1210 NE 100 St (13)Dat
Legal
Owner / Lessee / Tenant C-)d } Ey:46E4f, / Master Permit # "� 4� " %/
1
Owner's Address /'Q./° ✓f/ f°'' rag 7 Phone / 7j - , /(7 7
Contracting Co. 4/), � /'4!r-- l ;C Address 1 / ( 7o 4 3 /I/fG‘. (/‘ ,i 2r--
S4_ Phone 4 :' 933 7
Job Address /0 4F Tax Folio
Description
State # Municipal #0)1 Competency # Ins.Co. 9
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Address
Architect/Engineer
Bonding Company
Mortgagor
Permit Type(circle one): BUILDING ELECTRICALI
WORK DESCRIPTION
Address
Address
./
MECHANICAL ROOFING PAVING FENCE SIGN
Square Ft. 3c2r Estimated Cost(value) 6
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.
Sig
Dat
Nota j:s to Owner -nd /or
ission Expi es:
a? /8
resident
Mechanical Plumbi
Signatur- of Contp ctor or Owner- Builder
Date:
tary as to Co
Commiss o xpi
-,i
*
v +nr nr owner- Builder
es: OFFICIAL NOTARY SEAL
JORGE A JEREZ
NOTARY PUBLIC STATE OF FLORID
COMMISSION NO. CC267905
MY£OMMISSION EXP.1MAR.171907
FEES: PERMIT RADON C.C.F. I NOTARY TOTAL DUE
APPROVED: Fire Other
Buildin
Electrical
Engineering
APPLICANT:
LOT:
PROPERTY ID #:
BLOCK:
TANK INSTALLATION
[ ] [01] TANK SIZE [1]
[ ] [02] TANK MATERIAL (I)
[ ] [03] OUTLET DEVICE
[ ] [04] MULTI — CHAMBERS
[ ] [05) LEGEND
EXPLANATION OF VIOLATIONS:
[
[
[
[ ]
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE.SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter 10D -6, FAC
PROPERTY STREET ADDRESS:
I A7
[ ) [06] WATERTIGHT
[ ] [07] LEVEL
[ ] [08] DEPTH OF LID
DRAINFIELD INSTALLATION
[ •. [09) AREA [1]`:,.,.5'Y /2 [2]300 SQFT
[ .„.. 1 [10] DISTRIBUTION BOX/HWEVEP
[ - [11] NUMBER OF DRAINL.INES
[ ,.-er°
[12) DRAINLINE SEPARATION
DRAINLINE SLOPE
[;-71' [14] DEPTH OF COVER
[;;• j [15] SYSTEM ELEVATION
[ colr" [16] SYSTEM LOCATION
[5) [17] DOSING PUMPS
[ --/ • [18] AGGREGATE SIZE
[ ✓J [19] AGGREGATE SOURCE
[It] [20) AGGREGATE WASHED
[21] AGGREGATE DEPTH
FILL /EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] EXCAVATION AREA ,
[26] REPLACEMENT MATERIAL
SUBDIVISION:
; AGENT: 141 f L �] �.` ~� * G f`3 „•€� .
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
CONSTRUCTION ,[•APPROVED7'DISAPPROVED] : , iiteb (-1441
FINAL SYSTEM TARPROVEDjDISAPPROVED] :
SETBACKS
[ ] [27] SURFACE WATER
[ € ] [28] DITCHES
[I ] [29] PRIVATE WELLS
[ [30] PUBLIC WELLS
[ f] [31] IRRIGATION WELLS
[i ] [32] POTABLE WATER LINES
[1 ] '[33] BUILDING FOUNDATION
[ [34] PROPERTY LINES
[ ] [35] OTHER
ADDITIONAL INFORMATION
[a [40] UNOBSTRUCTED AREA
[ ] [41] STORMWATER RUNOFF
[ ! ] [42] ALARMS
[I ] [43] MAINTENANCE AGREEMENT
[ ] [44] BUILDING AREA
[ ] [45] PLUMBING FIXTURES
[ 1 ] [46] FINAL SITE GRADING
[ 1 ] [47] CONTRACTOR awe'(,! ! ` ; 1).61(t Pri
[ ] [48] OTHER
ABANDONMENT`
[49] TANK PUMPED
[50] TANK CRUSHED AND FI
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4016-4)
FILLED /MOUND SYSTEM
[t ] [36] DRAINFIELD COVER
[ ] [371 SHOULDERS
[ ]
[38] SLOPES
[ ] [39] STABILIZATION MATERIAL
INSTALLER /CONTRACTQRti
PERMIT # :/
RECEIPT # •a6
FEE PAID $ i /22 r
DATE PAID if, •-
/
/ /
" — :r
�4' . •� CPHU DATE : _ /rte
a �
CPHU DATE: e "97
Page 2 of 2