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145 NE 101 St (15)Approved Correction Re- Insp'n Fee MIAMI SHORES VILLAGE BUILDING DEPARTMENT 305- 795 -2204 Building Inspection Request Date 61- o Time O-� Type Insp'n (51 raiiK Permit No. ,PL .2 - 73 Name Address Company d- L 4 ' "I Phone # For Inspector: 6-/p.. Date RECEIVED PERMIT APPLICATION FOR MIAMI SHORES VILLA _ 1 2003 10050 N.E. 2nd Avenue • Miami Shores, Florida 33138 • Phone: 305- 795 -2204 • Fax: 305 -7 -89' 2 Date 63 Job Address / T !�/C // Legal Description Historically Designated: Yes No Lessee/Ten" et /77' ' Owner's Address /4/5 /e)/ Contracting Co. i �6 ...E047 ` - 'r' v � 5V-1/ / * CC s �/Z Qualifier State # � � � J 89d-k7 Municipal # Permit Type (circle one): WORK DESC ION: BUILDING FEES: PERMIT / (1 RADON APPROVED: Zoning Building Mechanical ELECTRICAL .9GGf9/7a;V Square Ft. Estimated Cost (value) regulating construction and zoning. Furthermore, 1 authorize the above named contractor to do the gnatur• of owner and/or Condo President Date Notary as to Owner and/or Condo President Date My Commission Expires Master Permit` $ 20 3 - o{ aO Phone .3•C tkO • �3 • Address /0667 At ' .ee- -sWif& C.C.F Tax Folio SS# Phone 23/ 2ZZ— Competency # Ins. Co. IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY, THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE BEFORE CALLING FOR ANOTHER INSPECTION. LUMBING J MECHANICAL ROOFING 2G66,ez) 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 ANY 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. 1 understand that separate permits are required for all disciplines. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work wil done in compliance with all applicable laws Aiglk rk state otary as to C tractor My Commission Expir Contractor or Owner Builder Date L - S6 -0 Owner B. der Angela M Becker • My Commission DD150045 %%01 Expires November 15, 2008 a s NOTARY S, � BO D 300 tf�t� TOTAL DUE Electrical Structural Engineer ate STATE OF FLORIDA' , DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ X ]New System [ ]Existing System [ [ ]Repair [ ]Abandonment APPLICANT: Pijuan, Michelle M. PROPERTY STREET ADDRESS: 145 NE 101 St Miami FL 33138 LOT: 20 BLOCK: 14 SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3206 -013 -1940 [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 [ 900 ]Gallons SEPTIC TANK A [ 0 ]Gallons N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS Q D [ 429 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ Y ]STANDARD [ N ]FILLED I CONFIGURATION: [ N ]TRENCH [ Y ]BED N F LOCATION TO BENCHMARK: CL NE I ELEVATION OF PROPOSED SYSTEM E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: [ 0.0 ]INCHES OTHER REMARKS: *Install a 900 gl. C -1 septic tank with an approved *Install 429 sq.ft. of drainfield. (it shall have a *Invert elevation to be no less than 9.00' NGVD. *Bottom elevation to be no less than 8.50' NGVD. SPECIFICATIONS BY: Icaza, Carlos APPROVED BY: Icaza, Carlos DATE ISSUED: 2 q AGENT: OWNER, 101 St. & E PL., 11.34' NGVD. SITE [ 4.1 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT [ 34.1 ] [ INCHES ] [ BELOW] BENCHMARK /REFERENCE POINT 03 �,�� �H DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) [ostds_cons_4016 -1J CENTRAX #: 13 -SG -15227 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 03 -0143- -N ]Holding Tank [ ] Innovative Other ] Temporary [ NA ] EXCAVATION REQUIRED: [ 30.0 ] INCHES outlet filter. regular shape). MULTI - CHAMBERED /IN SERIES: [Y ] MULTI - CHAMBERED /IN SERIES: [Y ] [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] [ N ]MOUND [ N ] [ N INSTALL 6.OF SLIGLITFILY LIMITED SOIL UNDER BOTTOM OF DRA INVERT ELEVATION - 6 ", BOTTOM OF DRAINFILED ELEVATION $. , PERIMi N R OF EXCAVA , 'OIN ARF SLIM, ' E AT /. S r 2.' FE WWiD , AN LO - 0 D ITLE : " (bt /ii/ a TITLE: Engineer I ----------- Dade / CHD EXPIRATION DATE: �/ / ��Q `f Page 1 of 2 'STATE OF FLORIDA DEPARTMENT OF HEALTH 6NSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS APPLICANT: Pijuan, Michelle M. AGENT: , OWNER LOT: 20 BLOCK: 14 SUBDIVISION: Miami Shores ID #: 11- 3206 - 013 -1940 TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST PROVIDF RFGTSTi2ATION NUMRFR AND SIGN AND SFAT, EACH PAGE OF SUBMITTAL. COMPT,F,TF ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN:[X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.20 ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [64E -6, TABLE 1] AUTHORIZED SEWAGE FLOW: 500 GALLONS PER DAY [1500GPD /ACRE OR 2500GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: 1740 SQFT UNOBSTRUCTED AREA REQUIRED: 857 SQFT BENCHMARK /REFERENCE POINT LOCATION: CL NE 101 St. & E PL., 11.34' NGVD. ELEVATION OF PROPOSED SYSTEM SITE IS 4.08 [ INCHES ] [ BELOW ]BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: N/A FT DITCHES /SWALES: N/A FT NORMALLY WET? [ ]YES [ X ]NO WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON- POTABLE: N/A FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 50 FT SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO 10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SOIL PROFILE INFORMATION SITE 1 Mansell # /Color Texture 1 0YR Fi /7 - T. R (:Y Vino Rana USDA SOIL SERIES: 15 Urban land Depth n to 79 to to to to to to to SITE EVALUATED BY: Carlos Icaza DH 4015, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 003 - 4015 -1) (ostds eval 4015 -3] CENTRAX #: 13 -SG -15227 OSTDSNBR : 03- 0143 -N OWNER SITE ELEVATION: 11 FT NGVD SOIL PROFILE INFORMATION SITE 2 Munsell # /Color Texture Depth 1 OYR (, /2 - T. R mY Vino Rana n to to to to to to to to USDA SOIL SERIES: 15 Urban land OBSERVED WATER TABLE84.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [ PERCHED ESTIMATED WET SEASON WATER TABLE ELEVATION:84.00 INCHES [ BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:Fine Sand/0.70 DEPTH OF EXCAVATION:30.0 INCHES DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE: 1/23/03 Page 3 of 3 P eso AGENT: F i� �- &k LOT: 2 , O v � j BLOCK: 1 L k SUBDIVISION ` � 14 � pie) JiA�. O PROPERTY ID #: 1k 3 Z0 G a `� 1 W O [Sec tion /Township /Range /Parcel No. or Tax ID Number] l tai l \ 1 ci• 3 - 5 \3ie:, - -- APPLICANT: ,STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS TO BE COMPLETED BY ENGINEER,t HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. SOIL PROFILE INFORMATION SITE 1 PROPERTY SIZE CONFORMS TO SITE PLAN: [ tYES [ ] TOTAL ESTIMATED SEWAGE FLOW: 30C) GALLONS AUTHORIZED SEWAGE FLOW: GALLONS UNOBSTRUCTED AREA AVAILABLE: lk.N50 SQFT /REFERENCE POINT LOCATION: (L 1\-) E ELEVATION OF PROPOSED SYSTEM SITE IS 4.04Z' THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PRO OSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: lJ %- FT DITCHES /SWALES: L FT NORMALLY WET? [ ] YES NO p/pc_ WELLS: PUBLIC: FT LIMITED USE: .9/A FT PRIVATE: 0//\--FT NON- POTABLE: FT BUILDING FOUNDATNS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: SC) FT Munsell # /Color Texture Depth IP7,r( to `t t to to to to to to to to USDA SOIL SERIES: �� �'- (117 t 4 k , ( A 0 0 t - " OBSERVED WATER TABLE: S iA INCHES [ABOVE ESTIMATED WET SEASON WATER TABLE ELEVATION: HIGH WATER TABLE VEGETATION: [ ] YES [,x] NO SITE EVALUATED BY: ` i! `c, i 011 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used) (Stock Number: 5744- 003 - 4015 -1) NO NET USABLE AREA AVAILABLE: '6_2.3 ACRES PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] PER DAY [1500 GPD /ACRE OR 500 GPD /AC — UNOBSTRUCTED AREA REQUIRED: S SQFT C7 11:3y /FT] [(tt80V INCHES [ ABOVE / SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [p() BED ` 0 ] OTHER (SPECIFY) MARKS(ADDITIONAL ` CRITERIA: Vwo - -‘ O� �=a• -- s 0 n - : t y �ure <- . S �o �K�..- Y � \ SOIL PROFILE INFORMATION SITE 2 PERMIT # O3 _Q J L) 10 YEAR FLOODING? [ ] YES /REFERENCE POINT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES pei NO 10 YEAR FLOOD ELEVATION FOR SITE: NVA.„ FT MSL /NGVD SITE ELEVATION: FT MSL Munsell # /Color Texture Depth j O Y VL L /'1 __to 7 Z to to to to to to to to USDA SOIL SERIES: ( L n .,,, Z3,A- �2 6 blfa 1 H 10 ] EXISTING GRADE. TYPE: / APPARENT] ] EXISTING GRADE. MOTTLING: [ ] YES [A NO DEPTH: 0/A INCHES D ; DEPTH OF EXCAVATION: 314 INCHES DATE: O !Z 3A)3 Page 3 of 3 APPLICANT: AGENT: 1 2 3 4 APPLICATION FOR: [><J New System [ ] Repair PROPERTY ID #: • STATE,OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental [ a donment [ ) Other(Specify) N t the Ile m. Piqua, • a. • A (Ack" Fouls , 1r,c MAILING ADDRESS: - 7( . 44g / J J` 5e4 y TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] LOT: 2p BLOCK: I SUBDIVISION: Gv' CA rr,e. racabgt + 941 16 /-7C DATE OF PROPERTY STREET ADDRESS: APPLICANT'S SIGNATURE: it -32o(o -013- 190 PROPERTY SIZE:7.0 I!' ACRES [Sqft/43560] PROPERTY WATER SUPPLY: }v w � 0 seQ( °1 "( I q 5 101 `- e e- Y1n96k t DIRECTIONS TO PROPERTY: rT t� /'- t o ' 3 BUILDING INFORMATION [X] RESIDENTIAL [ ] COMMERCIAL Unit Type of No. of Building # Persons No Establishment Bedrooms Area Sqft Served 01-1 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1) which may be used) (Stock Number: 5744 -001- 4015 -1) W�Q0.Ml S Se4 • °) SUBDIVISION. [Section /Township /Range /Parcel No.) ZONING: / - e- p: s M I a PERMIT # CrJV V� DATE PAID FEE PAID $ IrgIPT # A TELEPHONE : / DS ) =� I ( �, 3 c 'L- l / lL�'f Mci'ck yN T1 ) 2 [ DATE: 1935 ] PRIVATE p.41 PUBLIC St,av-e'S, 1 33 i Business Activity For Commercial Only [ ] Garbage Grinders /Disposals [ ] Spas /Hot Tubs [ J Floor /Equipment Drains [ ) Ultra -low Volume Flush Toile t [ ] Other (Specify) Page 1 of 3 B4. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8. FLOOD B9. BASE FLOOD ELEVATION(S) NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO, use depth of flooding) 120250 0 093 J ; 7 -17 -95 3 -2 -94 X ORD &:# 12- 02 -5 PROCESS# FOLIO# ' C.O.R. 11.34 BUILDING OWNER'S NAME Mario Perez Cl Miami FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Important: Read the instructions on pages 1 - 7. SECTION A -PROPERTY OWNER INFORMATION BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. 45 NE 101 Street STATE FL PRQPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) 0 0 &.E1 / 2.of Lot 19, Blk 14, An Amended Plat of Miami Shores Sec. No.1 BUILDING USE (e o., Residential :Non- residential, AdditionT Accessory, etc. Use Comments section if necessary.) . PB 10, PG 70 Residential LATITUDE/LONGITUDE (OPTIONAL) ( ## - ##' - ##.#fY' or ##.#####°) J NAD 1927 LJ NAD 1983 HORIZONTAL DATUM: SOURCE: Li GPS (Type): SECTION B - FLOOD. INSURANCE RATE MAP (FIRM) INFORMATION O.M.B. No. 3067 -0077 Expires July 31 20f.)2 o3N-0) L-13 For Insurance Company Use: Policy Number Company NAIC Number ZIP CODE JJ USGS Quad Map L1 Other. B1. NFIP COMMUNITY NAME & COMMUNITY NUMBER 120652 Miami Shores B2. COUNTY NAME Miami -Dade B3. STATE FL. B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9. J-1 FIS Profile al FIRM LJ Community Determined LJ Other (Describe): B11. Indicate the elevation datum used for the BFE in B9: 'xi NGVD '1929 LJ NAVD 1988 LJ Other (Describe): B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? LJ Yes LJ No Designation Date: SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: LJConstruction.Drawings• LJBuilding Under Construction' • ULIFinished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number 1 (Select the building diagram most similar to the building for which this certificate is being completed - see pages 6 and 7. If no diagram accurately represents the building, provide a sketch or photograph.) C3. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1 -V30, V (with BFE), AR, AR/A, AR/AE, AR/A1 -A30, AR/AH, AR/AO Complete Items C3a -i below according to the building diagram specified in Item C2. State the datum used If the datum is different from the datum used for the BFE in Section •B, the datum to :that used for the BFE: Show field measurements and datum conversion calculation. Use the space provided: or the Comments area. of Section D or Section G, as appropriate, to document the datum conversion : Datum NGVD 1 929Conversion/Comments Elevation reference mark usedMi am i Dade BM Does the elevation reference mark used appear on the FIRM? O a) Top of bottom floor (including basement or enclosure) O b) Top of next higher floor n/ a ft.(m) O c) Bottom lowest horizontal structural member (V zones only). n/ a . _ ft.(m) O d) Attached garage (top of slab) 10 .90 ft.(m) ❑ e) Lowest elevation of machinery and/or equipment servicing the building . O f) Lowest adjacent grade (LAG) O g) Highest adjacent grade (HAG) 11 .0 ft.(m) 0 h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade n/ a O i) Total area of all permanent openings (flood vents) in C3h n/ I a - sq. in. (sq. cm) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information in Sections A, B, and C on this certificate represents my best efforts to interpret the data available. I understand that any false staternent may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. CERTIFIER'S NAME LICENSE NUMBER 612.3 ARTURO J. PEREZ • TITLE COMPANY NAME CONTINENTAL LAND SURVEYORS,INC ADDRESS ' CITY STATE ZIP CODE 1 700 SW 5 ; ,„ • VE, SUITE #201 MIAMI FL 33155 V Or SIGNATURE FEMA Form 81 -31, A LAND • SURVEYOR 12-30- 02 12.51 ft(m) W N r J 11 02 to 10 .9 ft.(m) TELEPHONE 305 262 - 1925 L J Yes fag No SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS Miami Shores Village / 10050 NE 2nd Avenue Phone: 305 - 795 -2204 ` Printed: 5/6/2003 Or Applicant: MARIO ' Owner: PEREZ O JOB ADDRESS: 145 NE 101 /V Contractor A LEAGUE CONTRACTORS, INC. Local Phone: Parcel # 1132060131940 ,Y TO THE RDER OF Fees: FEE2003 -2719 FEE2003 -2720 FEE2003 -2721 FEE2003 -2722 illages of Miarn► Shores Description Building Fee CCF Notary Fee Builders Bond T 4 . 5 helle P►Juan q till: II M 1 zits x:0 6 6 0 094 MEMO III I] 4 3 3 y Plumbing Permit Permit Number: PL2003 -123 PEREZ MARIO ST Contractor's Address: 10651 N. KENDALL DRIVE #205 Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOT 20 & E1/2 LOT 19 BLK 14 LOT SIZE Amount $160.00 $1.20 ... ;,..; . TORS, INC. ; � A- LEAGUE CONTRACTORS, SEPTIC PAVING AND DRAINAGE 10651 NO KENDALL DRIVE SUITE MIAMI, FL 3317 .:.,. '. PH. 305-2 0306 CONY K U AM OF M► • m pMI, Fl. 33155 BY: DOLLARS Page 1 of 1 "otal Fees: $466.20 Receipts: $0.00 srtaining thereto and in strict ;ume responisibility for all work DISPLAY THIS CARD ON FRONT OF JOB "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 ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." MIAMI SHORES a ' ! at 41 Icy � ✓• � r y'y'�j yy 'y ({� I �N�fli8 Mk Cl, ' } IV „4 N �.. BU D NG "" k ;-,'.7 S C l8 �S�:e u PERMIT # - ...2 .. 00 3 DATES ` 2 .l OWNER e c C z. ADDRESS )4.s tV. E. 1 i s ' $. CONTRACTOR A Le. CO r�� sue .. H� 't. ot.r PERMIT TYPE ► 1 . 1 ' I A DISPLAY THIS CARD ON FRONT OF JOB "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 ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." MECHANICAL INSPECTION TYPE NSPECTOR DATE Undgr NC Pipe Footing Slab condensate Tie Beam Slab Jenn -Aire Rake Beam Rough Duct 2nd Floor Slab Rough Pipe 2nd Floor Tie Beam Exhaust Fan Rough Roof Sheating Hood Rough Wall Sheathing Pool Heat Pump Truss, Roof Fire Dampers y Truss, Floor Fireplace Vent Store Front Vacuum Pipe Rough Lath Vacuum Pipe Final Window Installation Equipment Anchor Door Installation Suppression Test Mop in Progress Tuct Detector Tile in Progress Ventilation Pressure Test FINAL STRUCTURAL INSPECTION TYPE INSPECTOR DATE Footing Columns / Poured Cells Tie Beam Rake Beam 2nd Floor Slab 2nd Floor Columns 2nd Floor Tie Beam Roof Sheating Wall Sheathing Floor Sheating Truss, Roof Truss, Floor Store Front Buck Lath Window Installation Door Installation Tin Cap Mop in Progress Tile in Progress NO INSPECTION WILL BE MADE UNLESS PERMIT CARD IS DISPLAYED AND APPROVED PLANS ARE READILY AVAILABLE WORK MUST BE COMPLETED PRIOR TO REQUESTING INSPECTIONS 24 HOUR NOTICE FOR ALL INSPECTIONS INSPECTION RECORD MIN. 12" x 18" BACKING BD. 12" THIS PERMIT CARD MUST BE DISPLAYED ON THE FRONT OF THE JOB BY ONE OF THE FOLLOWING METHODS OR NO INSPECTION WILL BE MADE 18" A MIN. 4' MAX. 5' MIN 18" ~r PENETRATION 1"x8" PROTECTIVE LEDGE OR VISOUEEN FLAP WITH FASTENER OR- FASTEN TO BACKING AS INDICATED ON CARD ON FACE OF BUILDING WITH PROTECTIVE COVERING PERMIT kikkgaUalaifigiMi PLUMBING INSPECTION TYPE NSPECIDR DATE Ground Rough Top Out 2nd Floor Rough 3rd Floor Rough Condensate Dralnfield Suppression Test Septic Sewer Water Service L P Tank Gas Rough Gas Final Irrigation Int: Ext: Well Interceptor Pressure Test Fire Sprinkler Final Pool Maindrain Pool Piping FINAL STRUCTURAL INSPECTION TYPE Shingle in Progress Framing Insulation Drywall Sidewalk Driveway Form / Rock Storm Shutter Anchors Storm Shutter Final Patio / Deck Final Fence Final Pool Steel Pool / Patio Deck Screen Encl Final Pool Final Roof Final INSPECTOR DATE FINAL ELECtRICAL INSPECTION TYPE Temporary Pole Footer Grounding Slab Service Rough B. Alarm Prewire T.V. Prewire Intercom Prewire Phone Prewire B. Alarm Final T.V. Final Intercom Final Phone Final 30 Day Temp Power Pool Grounding Pool Slab N6PECTOR DATE FINAL FOR INSPECTIONS CALL 305 - 795 -2204 INSPECTION REQUESTS ARE ACCEPTED DURING THE HOURS OF 8:30 AM TO 3:30 PM FOR INSPECTIONS THE FOLLOWING BUSINESS DAY. CERTIFICATE OF OCCUPANCY MUST BE SECURED BEFORE THIS BUILDING CAN BE USED FOR ANY PURPOSE DO NOT REMOVE THIS CARD BEFORE COMPLETION OFFICE PHONE NUMBER: 305 - 795 -2204 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT OSTDSNBR : 03 -0143- -N CONSTRUCTION PERMIT FOR: [ X ]New System [ ]Existing System [ [ ]Repair [ ]Abandonment APPLICANT: Pijuan, Michelle M. AGENT: OWNER, PROPERTY STREET ADDRESS: 145 NE 101 St Miami FL 33138 LOT: 20 BLOCK: 14 SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] PROPERTY ID #: 11- 3206 - 013 -1940 [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 [ 900 ]Gallons SEPTIC TANK A [ 0 ]Gallons N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ D [ 429 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ Y ]STANDARD [ N ]FILLED I CONFIGURATION: [ N ]TRENCH [ Y ]BED N F LOCATION TO BENCHMARK: CL NE 101 St. & E PL., 11.34' NGVD. I ELEVATION OF PROPOSED SYSTEM SITE [ 4.1 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 34.1 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 30.0 ] INCHES OTHER REMARKS: *Install a 900 gl. *Install 429 sq.ft *Invert elevation *Bottom elevation SPECIFICATIONS BY: Icaza, Carlos APPROVED BY: Icaza, Carlos DATE ISSUED: C -1 septic tank with an approved outlet filter. . of drainfield. (it shall have a regular shape). to be no less than 9.00' NGVD. to be no less than 8.50' NGVD. INSTALL WA OF SLIGHTIILY LIMITED SOIL c�3 DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) [ostds_cons_4016 -1) ]Holding Tank [ ] Innovative Other ] Temporary [ NA ] [:AI .14L CENTRAX #: 13 -SG -15227 DATE PAID: FEE PAID : $ RECEIPT . MULTI - CHAMBERED /IN SERIES: [Y ] MULTI - CHAMBERED /IN SERIES: [Y ] [0 ]DOSES PER 24 HRS # PUMPS[ 0 ] [ N ]MOUND [ N ] [ N ] UNDER BOTTOM OF D�LD INVERT ELEVATION BOTTOM OF DRAINFILED ELEVATION 4 1. `' ) PERIMETER EXC 4. '[O T P,E A AT A.1ST 2 OF "ET ; ] ,..VA R A': T A 0 . t, u 4 P 4 ' • AB TIO1 .ED OR DRAIN TITLE: Ci• . 01....//1/0-5 TITLE: Engineer I Dade BE EXPIRATION DATE: p llki / Q g CHD Page 1 of 2 AGENT: , OWNER STATE OF FLORIDA DEPARTMENT OF HEALTH ONS SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS APPLICANT: Pijuan, Michelle M. LOT: 20 BLOCK: 14 BENCHMARK /REFERENCE POINT LOCATION: CL NE 101 St. & E PL., 11.34' NGVD. CENTRAX #: 13 -SG -15227 OSTDSNBR : 03- 0143 -N SUBDIVISION: Miami Shores ID #: 11- 3206 - 013 -1940 OWNER TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST PROVTDF REGISTRATION NUMBER AND SIGN AND SEAT, EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN:[X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.20 ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [64E -6, TABLE 1] AUTHORIZED SEWAGE FLOW: 500 GALLONS PER DAY [1500GPD /ACRE OR 2500GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: 1740 SQFT UNOBSTRUCTED AREA REQUIRED: 857 SQFT ELEVATION OF PROPOSED SYSTEM SITE IS 4.08 [ INCHES ] [ BELOW ]BENCHMARK /REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: N/A FT DITCHES /SWALES: N/A FT NORMALLY WET? [ ]YES [ X ]NO WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON - POTABLE: N/A FT BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 50 FT SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X INC 10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SOIL PROFILE INFORMATION SITE 1 Munsell # /Color Texture Depth 1 OYR- Fi /7 -T. R ay' Vi na Sanel O to 79 to to to to to to to USDA SOIL SERIES: 15 Urban land OBSERVED WATER TABLE84.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [ PERCHED ESTIMATED WET SEASON WATER TABLE ELEVATION:84.00 INCHES [ BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:Fine Sand/0.70 DEPTH OF EXCAVATION:30.0 INCHES DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: SITE EVALUATED BY: Carlos Icaza DH 4015, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 003 - 4015 -1) [ostds eval 4015 -3] 10 YEAR FLOODING? [ ]YES [ X INC SITE ELEVATION: 11 FT NGVD SOIL PROFILE INFORMATION SITE 2 Munsell # /Color Texture Depth 1 OYR- Fi /9 -T. R nY Fi na Rand O to to to to to to to to USDA SOIL SERIES: 15 Urban land DATE: 1/23/03 Page 3 of 3 APPLICANT: �1. LOT: 2c 1 BLOCK: PROPERTY ID . #: STATE OF, FLORIDA DEPARTMENT•OF HEALTH . ONSITE SEWAGE DISPOSAL SYSTEM SITE' EVALUATION AND SYSTEM SPECIFICATIONS (ic,1,e_11e ' A 1� '52.oc, 1a1 0 TO BE COMPLETED BY ENGINEER HEALTH UN. PROVIDE REGISTRATION NUMBER AND SIGNr}' ND PROPERTY SIZE CONFORMS TO SITE PLAN: [ TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: /REFERENCE POINT ,LOCATION: ot ELEVATION OF PROPOSED SYSTEM SITE IS t H'8 bU NH 1 5 /FT) [ THE SETBACK WHICH CAN BE MAINTAINED FROM THE SURFACE WATER: P /py.. FT DITCHES /SWALES: WELLS: PUBLIC: _ /� - FT. LIMITED USE: U//�..FT 4 hUILDING FOUNDAT ONS • 1L SITE. SUBJECT TO FREQUENT FLOODING: 10 YEAR FLOOD ELEVATION FOR SITE: SOIL PROFILE INFORMATION.SITE 1 1 LA l h OBSERVED WATER TABLE: SIA INCHES [ABOVE EXISTING GRADE. TYPE: ESTIMATED WET SEASON WATER TABLE ELEVATION: rt-` INCHES [ ABOVE / HIGH WATER TABLE VEGETATION: [ ) YES.[) NO MOTTLING: [ YES 0 NO 306 s 11 N 0 Munsell # /Color Te,cture Depth 1.712 • G/2 r,ap SA-1 to 1 -. to to , to to to to to USDA SOIL SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [X] REMARKS / ADDITIONAL CRITERIA: 5 sl � o r � SITE EVALUATED B Y : .. G,10 . DH,4015,'10/96 (Replaces HRS -H Form 4015 [Page 31 which may be used) (Stock Number:. 5744, 003 - 4015 -1) SUBDIVISION: ,� \O ' '� Q [Section /Township /Range /Parcel No. or Tax ID Number] I T EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL,, ITEMS. S FT PROPERTY LINES.:`' YES [ ] NO NET USABLE AREA AVAILABLE: C�_ 2. ACRES GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] GALLONS PER DAY (1500 GPD /ACRE 0 SQFT UNOBSTRUCTED AREA REQUIRED: /REFERENCE POINT PROPOSED SYSTEM TO THE FOLLOWING FEATURES: PRIVATE: �/ NORMALLY NON - POTABLE: W/ FT S FT POTABLE WATER LINES: SO FT [ ]"YES [ NO "10' YEAR FLOODING? [ ] YES t _ NO I.)/A, FT MSL /NGVD SITE ELEVATION: 11•C‹) FT MSL SOIL PROFILE INFORMATION SITE'2 Munsell # /Color I a y v.. c/ i USDA SOIL SERIES : I Cf n _, D .77 DEPTH OF EXCAVATION: INCHES BED ] OTHER (SPECIFY) 4 , 1 - ,A •A A,�-- 4 - aO4 r ter•( r., Hi� AGENT: 1,, PERMIT # Q� - 019 Texture Depth Z 3 4-( / APPARENT] EXISTING GRADE. DEPTH: OA INCHES rt'1 PERCH DATE: (f) to 7 2 to to to to to to to to INSTRUCTIONS: PERMIT NUMBER: Permit tracking number by County Health Department. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number). PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. SEWAGE FLOW: UNOBSTRUCTED AREA: MINIMUM SETBACKS: Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non - residential), Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter IOD -6, FAC. The unobstructed area must be contiguous to the drainfield. BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the proposed system site in relation (above or below) to the benchmark. Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public drinking well within 200 feet of the applicant's lot must also be verified. FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual site elevation. SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined. WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if.there is high water table vegetation present. Indicate if mottling is present and depth. SOIL TEXTURE: Record soil texture or loading rate for system sizing. DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable. DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type. ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required. SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: BENCHMARK SITE I SITE 2 SITE 3 [ + ] SHOT H.I. H.I. H.I. H.I. [ - ] SHOT [ - ] SHOT [ - ] SHOT Date / / 7 Job Address CM L /5 / C9 .( Tax Folio Legal Description Historically Designated: Yes No Owner/Lessee / Tenant f // 4 11 a PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Owner's Address ) 4 -/ 5 41 r - /0 Contracting Co. "A„ sc._ oc,, '2x Address 670,/, - sc,J 3 s' C7- Qualifier J c II., 1 i, Fr-- SS# Phone State # ,C/o 24. Municipal # Competency # Ins. Co. Address Architect/Engineer Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICA UMBING' ECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION �� V'c$- Square Ft. oo 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 doe in compliance with all applicable laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to d. to k stated. �ture of owner and/or CPresident Date Notary as to Owner and/or Condo President My Commission Expires: t QY ? /, wrr,. "', ^,Rl:'v�� ^ODARD moo• -/14,a q �� ^rnMiSSIOt i # CC 625712 tXFI2E5 MAR 2 2001 frr Or . i: ovivL. '4.' CO., INC. FEES: PERMIT 3S. RADON APPROVED: Zoning Mechanical Plumbing Date G?‹d1 a 1-1-. : J Estimated Cost (value) o f 50,0 Building _ Master Permit # 40 173 Phone Electrical Notary as to Contractor or Owner - Builder My Commission Expires: y Y PG B Wm. MARK WOODARD COMMiSSiON # CC 625712 9 1 ii 1 c • EXPIRES MAR 2,2001 ^� '� V 80NDED7r1RU OF 1 ATLANTIC BONDING CO., INC. O ° pp C.C.F. / - NOTARY BOND Joie TOTAL DUE 3 3 C . t l� 2.4-1 Engineering CONSTRUCTION PERMIT FOR: [0] New System [{v] Existing System [/v] Holding Tank '[k] Temporary /Experimental •[ "3t] Repair (h)] Abandonment [ pj] Other(Specify) APPLICANT: PROPERTY ID #: /QPI 'STATE OF FLORIDA DEPARTMENT OF HEALTH AND ONSITE SEWAGE DISPOSAL S CONSTRUCTION PERMIT Authority: Chapter 381, PROPERTY STREET ADDRESS: / a/ -p 1 I �S iV.� • f• i�� LOT: hj'A BLOCK: i, j/ 4 SUBDIVISION: 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 AND SPECIFICATIONS T [/ S o ] / GPD](SEPTIC TANK/AEROBIC UNIT CAPACITY ' MULTI- CHAMBERED /IN SERIES:[ ] A [ !, ] [ / 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: [ 0 T H E R D [ 300 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ — ] SQUARE FEET SYSTEM A TYPE SYSTEM: ' \ '[L./) STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [,/4BED [ ] N F LOCATION OF BENCHMARK: S• 7 0' 7. I ELEVATION OF PROPOSED SYSTEM SITE [9/4 E BOTTOM OF DRAINFIELD TO BE [ h L D FILL REQUIRED: ON ] INCHES SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: JI /2 s/9 116 PERMIT # rj 7/2 — REHABILITATIVE SERVICES DATE PAID //- 254-1'7 YSTEM FEE PAID $ 5 t) RECEIPT Ai' l 1 7 ? 9 FS & Chapter 10D-6, FAC AGENT : n /) S 1. Pool [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] € / 4°d C V"(C ZVa am. ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [50 ] INCHES TITLE: nPEDLOCQOJ4 l'?I Ni 6.. UV': J id V7 <i .".f 1: �S it �.+ he v_g E (� GAVE T ELE ATONAL Oie..._ [ OTTOfJ1 OF DRAINFRE'_,rD fra, WC il TITLE: �^ , f • EXPIRATION DATE: TEE ©NHOC gaCOC3 ma Di; RATED tam G1 30Ein B[ G;O EgUllCCO BONE 1118p . [ C CE9 ON CARET YEE HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001- 4016 - 0) Z 2 CPHU Page 1 of 2 INSTRUCTIONS: PERMXT NUMBER: Permit tracking number assigned by CPHU. APPLICATION 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. (CPHU may require property appraiser ID N or section/township /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter IOD-6, FAC. DRAINFIELD: Minimum specifications from Chapter 1OD -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 Public Health Unit (CPHU) personnel reviewing and approving permit. DATE ISSUED: Date permit is issued by CPHU. 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. LOT• PROPERTY ID #: 405 ,1/4 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: TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW:,, <` UNOBSTRUCTED AREA AVAILABLE: BENCHMARK /REFERENCE POINT LOCATION: 7: �✓�� ELEVATION OF PROPOSED SYSTEM SITE IS ! if [INCHES /FT] (ABOVE /BELOW] BENCHMARK /REFERENCE POINT d ® s THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE 'FOLLOWING FEATURES: SURFACE WATER: 4 FT DITCHES /SWALES: FT NORMALLY'WET? [ ] YES { J. NO WELLS: PUBLIC: - 40' FT LIMITED USE: � FT PRIVATE: ,,� 24 FT NON - POTABLE: /a. FT BUILDING FOUNDA IONS: � FT PROPERTY LINES: /c)t FT POTABLE WATER LINES: 7< FT SITE EVALUATED BY: ;STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM r SITE EVALUATION AND SYSTEM SPECIFICATIONS ( BLOCK: SUBDIVISION: [ ] /4.!r!/7 [Section /Township /Range /Parcel No. or Tax ID Number] YES [- --i NET USABLE AREA AVAILABLE :. 4" ACRES GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] SQFT UNOBSTRUCTED AREA REQUIRED: SQFT r ud 0 SITE: SUBJECT TO FREQUENT FLOODING: '[ J YES 1E 1J10 F 10 YEAR FLOOD ELEVATION FOR SITE: ' /AFT MSL /NGVD SITE ELEVATION: et.,STO FT MSL /NGVD SOIL PROFILE INFORMATION SITE 1 Munsell # /Color Texture Depth ' 1 tea.- 4 %) to to to to ,$,.'? . to .USDA SOIL SERIES: / HRS -H Form 4015, Mar 92 (Obsoletes prey' 7:'s ed' on (Stock Number: 5744- 003 - 4015 -1) ' ff AGENT: SOIL PROFILE INFORMATION SITE 2 Munsell # /Color Texture Depth t USDA SOIL SERIES: to - to _- �, to r to /S'. 4,tor" . to t to to , OBSERVED WATER TABLE: 7` INCHES [ABOVE /egilaTLEXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES [,i]�N�O MOTTLING: [ ] YES [ ] NO DEPTH: ---- INCHES may not be used) . 10 YEAR FLOODING? [ ] YES [ ] NO PERMIT # c DEPTH OF EXCAVATION: L 'INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: ''DRAINFIELD CONFIGURATION: [ ] TRENCH (/4 -BED [ ] OTHERASPECIFY) REMARKS /ADDITIONAL-CRITERIA: DATE: ,// -"„; 1 /. S Page 3 of 3 INSTRUCTIONS: PERMIT d: Permit tracking number assigned by CPHU. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY ID#: 27 character number for property. (property appraiser ID f/ or section/township /range /parcel number) UNOBSTRUCTED AREA: MINIMUM SETBACKS: SEWAGE FLOW: - PROPERTY SIZE: Check if properly size at site conforms to submitted site plan. Record net usable area available - lot area exclusive of all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakeo, normally wet drainage ditches, marshes, or other such bodies of water. Record the estimated sewage flow for the establishment from Table I (residences) or Table 2 (non - residential), Chapter 1OD -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow does not .equal or exceed the estimated sewage flow, the application must be denied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 1OD -6, FAC. The unobstructed area must be contiguous to the drainfield. BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the proposed system site in relation (above or below) to the benchmark. Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA" for non applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public drinking well within 200 feet of the applicant's lot must also be verified. FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual site elevation. SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined. WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present and depth. SOIL TEXTURE: Record soil texture or loading rate for system sizing. DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable. DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type. ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required. SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: BENCHMARK SITE I SITE 2 SFFE 3 [ +] SHOT: H.I. H.I. H.I. H.1. [ -] SHOT [ -] SHOT [ -] SHOT - -^ CLO[[T[ BATH Tuns S HOWER/ LAVA• TORIES SINKS SLOP •INKS LAUNDRY TUSS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT'NS TOTAL FIXTURES CONTR. LIST ^. CHICK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR 5 Swim 'G POOL CONTR. LIST CHECK MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No .a I S 0 Date.. January 16, 1980 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. Owners Name and Address Mildred Ea N o 145 S 101 _ .. Registered Architect and /or Engineer Employing Plumber's Name 0.G.Ll pyd Se r]1' _Tank. S,er itnetal. .::, egt a,.3 IC/ Location and Legal Description Lot Block Subdivision.____ 145 NE 101 Street and Number where work is to be performed —No Street.. _..._.._._ State work to be performed and purpose of building (By Floors) New Building - -__ _ _ ----- •-- ....._.___ Remodeling __ __ Addition Repairs. No. of Stories. ..... Size Septic Tank_ Type of Tank_____ Feet of Drain Tile 125 S g . f t a _ )f Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well. Size of Soakage Pit Amount of Permit =I_ (Si W� I31 Plumbing Inspector. 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 6988, 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 performed 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, k to be ormed under this permit, as are licensed by Miami Shores Villages (Signed) Muter Plumber. STATE OF FLORIDA, µ COUNTY OF DADE. j 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 Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when web swi ssp•otion is mad••aeotrnry by improper notice kw Mmpection, at faulty materials and /or woclsmanship. Permit No 4 Nature of Water Supply: City —Well Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. 1 My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING "r.l1T No / 5 Block_ _ .)' 0^ } (Signed)_ Date 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. Owner's Name and Address Registered Architect and /oiLngineer ______._____. _ Employing Plumber's Name .__ ~ No. a J Street. 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 ___ Remodeling_____ ___._ Addition_ Street � / / Subdivision treet_ Z o 5 4— c? e- — Repairs No. of Stories Size Septic Tank Type of Tank Capacity Gals. Feet of Drain Tile_ Dist. Feet of Tank or Drain Field from Well ._Size of Soakage Pit Pluming Inspector. 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 5986, 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 performed 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 this permit, as are licensed by Miami Shores Village. ( Signed );_ /_ ` 4 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. Notary Public, State of Florida 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 SS INK SLOP SINKS LAUNDRY Tuns U RINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT'NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HCATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST CHECK - Permit No 4 Nature of Water Supply: City —Well Amount of Permit $ STATE OF FLORIDA, COUNTY OF DADE. 1 My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING "r.l1T No / 5 Block_ _ .)' 0^ } (Signed)_ Date 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. Owner's Name and Address Registered Architect and /oiLngineer ______._____. _ Employing Plumber's Name .__ ~ No. a J Street. 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 ___ Remodeling_____ ___._ Addition_ Street � / / Subdivision treet_ Z o 5 4— c? e- — Repairs No. of Stories Size Septic Tank Type of Tank Capacity Gals. Feet of Drain Tile_ Dist. Feet of Tank or Drain Field from Well ._Size of Soakage Pit Pluming Inspector. 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 5986, 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 performed 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 this permit, as are licensed by Miami Shores Village. ( Signed );_ /_ ` 4 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. Notary Public, State of Florida 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. BUILDING ELECTRICAL PLUMBING ROOFING Owner of J Building rA Address of r uilding ° CONTRACTOR OR BUILDER MIAMI SHORES VILLAGE. FLORIDA DATE 195 7 PERMIT N? 5158 Architect 1 Contractor or Builder €r" Legal Lot Description Work to be performed under this Permit Bl BY Subdi- vision Value of Project $ 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 cr in the statements or specifications and that he assumes responsibility for work done by his agents, servants or employees. 1 Signed- 4,yt w '+ s BY- INSPECTOR Contractors License No. Amount of / Permit $ 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 ac- cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee. AUTHORITY Registered Architect and /or Engineer _— _____ —__— State work to be performed and purpose of building (By Amount of Permit $ ' C STATE OF FLORIDA, COUNTY OF DADE. f ss. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No. Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submit for (he { 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. Owner's Name and Address ----- No f Employing Plumber's Name " � , 444; := — — No. r � — -- Streeki ,! Location and Legal Description Lot__ _ ___— Y____Block_________________ Subdivision —�_ ------- ---- --- ------ r > Street and Number where work is to be performed —No ✓ ;!' _ - -- --- -- - - - -- -- =-- - - - --- - New Building_____- -____—______ Remodeling_ Addition Repairs Size Septic Tank_ Type of Tank Feet of Drain Tile___________________ —___—__ Dist. Feet of Tank or Drain ield from Well Nature of Water .SuppJy:fy —Well . i'ze Soakage Pit ._____� ■ Si ned : r ■ Plumbing Ins ctor. The undersigned applicant for this building permit does hereby certify that h/0'. nderstands and accepts 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 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 notice or notices as are required by the Act. The under signed agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) Date Street)__/ _ /6f _Capacity Gals lats^e.. No. of Stories_ 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. Notary Public. State of Florida 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 , CHECK Registered Architect and /or Engineer _— _____ —__— State work to be performed and purpose of building (By Amount of Permit $ ' C STATE OF FLORIDA, COUNTY OF DADE. f ss. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Permit No. Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submit for (he { 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. Owner's Name and Address ----- No f Employing Plumber's Name " � , 444; := — — No. r � — -- Streeki ,! Location and Legal Description Lot__ _ ___— Y____Block_________________ Subdivision —�_ ------- ---- --- ------ r > Street and Number where work is to be performed —No ✓ ;!' _ - -- --- -- - - - -- -- =-- - - - --- - New Building_____- -____—______ Remodeling_ Addition Repairs Size Septic Tank_ Type of Tank Feet of Drain Tile___________________ —___—__ Dist. Feet of Tank or Drain ield from Well Nature of Water .SuppJy:fy —Well . i'ze Soakage Pit ._____� ■ Si ned : r ■ Plumbing Ins ctor. The undersigned applicant for this building permit does hereby certify that h/0'. nderstands and accepts 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 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 notice or notices as are required by the Act. The under signed agrees to employ only such sub - contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. (Signed) Date Street)__/ _ /6f _Capacity Gals lats^e.. No. of Stories_ 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. Notary Public. State of Florida 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.