Chapter 641 -6, FAC I/M OR EQUIVALENT: [ Y / N ] WATER SUPPLY: [ ] PRIVATE PUBLIC ( 1«2000GPD [4>200oGPD 26/oti rr. Building commercial /Institutional System Design Page 1 of 3 STATE'OF FLORIDA bEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM ti SITE EVALUATION AND SYSTEM SPECIFICATIONS /7 AGENT: -A /9/ :7") BLOCK: SUBDISION: t,►rc.�r „I/MX j•- ,�i�.r i LOT: PROPERTY ID:Js hi-5064 "" 171, 1Sectioa /Towaship /Raaii/Parceif No.' or'.Tax; JD Nusaber = = = = = =______________ _- ____-- --- ___ = = = = ==== ==- ===r— -_--- _ - _F= = = == x = = = = =_ TO BE COMPLETED BY ENGINEER, HEALTH UNIT. EMPLOYEE, OR OTHER QUALIFIND PEIEd6 ° /':AENGtNEER'S NUS PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. = = = =a= = - = =a == _ - - - -= ==== ==== ===a= __== =_=== = ==- = == = =__ -_== == = - -= PROPERTY SIZE CONFORMS TO SITE PLAN: [ ) YES ( ) NO NET USABLE AREA AVAILABLE: '21? libRE TOTAL ESTIMATED SEWAGE FLOW: (}!" GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2 AUTHORIZED SEWAGE FLOW: Al % GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: /g;-.6 SQFT UNOBSTRUCTED AREA REQUIRED SQF BENCHMARK /REFERENCE POINT LOCATIONS .,, ' .,& ELEVATION OF PROPOSED SYSTEM SITE IS { (INCHES (ABOVE t0 J,'BENCHMARK /REFERENCE POIN THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE SURFACE WATER: (VP FT DITCHES /SWALES: /rib FT NORMALLY WET? [ ) YES [14 N WELLS: PUBLIC: JJk FT LIMITED USE: fie FT PRIVATE: ✓e ka, FT NON- POTABLE: „,i ° - F BUILDING FOUNDATIONS: _ . __ FT PROPERTY LINES: O FT POTABLE WATER LINES: _% F " SITE SUBJECT TO FREQUENT FLOODING: [ ) YES [pf/ ]'" NO 10 YEAR FLOODING? [ ] YES [vN 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: - FT MSL /NGV SOIL PROFILE INFORMATION SITE 2 SOIL PROFILE INFORMATION SITE 1 4.. .O . uasell ,' Co or Texture Depth P ,,• to `� D 9 to 1�,. to to to to to to USDA SOM SERIES: Fitt 6.44 , SITE EVALUATED B O41'401S 11113R /RsnIai a FIRS./.1 Fexm 4015 (Pam 31 which msv DI uttd1 • Texture Depth 4• g' ! i T. to to �' USDA SOIL SERIES: tie. f r ( -" a. OBSERVED WATER TABLE: fi)(` INCHES [ABOVE / BELOW) EXISTING GRADE. TYPE: [PERCHED / APPARENT ESTIMATED WET SEASON... WATER TABLE ELEVATION:1 INCHES ( ABOVE BELOW ) EXISTING GRAD! HIGH WATER TABLE VEGETATION: [ ] YES [✓(N0 MOTTLING: [ 1 YES [ -4 NO DEPTH: INCH! SOIL TEBTURE /LOADING RATE FOR SYSTEM SIZING: Ilifa ILL DEPTH OF EIICAVATION: 2- INC DRAINFIELD CONFIGURATION: [ ) TRENCH [,r) BED [ ) OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE: 4 " 2. age 3 of :ale: Each block represents 5 feet and 1 inch =50 feet. q g ibck4 i , ,e • .1 STATE OF FLORIDA A , '---A . -- . ..., ,-• , DEPARTMENT OF HEALTH .-- e. ' APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE fat T ' I ,-, . Permit Application Number r114 JV . PART II - SITE PLAN ''' --9 6 • , (..) DteS: i AI 1 addP4,0s10 7-4`) A,„2 fica f • "itimlf 904 d f, ty,fle.,-, kApici ka/do te Plan submitte an Approved \4 4 . 4 • ' \- • •••• ' " • • , „ =7* :s••,.. signature Not Approved A c L .0 A .7?-eZ 9V Title Date - Health Department ALL CHANG S MUS 13E-APPROVED BY THE COUNTY HEALTH DEPARTMENT Miami Shores Village 10050 NE 2nd Avenue Printed: 11 /4/2004 Applicant: Owner: JOB ADDRESS: 90 Contractor MR C'S SEPTIC TANK Local Phone: 305 - 651 -7859 Parcel # 1132060130890 Signed: NE 98 Plumbing Permit Phone: 305- 795 -2204 Permit Number: PL2004 -317 ST Contractor's Address: P 0 BOX 693239 Page 1 of 1 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOTS 1 & 2 BLK 7 LOT SIZE Fees: FEE2004 -10849 FEE2004 -10850 FEE2004 -10851 FEE2004 -10852 FEE2004 -10853 FEE2004 -10854 FEE2004 -10855 Description Building Fee CCF Notary Fee Training and Education Fee Technology Fee Scanning Fee Builders Bond Total Fees: Amount $175.00 $1.80 $5.00 $0.60 $4.37 $3.00 $300.00 $489.77 Total Fees: $489.77 Total Receipts: $489.77 Permit Status: APPROVED Permit Expiration: 5/3/2005 Construction Value: $2,200.00 Work: TO REPLACE DRAINFIELD (INSPECTOR) 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: Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 11 /4/2004 Applicant: Owner: JOB ADDRESS: 90 Contractor MR C'S SEPTIC TANK Local Phone: 305 - 651 -7859 Parcel # 1132060130890 NE 98 Plumbing Permit Permit Number: PL2004 -317 ST Contractor's Address: P 0 BOX 693239 Page 1 of 1 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOTS 1 & 2 BLK 7 LOT SIZE Fees: FEE2004 -10849 FEE2004 -10850 FEE2004 -10851 FEE2004 -10852 FEE2004 -10853 FEE2004 -10854 FEE2004 -10855 Description Building Fee CCF Notary Fee Training and Education Fee Technology Fee Scanning Fee Builders Bond Total Fees: Amount $175.00 $1.80 $5.00 $0.60 $4.37 $3.00 $300.00 $489.77 Total Fees: $489.77 Total Receipts: $489.77 Permit Status: APPROVED Permit Expiration: 5/3/2005 Construction Value: $2,200.00 Work: TO REPLACE DRAINFIELD Signed: (INSPECTOR) 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: Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Permit Number: PL2004 -317 Printed: 11/4/2004 Applicant: Owner: JOB ADDRESS: 90 Contractor MR C'S SEPTIC TANK Local Phone: 305 - 651 -7859 Parcel # 1132060130890 NE 98 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOTS 1 & 2 Fees: FEE2004 -10849 FEE2004 -10850 FEE2004 -10851 FEE2004 -10852 FEE2004 -10853 FEE2004 -10854 FEE2004 -10855 Description Building Fee CCF Notary Fee Training and Education Fee Technology Fee Scanning Fee Builders Bond Total Fees: Amount $175.00 $1.80 $5.00 $0.60 $4.37 $3.00 $300.00 $489.77 Total Fees: $489.77 Total Receipts: $489.77 Permit Status: APPROVED Permit Expiration: 5/3/2005 Construction Value: $2,200.00 Work: TO REPLACE DRAINFIELD Signed: (INSPECTOR) 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. Plumbing Permit ST Signed: (Contractor or Builder) Contractor's Address: P 0 BOX 693239 BY: Page 1 of 1 BLK 7 LOT SIZE PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date Job Address QO A/ - / 1510 Tax Folio 4 Legal Description Historically Designated: Yes No gl DoR.^g ELI s p G2 Owners Address � D � E • d Phone 50 7 b Owner/Lessee / Tenant Master Permit # X9 �A� f / 2 Contracting Co. P g ' -r J lal ft"-^ - �' Address / 9 3 2 - ,J a. 4 Qualifier •ti eial 1 le.- ' /e SS# Phone 3 ®s 6s/-11C7 State # Municipal # Competency # Ins. Co. Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION / 1110 'raw G.Q� /L 3 re - Square Ft. L F a afar- 4 „:�, 1 , . ..,• •,• 6 .11 tat. t STEPHEN E COCKING State of Florida My Comm. Exp: 08/04/0'• 2 /7 Notary My Commission Expires: L o.,I'eent Da 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 re: g construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated. Signature of • tractor or Owner - Builder / �5a 7�5 6/ Not s to Contra•, or or �w 1tki 11 . 1 My Commission E iF,t ARY PUBLIC STATE OF VUOR COMMISSION NO• f;C714103 MY COMMISSION EX!'. 14 A '2.1,2002 ate Q' / -9f Date FEES: PERMIT RADON C.C.F. f /l 111 C� BOND 3 0 TOTAL DU APPROVED: Zoning Building Mechanical Plumbing Electrical 3Y‘, Engineering STATE OF FLORIDA DEPARTMENT OF HEAL ONSITE SEWAGE DIISP CONSTRUCTION PERMI Authority: Chapte CONSTRUCTION PERMIT FOR: [T`J] New System [ A] xisting Sy ['''] Repair (Abandonment APPLICANT: PROPERTY STREET ADDRESS: 7 LOT: ) ? ,1 BLOCK: SUBDIVISION: f PROPERTY ID #: // _ 3 2 U c w , u , -,,, - 'j r /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] z 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. DEPARTMENT OF HEALTH 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 AND SPECIFICATIONS -7 T [ e', Sv L GAL[ LONE < / GPDS PTIC TApK /AEROBIC UNIT CApa,QS.Or 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 MRS NO. OF PUMPS: [ ) D [9i'�? t FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: (- ]',STANDARD [ 3 FILLED [ ] MOUND ( ] I CONFIGURATION: [ ] TRENCH [�] -BED [ 3 F LOCATION OF BENCHMARK: / --4- ' , "" ) ;--.1. 4 4 I ELEVATION OF PROPOSED SYSTEM SITE ( ,U] (INCHES /FTJ [ABOVE /BELOW BENCHMARK/ ERENCE- O E BOTTOM OF DRAINFIELD TO BE [ 5c/ J (LINCHES/JTJ (ABO BELOW ENCHMARR RENCE QOINT L D FILL REQUIRED: [ )-- I-NCHE S EXCAVATION REQUIRED: 1 INCHES 1 0 H � . R 7` SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: , - / 7 �) OH 4016, 10/96 (Replaces HRS-H Form 4016 (page 1) which may be used) (Stock Number: 5744 -001 - 4016 -0) TITLE: TITLE: BUILDING DEPARTMENT ` CHD EXPIRATION DATE: / 7 4 , , Page 1 of 2 INSTRUCTIONS: PERMIT NUMBER: Permit tracking number by County Health Department. API 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 10D -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. •r Scale: a Notes: /t fin a ;.JCft Ze ,aft � 01> Site Plan submitted by: Plan Approved By . OH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) (Stock Number: 5744 - 002 - 4015.6) I,".1.4, .:.!,a . r STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE ° Permit Application Number ` iCJ , ) PART II - SITE PLAN Each block represents 5 feet and 1 inch = 50 feet? C � STa• 0)-ki S s/u�J �411f QId (7) %'f // /014 7k . e tot 4 / 4 p 7'4 zf 00 / (O ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT . 1/ Date P —"/ Cdunty Health Department Page 2 of 3 Owner's Name and Address Registered Architect and /or Employing Plumber's Name Location and Legal Description Lot Street and Number where work is to be performed—No. State work to be performed and purpose of building (By Floors New Building Remode Addition Amount of Permit $___ 1MIAMI SHORES VILLAGE 5 PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No.4 Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application i$ made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State offFlorida, 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. No._ No. Street Block Subdivision J� r1____L..... Street Type of Tank __Capacity Gals. Size Septic Tank Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well Size of Soakage Pit_ ( Signed) _/ ( Signed) _ epairs No. of Stories Date = / eet 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 Lam 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 notic or notices as are required by the Act. The undersigned agrees. to employ only such sub - contractors, on work to be performed and this permit, as are licensed by Miami Shores Village. Plumbing Inspector. 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 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 state are true. Notary Public, State of Florida 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 faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LA ■4 TORIES SINKS SLOP SINKS LAUNDRY TUBS 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 t CONTR. LIST V� I �- 1 { / CHECK Owner's Name and Address Registered Architect and /or Employing Plumber's Name Location and Legal Description Lot Street and Number where work is to be performed—No. State work to be performed and purpose of building (By Floors New Building Remode Addition Amount of Permit $___ 1MIAMI SHORES VILLAGE 5 PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No.4 Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application i$ made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State offFlorida, 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. No._ No. Street Block Subdivision J� r1____L..... Street Type of Tank __Capacity Gals. Size Septic Tank Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City—Well Size of Soakage Pit_ ( Signed) _/ ( Signed) _ epairs No. of Stories Date = / eet 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 Lam 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 notic or notices as are required by the Act. The undersigned agrees. to employ only such sub - contractors, on work to be performed and this permit, as are licensed by Miami Shores Village. Plumbing Inspector. 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 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 state are true. Notary Public, State of Florida 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 faulty materials and /or workmanship. !MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT / - Permit No ! , 9 0 D Da 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 proyisions 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. Jr J Owner's Name and Address Registered Architect and /or Engineer Employing Plumber's Name it No Street Location and Legal Description Lot — Block r ff Subdivision Street and Number where work is to be performed— No._ _________1_Q ' C , 1v ■ Street State work to be performed and purpose of building (By Floors) New Building Remodeling Addition Repairs No. of Stories STATE OF FLORIDA, t COUNTY OF DADE. ss. � No. Street Type of Tank (Signed Capacity Gals e wo such pu on , work t• •e performed n Notary Public, State of Florida r, o Size Septic Tank Feet of Drain Tile Dist. Feet of Tank or Drain Field,from Well Nature of Water Supply: City —Well Size of Soakage Pit Amount of Permit $ - -- ! --------- --- --------------- ---- - - - - --- (Signed) - Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and acc'epts 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 • -• • ed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the 's' - . •tice or notices as are required by the Act. The undersigned agrfes to employ only such sub - contractor • - his permit, as are licensed by Miami Shores Village. 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 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 BATH TUBS SHOWERS LAVA TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN • DRINKING FOUNT'NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE P IT GREASE TRAP SOLAR H EATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST I — t /) y ` CHECK !MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT / - Permit No ! , 9 0 D Da 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 proyisions 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. Jr J Owner's Name and Address Registered Architect and /or Engineer Employing Plumber's Name it No Street Location and Legal Description Lot — Block r ff Subdivision Street and Number where work is to be performed— No._ _________1_Q ' C , 1v ■ Street State work to be performed and purpose of building (By Floors) New Building Remodeling Addition Repairs No. of Stories STATE OF FLORIDA, t COUNTY OF DADE. ss. � No. Street Type of Tank (Signed Capacity Gals e wo such pu on , work t• •e performed n Notary Public, State of Florida r, o Size Septic Tank Feet of Drain Tile Dist. Feet of Tank or Drain Field,from Well Nature of Water Supply: City —Well Size of Soakage Pit Amount of Permit $ - -- ! --------- --- --------------- ---- - - - - --- (Signed) - Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and acc'epts 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 • -• • ed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the 's' - . •tice or notices as are required by the Act. The undersigned agrfes to employ only such sub - contractor • - his permit, as are licensed by Miami Shores Village. 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 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. 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. Dill Owner's Name and Address Mr No Street Registered Architect and /or Engineer M • R. Wimmer i Contractor McCaughan Plumbing Co.,Inc. 7300 N. E. 4th Ct. Employing Plumber's Name No._ ______ —_ Street Location and Legal Description Lot Block_ Subdi isi - 7 +rill st. S . W. Cor. of N. E. 1st Ave. Street and Number where work is to be performed —No State work t i be performed and purpose of building (By Floors) New Building _ Remodeling Addition Repai> ac No. of Stories fli Size Septic Tank Feet of Drain Tile Nature of Water Sup Amount of Permit $__ STATE OF FLORIDA, 1 COUNTY OF DADE. I ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Type of Tank _Capacity Gals ^L / ++�� Dist. Feet of Tank or Drain Field from Well rm d— ___.m! _____ Size of Soakage Pit 1 ____�� / , 5 0 (Signed) (Signed) tree Date February 19, 1931 / Plumb ector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligati9lis 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 perfonned 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 tli1s ..permit, as are licensed by Miami Shores Village. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take Oftetokledgments, personally appeared 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 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. Notary Public, State of Florida 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 faulty materials and /or workmanship. LAVA- TOIRI ES SINKS SLOP SINKS LAUNDRY TUBS •CATCH URINALS n.• BASIN w • • - DRAIN •RINKING FOUNT'NS - ea er —_ TOTAL FIXTURES CLOSETS BATH TUBS SHOWERS CONTR. 3 1 2 3 1 q ! I. V 1 �� 1 1 it 1 1 J 4 II!: CHECK , r �0 O d SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP 'SOLAR HEATER tEl' WELL SPRKLR. SYSTEM SWIM'G POOL. SEPTIC TANK CONTR. LIST CHECK 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. Dill Owner's Name and Address Mr No Street Registered Architect and /or Engineer M • R. Wimmer i Contractor McCaughan Plumbing Co.,Inc. 7300 N. E. 4th Ct. Employing Plumber's Name No._ ______ —_ Street Location and Legal Description Lot Block_ Subdi isi - 7 +rill st. S . W. Cor. of N. E. 1st Ave. Street and Number where work is to be performed —No State work t i be performed and purpose of building (By Floors) New Building _ Remodeling Addition Repai> ac No. of Stories fli Size Septic Tank Feet of Drain Tile Nature of Water Sup Amount of Permit $__ STATE OF FLORIDA, 1 COUNTY OF DADE. I ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Type of Tank _Capacity Gals ^L / ++�� Dist. Feet of Tank or Drain Field from Well rm d— ___.m! _____ Size of Soakage Pit 1 ____�� / , 5 0 (Signed) (Signed) tree Date February 19, 1931 / Plumb ector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligati9lis 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 perfonned 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 tli1s ..permit, as are licensed by Miami Shores Village. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take Oftetokledgments, personally appeared 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 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. Notary Public, State of Florida 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 faulty materials and /or workmanship. 41.E ;Co/ crq L . 41 41: • BUILDING 1'ERIVIIT APPLICATION NW 2001 Slate 1 JL i N.1111 I✓ JL 1J t -b- Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Is Building flistorically Designated YES NO .loh Address (where the work is being done) Fe 4/6 77 S f Zip 33/3 'I'enanl /l,essee Nance Phone # City Miami Shores Village County Miami -Dade ou xve 1 7 2 f'1a Permit No.P 1 05 5 ter Permit: No. Permit. Type (circle): Building Electrical Mechanical Roofing Owner's Name (Fee Simple Titleholder) je /�� e[q Phone # ( 6 7 Y �r � � ()t�ncr's Address 5 ) 0 / � 7 t 5' -6 Cil }' L�'JIQ�tYI,� //Nei Zih 71/3S tool Factor's Company Nance ('onUacloi Address ('ilti Slate Zip Qualifier Archilccl /13ngineer's Name (if applicable) Value of Work For this Permit Total Fee Now Due $ ((� ontinncd on opposite side) Phone # fit;ilc ('eilificale or Regisilation No. Certificate of Competency No. Phone # Square Footage Of Work: Type of Work: ❑Addition ❑Alteration ❑New Repair /Replace ❑ Demolition Describe Work: k ex /5 SQ/y X /Pt 53s ************ ************fees****************************** Submittal Fee $ Permit Fee $ /So CCF $ CO /CC Nnlar`• $. Training /Education Fee $ Technology Fee $ Scanning $ Radon $ Zoning Bond $ ('ode Enforcement $ Structural Plan Review. $ 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 per►nit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: 1 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constn►clion and zoning. "WARNING TO OWNER: YOUR FAILURE '1'O 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose properly is subject to attachment. Also, a certified copy oldie recorded notice of commencement must be posted al the job site for the first inspe ion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection ► Signature 'Der or Age► The foregoing instrument was ac owledged before me this 1 day of - , 20 y e Urea .�( ) who is personally known to Die or who has produced who is personally known to me or who has produced______ __ As identification and who did take an oath. as identification and who did take an oath. NOTARY P LIC: Sign: �nLi) Print: vil e approved and a reinspecliou fee will be charged. r My Commission Expires: Sign: l j�) 1 c-16- I Print: 1 i • b, LESLIE RACKL E*: �•� ..*: MY COMMISSION # DD 005946 ; , *** E)EPIRE'BtltMetit#ic$!206'� * * * l y ,j ' ' pf,: Bonded Thru Notary ublic Underwriters * * * * * * * * * * * * * * * * * * * * * * * ** ** * * * * * * * * * * * * * * * * * * * * * * * * * ** ** ** ** $*'******************************************************** APPLICATION APPROVED B Chi 05/13!13 Signature NOTARY PUBLIC: My Commission Expires: Contractor The foregoing instrument was acknowledged before me this day of , 20 , by ********************** * * * * * * * * * * * * * * * * * * * * * ** * * * * * * ** U 3 Plans Examiner Engineer Zoning Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 2/25/2005 Applicant: Owner: JOB ADDRESS: 90 Contractor Local Phone: Parcel # 1132060130890 NE 98 Signed: (INSPECTOR) Signed: (Contractor or Builder) Plumbing Permit Permit Number: PL2005 -58 ST Contractor's Address: Legal Description: MIAMI SHORES SEC 1 AMD PB 10 - 70 LOTS 1 & 2 Fees: FEE2005 -2514 FEE2005 -2515 FEE2005 -2516 FEE2005 -2517 FEE2005 -2518 Description Building Fee CCF Training and Education Fee Technology Fee Scanning Fee Total Fees: Amount $150.00 $0.60 $0.20 $3.75 $3.00 $157.55 Total Fees: $157.55 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 8/16/2005 Construction Value: Work: LAWN SPRINKLERS SYSTEAM 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. BY: Page 1 of 1 BLK 7 LOT SIZE MIAMI SHORES VILLAGE BUILDING DEPARTMENT '7 305- 795 -2204 u (ding Inspection Request �� r Type Insp'n n3 \ ‘f Permit No. v■ as -s Name /c Address CIO N e— Company Phone # Inspection Date Approved Correction Re-Insp'n Fee 5KETC l-1 of BOU NDkRY SURVEY ADD IZE s S 90 NE IS rH STREET Si1oRE .s, FL 3313 8 NE qg 1" 1 STY GB $ 2E 5. 1" P V MT 51- 75' R V� • 3(7 ti's 3 /44-4e :pith 4 ce �Jc IFece I06.0O . (F) IS PAVE) 64/47dAylivA 7 , s1 - 74 707 imind qi 04 012 dfiqi APL / --/11 ,5' UDJECT TO COMPLIANCE WITH ALL FEDERAL, STATE AND COUNTY RULES AND REGULATIONS. APPROVED ZONING t S; 2;;CTURAL r li ELECTZiCA, a ` d ' PLUM3ING MECHAN .0AL BLDG. il BY DATE It', r4tLCEO1VE Y If s 2 5 2H5 II OWNER BUILDER DISCLOSURE STATEMENT IG.,. pp, fr. ca Located at: 70 ,v6 ?g Sfie-t Legally described as /1!%q h; $htes 5c. / Oa/ /o - 7D f A'Z . Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S. 489.103(7),,,nd I have read and understand the following disclosure Statement, which entitles me td *ork as my own contractor, I further understand that I as the owner must appear in person to complete all applications. State law requires construction to be done by licensed contractors. You have applied for a permit under an exemption to that law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two-family residence or a farm out - building. You may also build or improve a commercial building at a cost of 525,000.00 or less. The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is completed, the law will presume that you built it for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as your contractor. It is your responsibility to make sure that people employed by you have licenses required by state law and by county or municipal Iicensing ordinances. Any person working on your building who is not Icensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A. and with- holding tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, building codes and zoning regulations. Proof of ownership provided ( ) initial of reviewing clerk. The foregoing instrument Was acknowledged before me this 1 day of Peb. , 20 By 6o 4 p p t2 f67e who is personally known to me or who has Produced as identification and who did take an oath. VILLAGE OF MIAMI SHORES BUILDING DEPARTMENT being the legal property owner, for the property DISCLOSURE STATEMENT `gebwet-e 20.2RP Notary 1 LESLIE RACKL :._ =46' 1-ks MY COMMISSION H DD 005946 . :1 EXPIRES: . p 5 Bonded Tim Notary Public d�vi 1 ITEM BATH TUB UNIT FEE ITEM SWITCH OUTLETS UNIT FEE ITEM SPACE HEATERS UNIT FEE BIDET LIGHT OUTLETS CENTRAL HEATING DISHWASHER RECEPTACLES A/C (WIND) DIAL SERVICE TEMPORARY A/C (CENTRAL) DRINKING FOUNTAIN SERVICE SIZE IN AMPS DUCT WORK FLOOR DRAIN SERVICE REPAIR/METER CHANGE REFRIGERATION GREASE TRAP APPLIANCE OUTLETS PROCESS AND PRESS PIPING INTERCEPTOR RAGE TOP UNDERGROUND TANKS LAVATORY OVEN ABOVE GROUND TANKS LAUNDRY TRAY WATER HEATER U.F. PRESSURE VESSELS CLOTHES WASHER MOTORS 0- 1 HP STEAM BOILERS SHOWER MOTORS OVER 1- 3 FP HOT WATER BOILERS SINK, POT /3 COW'. MOTCRS OVER 3- 5 HP MECHANICAL VENTILATION SINK, RESIDENCE MOTORS OVER 5- 8 HP TRANSPORTING ASSEMBLIES SINK, SLOP MOTORS OVER 8- 10 HP ELEVATORS/ESCALATORS TEhFORARY WATER CLOSET MOTORS OVER 10- 25 HP FIRE SPRINKLER SYSTEMS URINAL MOTORS OVER 25-100 HP COOLING TOWERS WATER CLOSET MOTORS OVER 100 FP VIOLATION INDIRECT WASTES - A/C WINDOW REINSPECTION WATER SUPPLY TO: AIR CONDITIONERS A/C UNIT STRIP HEATER FIRE SPRINKLER GENERATORS TRANSFORMERS 'HEATER -NEW INST. GENERATORS TRANSFORMERS HEATER - REPLACE i GENERATORS TRANSFORMERS LAWN SPRINKLER=Witk 1 SPECIAL PURPOSE SWIMAING POOL OUTLETS COMdERCIAL WATER SERVICE SIGN TUBES SEWER CONNECTIONS SIGN TRANSFORMERS UTILITY -SEWER SIGN TIME CLOCK UTILITY -WATER FIXTLRES SEPTIC TANK ANTENNA RELAY TELEVISION OUTLETS DRAINFIELD, 4' TILE/RES. VIOLATION PUM' & ABANDON SEPTIC TANK REINSPECTION SOAKAGE PIT CU. FT. CATCH BASIN DISCHARGE WELL DOMESTIC WELL • AREA DRAIN ROOF INLET SOLAR WATER HEATER FIRE STANDPIPE POOL PIPING LAWN SPRINKLER SYSTEM GAS RANGE M`TER SET (GAS) GAS PIPTN2 A. ENDUM TO BUILDING PERMIT APPLICATION (AN APPLICATION FOR BbILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS B. OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS.) PLUMBING ELECTRICAL MECHANICAL