1351 NE 101 St (10)BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder)
Owner's Address 5 /
State
city ft, 54
Tenant/Lessee Name
Job Address (where the work is being done)
City Miami Shores Village
Is Building Historically Designated YES
Architect/Engineer's Name (if applicable)
Total Fee Now Due $
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Contractor's Company Name 4 P Se .7.;'c ` ! Ohone #
Contractor's Address /2 ,1/ Piz / Z C°i�
City - t 2 s f State �f Zip
Qualifier
a dd
Electrical
vefi
� /2 r✓L_ e
County Miami -Dade Zip —3 -3 /3 g
NO
/ VI
Submittal Fee $ Permit Fee $ f 7)
Notary $ ( Training/Education Fee $ ►
Scanning 13 s Radon $
Code Enforcement $ structural Plan Review. $
Permit No. PL 9.0 9 r 37
Master Permit No. c R - 03 1
Mechanical Roofing
A 3rd /1C S Phone # - 2 cp
Zoning
i c2
c y
Zip '? "
Phone #
Phone #
3 0 5 Z 7-g3Za
$ Value of Work For this Permit Square Footage Of Work:
Type of Work: ❑Addition ❑Alteration ❑New i... ❑ lace Re P air/Re P Demolition
/'
Describe Work: « 3oo S� I% f�T /7! -j mart / e'i / ppi eJC r.ST7
J
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
CCF $ I. 2 O CO /CC
Technology Fee $ 3 7
Bond $ 3aa "
4;444
r -
FE3 16'
/(/A
Bonding Company's Name (if applicable)
Bonding Company's Address
w
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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
The for
day of
who i
NOT
Sign:
Print:
My Commissi
* * * * * * * * * **
State Certificate or Registration No.
Chc 12/15/03
!edged before me this
or w to has produced
\ dn
* * * * * * * * * * * * * * * * * * * * * * * * ** * * *
d� ,
APPLICATION APPROVED c Y. ' , _
State f ' / i Zip
t 1 and who did take an oath.
The foregoing
day of
who is perso
NOTARY P
Sign:
Print:
(Certificate of Competency Holder)
*********** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Contractor
Certificate of Competency No.
*************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Plans Examiner
Engineer
Zoning
CONSTRUCTION PERMIT FORg
EttY: New System. - [t
Repair
,
APiii CANT , „ ;;;Li. (.4
—
PR
,EK2Y ADDRESS:..: -.:,
r4
PROMERTY ID#,
...,:.!
- SYSTEM MUST BE"CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.8., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
, .. . • .
• • . . -
• . .
SYSTEM DESIGN AND SPECIFICATIONS
T 00],ajkotia / GPD SEPTIC TANK/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 DOSING TANK CAPACITY [ 1 GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ]
`‘b
D 3 0 0 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
SYSTEM
A'TYPE SYSTEMVA■./..] STANARD [ ] FILLED [ ] MOUND (
'CgINFIGURATION ] TRENCH (4 BED 1
F LOCATION OF BENCHMARK: ) 0 1 G. J C . r
I ELEVATION OF PROPOSED SYSTEM SITE [32,Lia LWOW/FT] [ABOVE/BELOW]
E BOTTOM OF DRAINFIELD TO BE [0:6o] [INCHES/FT] [ABOVEZBELOW]
L
D FILL REQUIRED: [AA ] INCHES EXCAVATION REQUIRED: [ iZ ] INCHES
O "
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF. FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Existing System
Abandonment
0
SO
BLOCK: SUBDIVISION:
:32 0 6
VAk fmA.
2 / / 0
(1 )
.[ Holding Tank
Temporary
. It or 1-72 1.
/ 1.4.t. kcrre &4f
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
krIUM GI
UNDER. BOTTOM OF r ATNIPTFI n
THIS PhRIVII .IS NO 1 FOiUiiU
PERMIT NO. i ? - 4 3 El
DATE PAID: 7 - Li -
FEE PAID: 7,c G
RECEIPT #: C) 1
I 7 '3 S - 12.
Innovative
'BENCHMARK/REFERENCE.POINT
BENCHMARK/REFERENCE POINT "
IN V La A
1 • C.J
BU110A6A)r-u
I -) 6 VOAFFR. OF EXC wATIDA' lig
AT 1.1AST .2..C 7= --7- 7 7 7 1 .::' 7 : - 7 - .;N r T"
PROPOSM ilo2LORI OVRAIN TR-.
TITLE: 6lAL 0 (r<4e c
EXPIRATION DATE:
DATE:
DH 4016, 12/99 (Page 1) (Previous Editions May Be Used) Page 1 of 3
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer/Contractor
pt. 4: Building Department
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
E2EIVfV
BLOCK: Z SUBDIVISION:
. P. .sOr\Q-5
APPLICANT:
LOT:
PROPERTY ID #: //_ > � 2>73_ QO a [Section /Township /Range /Parcel No. or(ax ID Numb
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: 01 YES [ ]
TOTAL ESTIMATED SEWAGE FLOW: Z027 GALLONS
AUTHORIZED SEWAGE FLOW: ,6 S GALLONS
UNOBSTRUCTED AREA AVAILABLE: ..30
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS 2,
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: A/,(11 FT DITCHES /SWALES: / FT / NORMALLY WET? [ ] YES [Wig
WELLS: PUBLIC: /V /A FT LIMITED USE: 4///4 FT PRIVATE: /V`,44/ FT NON- POTABLE: /P/ FT
BUILDING FOUNDATIONS: Si FT PROPERTY LINES: /) FT POTABLE WATER LINES: ZQ FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ NO
10 YEAR. FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used)
(Stock Number: 5744 - 003 - 4015 -1)
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ✓
NO NET USABLE AREA AVAILABLE: ,Z S 8' ACRES
PER DAY CRERT FS ABLE 1 / OTHER -TABLE 2]
PER DAY [1500 GPD /ACRE OR 1500 GPDtACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: G7,&? SQFT
[INCHES
/
OBSERVED WATER TABLE: ti/'A INCHES [ABOVE.- %YBELOW
ESTIMATED WET SEASON WATER TABLE ELEVATION*
HIGH WATER TABLE VEGETATION: [ ] YES [ NO
AGENT:
10 YEAR FLOODING? [ ] YES [O
FT MSL /NGVD SITE ELEVATLON[: !r, ( FT MSL.1,22a
SOIL PROFILE INFORMATION SITE 2
, 431
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY: .4/"2 'P_ 9- _..,-__ --
PERMIT #
CYO/ to c1
f )
Wca / a c. C eoridc.
H/Ar(; ShvKes IL D"GIrk
3' N T IA_
[ABOVE / 1i"] BENCHMARK/ FERENCE PO
Munsell # /Co'1or Texture
I0 V2 ,L1Y23
/ l
I 0 Z /' /
1l
\ \ . 1
/ / •
U ' DA SOIL SERIES:
Depth
� U :to
to
to
to
to
to
to
to
2'
EXISTING GRADE.
INCHES [ ABOVE /
TYPE•
MOTTLING: [ ] YES [ t,.]- ,DEPTH
Xv h/e DEPTH OF EXCAVATION,
ERCHED / APPARENT]
] EXISTIar DE.
] BED [ ] OTHER (SPECIFY) 4-7
DATEG'� r V
INCHES
INCHES
Page 3 of 3
Notes:
e)0
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CO NSTRUCTION PE
Permit Application Number
------ — ----
PART II - SITE PLAN- — — — — —
Scale: Each block represents 5 eet and 1 inch = 50 feet.
__ ______________ „ ate I •
).-.- -; ; Z.
i I
•••••••••■••,■••••••••P.4.44.2...
4-4 -- I-- ' -,t-1-4-4- --L •,--• '-4-4--b -- :1
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- -..71---*--7--
- t__-t.... - i ' '. - ' - 4 , te 4 4 - .., . s 1 , r .....,..___4:L.:-. ■ . .1" -11- -:',,-/T-4-i -,. .1`c -,,.-..,.. ... _ .__ ,I. ... _
ii .1
+.
.
„: 5, ,L
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. 1
....... 5.._ .1- .7."$._ ' -II,.1'irj'-::.fl-Se.7 j' .;.12:....±14:-.L.-17.:7-7::i "-:;.4"..-.e'.1-\j"'"4::
I 4 s ....,„: ...: , ?- „
' 4 - ' 4 - .. :- -4-- , .1 ,
' 1 1~ V . ,- ' '
. - 1* - - -. - --.1 -. ,
' ' , ' ■ I ' , , , , I ,
f-L-1--1,--i-ii-4 : .--H--4:-1-+._i4_I .....ji.....1_-.1.
' t ' t -1-1-1- -.i.--r --1- i-4-i ---f --4-
-t- . , , .1.....L .
--4-1-4.-
-
_ ,T
-- ' - 4 --T....
-i___ _I
ite Plan submitted by:
Ian Approved
gnature
Not Approved
Date fr
44(44, _AgFte
County Health Department.
axes h may be wed)
ALL C ANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
715 1 0/96 (Fixpl HRS-H Fcxm 4015 whic
Number: 5744-002-40154)
2; 2 f- 3 -
PROPER
0
T
H
E
R
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
• { . •
•
• •
• • •
• •
DATE ISSUED:
SPECIFICATIONS BY:
APPROVED BY:
DH 4016, 12/99 (Page
•
D FILL REQUIRED: (1 ] INCHES EXCAVATION REQUIRED:
21 1 4- I o
Ug\c-c. c
1) (Previous Editions
/ a I . ii c Sli cies - 1-=
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer/Contractor
pt. 4: Building Department
4 1 iNcHEs'
t "
1NSTALI I OF ELIGHWLYLIMIT7 Sari
UNDER BOTTOM AINCTP-T fl
PERMIT NO. COW- 6 3
DATE PAID: 2, - -
FEE PAID: 7 ,C cTO
RECEIPT .#: (-1 c.q,,o
1 (=> - l , 4 I
Innovative
14.,L skume
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE 'CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T (C1 00] / GPD SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN-SERIES I ]
A [ ] GALLONS / GPD CAPACITY MULTI - CHAMBERED/ IN- SERIES [ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK : 1250 GALLONS]
K r ] GALLONS DOSING TANK CAPACITY [ ] GALLONS go [ 1 DOSES PER 24 HRS # PUMPS [ ]
D FZr3 0 0 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R -- 1 SQUARE FEE/ SYSTEM
A TYPE SYSTEM:-": [V] STANARD [ 1 FILLED [ ] MOUND 1 ]
I CONFIGURATION: 1 ' [ ] TRENCH [ A BED [
N
F LOCATION OFBENCHMARK 0 • 6fev.
I ELEVATION OF PROPOSED SYSTEM SITE [32,4a IIKEEPFT] [ABOVE/BELOW]
E BOTTOM OF DNAINFIELD TO BE (q. (,Q] [INCHES/FT] (ABOVE/BELOW] BENCHMARK/REFERENCE POINT
BENCHMARK/REFERENCE POINT
THIS Pt:111 IS NO I k01(
IN V t.1..Z. I t, e
May Be Used) Page 1 of 3
3 I30110.1viUr
1 rtNIA„-'11; OF E),,q: A.TiOr&Vg.:e64..Vb ;
Ai -- LA-1,t-i3T !LC)
PROPOSTID GVRAIN I
TITLE:
EXPIRATION DATE : CI'
APPLICANT:
LOT:
3
PROPERTY SIZE CONFORMS TO SITE
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
SOIL PROFILE INFORMATION SITE 1
SITE EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
E
PLAN:
,!o
30 0
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3j which may be used)
(Stock Number: 5744- 003 - 4015 -1)
BLOCK: a SUBDIVISION:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS 2,
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ NO
( WJf,0'J
OBSERVED WATER TABLE: AMA INCHES [ABOVE%
ESTIMATED WET SEASON WATER TABLE ELEVATION•
HIGH WATER TABLE VEGETATION: [ ] YES ( NO
AGENT:
REMARKS /ADDITIONAL CRITERIA:
i
PERMIT
! / -,i 1c1
f'
VI/cJt llaGC r)dc
1/1/ ( 64M/ '
// 61 M / 5 P' C s &G? / , gr /-
PROPERTY ID i s / 32a5 723 p0 a0 [Section /Township /Range /Parcel No. orCiax ID Nt tuber)
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.
[vc YES [ ] NO NET USABLE AREA AVAILABLE: ,Z 5 8" ACRES
GALLONS PER DAY (XF.ST F M S ABLE 1 / OTHER -TABLE 2 ]
GALLONS PER DAY [1500 GPD /ACRE OR
SQFT UNOBSTRUCTED AREA REQUIRED: O SQFT
]
[ INCHESJ [ABOVE / j ] BENCHMARK /,FERENCE PO
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: fV ol FT DITCHES /SWALES: N /41 FT NORMALLY WET? [ ] YES [ L]-1Q0
WELLS: PUBLIC: /y/A FT LIMITED USE: /1/ //4 /�
FT PRIVATE: ,/,4 FT NON- POTABLE: /4/I FT
BUILDING FOUNDATIONS: -.P FT PROPERTY LINES: / FT POTABLE WATER LINES: Z FT
10 YEAR FLOODING? [ ] YES [ -]•
;aro //
10 YEAR.FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVAT]ONt: ,.�,to\ FT MS141TelE1
4
SOIL PROFILE INFORMATION SITE 2
'BELOW EXISTING GRADE. TYPE ERCHED / APPARENT]
if INCHES [ ABOVE / =ELO ) EXIS� j I �N r G CR DE.
MOTTLING: [ ] YES [ • 1,} -1r5� , DEPTH: y� INCHES
-- c2h/e DEPTH OF EXCAVATIONIC_ INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING :,
DRAINFIELD CONFIGURATION: [ ] TRENCH [V] BED [ ] OTHER (SPECIFY) 7
DATE2 r O /
Page 3 of 3
Notes:
— PART II - SITE •LAN-
Scale: Each block represents 5 eet and 1 inch = 50 feet.
ite Plan submitted by:
Ian Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CO NSTRUCTION PE
Permit Application Number
---
---
gnature
Not Approved
---
le
Date
MEMO
• '
County Health Department,
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
)15, KM (Replaces HRS-H Form 4015 which may bowed)
Number: 5744-002-401544
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 2/9/2004
Applicant: EVELYN
Owner: JONES
JOB ADDRESS: 1351 NE 101
Contractor W P SEPTIC TANK CO INC
Local Phone: 305 - 620 -6320
Parcel # 1132050230080
Signed: (INSPECTOR)
Signed: (Contractor or Builder)
Legal Description: M SHORES BAY PK ESTS PB 55 -83 LOT 3
Fees:
FEE2004 -1356
FEE2004 -1357
FEE2004 -1358
FEE2004 -1359
FEE2004 -1360
FEE2004 -1361
Description
Building Fee
CCF
Training and Education Fee
Technology Fee
Scanning Fee
Builders Bond
Total Fees:
Amount
$175.00
$1.20
$0.40
$4.37
$3.00
$300.00
$483.97
Total Fees: $483.97
Total Receipts: $483.97
Z -S_
Permit Status: APPROVED Permit Expiration: 8/3/2004 Construction Value: $2,000.00
Work: INSTALL 300 SQ FT OF DRAINFIELD ON EXISTING TANK
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
Permit Number: PL2004 -39
JONES
EVELYN
ST
Contractor's Address: 17235 NW 12 CT
BY:
Page 1 of 1
BLK 2 LOT SIZE 99.600 X
Y
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
1
Lot
m ❑ PERMIT N? 14882
L!irl
❑ Work to be performed under this Permit
�.
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
Subdi-
vision
Value of
Project $
DATE , ;, 195 -
Contractor's
License No
Amt. of
Permit
•
BY AUTHORITY
$ I
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 understanding 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 the plans or drawings or in the statements or specifications and that he assumes responsibility for work
done by his agents, servants or employees.
, t
Signed: ! , l �r "'r p' BY'
ar .:i • i i a a .. . /c4Y"'"
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 responsibility for all work done by either, myself, my agent, servant or employee.