1165 NE 100 St (6)penult 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.
• (14Z
Owner's Name and Address
Registered Architect and /or Engineer ' ,� 1 n /��-� !� / f�
Em to P1 tier's N g, ile.to _ S ' " NO1. Z ! ,....�.,
. l;ICG�,. . ...... gtreetl.�':�." -t�. Qce.
// 'Loon an d `(/ Legal escriptio Lo �� /� s1oc3� / subdi,•Ision._? )) '
/l Street and Number where work is to be performed —No St a t. W •� / (O ST • -- - -
State work to be performed and purpose of building (By Floors)___ eY.Z1.1.5.e _ yr, ,
New Building Remodeling__ —_ ___ - - -_ Addition.- .__ - -_— Repairs No of Stories ....
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Size Septic Tank__._—_— S AL _. of Tank.—_ �(S� Capacity Gala. - -_ -- _
Feet of Drain
Nature of Water Supply: ell.—
Feet of Tank or Drain Field from Well
of Soakage Pit
Amount of Permit $ � r a" ( Signed) 0
Date
No. H&C Street' /00 S _'.
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 5988, 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 - contractor the work to be
performed under this permit; and will post or cause to be posted' for inspection on the si - -. wor such pu notke •+ notices as are
required by die Act. The undersigned agrees to employ only such sub- contract • on work. ; perf • nder s permit, as are
licensed by Miami Shores Village.
My Commission Expires Notary Public, State of Florida
Plumbing Inspector.
STATE OF FLORIDA, I µ
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 andapplication, says that hth hat he did sign the same, and that all fads
of the above described construction, that he has carefully read the foregoing gn
therein by him stated are true.
NOTE: A re- inspection fee of ;1.00 will be made when ach re inspection L made•neoewry by improper notice for inspection, or faulty
materials and /or worlananship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA-
TORIgS
SINKS
SLOP
IN
smug
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
SWIM'O
POOL
Co. NTR
LIST
CHICK
penult 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.
• (14Z
Owner's Name and Address
Registered Architect and /or Engineer ' ,� 1 n /��-� !� / f�
Em to P1 tier's N g, ile.to _ S ' " NO1. Z ! ,....�.,
. l;ICG�,. . ...... gtreetl.�':�." -t�. Qce.
// 'Loon an d `(/ Legal escriptio Lo �� /� s1oc3� / subdi,•Ision._? )) '
/l Street and Number where work is to be performed —No St a t. W •� / (O ST • -- - -
State work to be performed and purpose of building (By Floors)___ eY.Z1.1.5.e _ yr, ,
New Building Remodeling__ —_ ___ - - -_ Addition.- .__ - -_— Repairs No of Stories ....
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Size Septic Tank__._—_— S AL _. of Tank.—_ �(S� Capacity Gala. - -_ -- _
Feet of Drain
Nature of Water Supply: ell.—
Feet of Tank or Drain Field from Well
of Soakage Pit
Amount of Permit $ � r a" ( Signed) 0
Date
No. H&C Street' /00 S _'.
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 5988, 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 - contractor the work to be
performed under this permit; and will post or cause to be posted' for inspection on the si - -. wor such pu notke •+ notices as are
required by die Act. The undersigned agrees to employ only such sub- contract • on work. ; perf • nder s permit, as are
licensed by Miami Shores Village.
My Commission Expires Notary Public, State of Florida
Plumbing Inspector.
STATE OF FLORIDA, I µ
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 andapplication, says that hth hat he did sign the same, and that all fads
of the above described construction, that he has carefully read the foregoing gn
therein by him stated are true.
NOTE: A re- inspection fee of ;1.00 will be made when ach re inspection L made•neoewry by improper notice for inspection, or faulty
materials and /or worlananship.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant H• "--/EN de Z � " ber ,0 6
L), E /00 Jr ( �/I
PART I1 - SYSTEM INSTALLATION INSPECTION AND FINAL INSTA LATIONAPPROVAL
Installer -.6kA;AiRitc
Proper tank legend: Yes
Tanks watertight: Yes
Proper tank outlet device: Yes No
Drainfield Trench
Length Width Length Width Length .i- '/feetx 9 feet =Lft
feet - - fee f- -t Length —feet x feet = — ft
feet feet feet feet Proper No. drainlines: Yes ,/ No
et eet -et -et Proper pipe separation: Yes No
ft Distribution box level: Yes No
Total =
ft
Systems located as permitted: Yes No
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade a inches Maximum depth: - 29-Inches
Average depth of drainfield gravel: 0, inches Minimum depth of gravel _ inches
Proper gravel size: Yes No Gravel is suitable quality: Yes "✓ No
Backfill or fill material as required: (Quality) Yes ✓ No (Quantity) Yes ✓ No
Other findings
Inspected by ?4-r. i / (//Mi)ci
Date
Approved by:
AN APPROVED IN ALLA OES NOT GUARANTEE PERFORMANCE
Note: Completed copies of this form wi I be provi• -d to the applicant, installer and the building department.
Page 2 of 2
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4016-0)
97 t _LA C Tank Manufacturer
Tank material
Tank size
Total =
INAT4LLATION APPROVAL
Tank level: Yes Al No
gallons gallons gallons
No
A/A
Manhole or marker to grade: Yes
Absorption Bed
Date / /Y/
COUNTY PUBLIC HEALTH UNIT
UILDING •
ECTRICAL
UMBING
wner of
Aiding
chitect
ontractor la
Builder
:gal Lot
escription
MIAMI SHORES VILLAGE, FLORIDA
PERMIT N? 5363
Work to be performed under this Permit
e' cf
Bl.
Subdi-
vision
dress of e ,,, Value of Amt. of /
iilding /i ll C 1 ` 1,, ` el C w Project Permit . - /
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device describes• in the appli-
tion herefor in strict compliance with all ordinances pertaining thereto and w'th the understanding that the work will be performed in compliance with any
ins, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
any time if the work is not done in compliance with such ordinances or if the plans . 6 chanted witl out authorization. A further condition upon which this
rmit is granted is the understanding that the contractor or builder named above as es espon .ility a thorough knowledge of the ordinances and
',illations pertaining to the work covered hereby whether shown on the plans or l t • � i ter i cit; s"reorfieations and that he assumes respon-
;ility for work done by his agents, servants or employees. ,�, �, ` '
Signed • : A ' i..±;r - By
INSPECT
In consideration of the issuance to me of this permit I agree to perform the work coveted hereunder in compliance with all ordinances and regulations
rtaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
acce tin this permit I assume responsibility for all work done by ether ?ysee f, my/gent, servant or employee.
Jy/a /��/ """
•
DATE 194_
Contractor's
License No
CONTRACTOR OR BUILDER BY AUTHORITY