205 NE 101 St (5)1
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Penn: No (4a. D 1 1,
New Building Remodeling
Size Septic Tank_.. Type of Tank
STATE OF FLORIDA,
/a.
COUNTY OF DADE.
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
,spplic,,til, is hereby made for the approval of the detailed statement of the plans and specifications herewith eubr.w...-1 for the lluilding or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Mia ••! Shores Village, Florida,
a,uf all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulatic '. of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plane and spet'ficatlons must be kept at
'iuilding during progress of work.
`.)wner's Name and Address
.e 'sired Architect and /or Engineer • --�
sp
ru� '�!� �� pp
employing Plumber's Name / � .111 Np.._ .:24.9(.. �!(•.
Location and Legal Description Lot- • 3 Block Subdivision.._..P
Street and Number where work is to be performed —No c 90 6 --
State work to be performed and purpose of building (By Floors)
No.
Addition.- ._...__ Repairs No of Stones
Feet of Drain Tile __Dist. Feet of Tank or Drain Field from Well.
Nature of Water Supply: City — Well..__— .•_- .•- _---- _ -. - -- _ ---- . -__ -- - ..Size of Soakage Pit
(Signed) _
Capacity ^ .a1s.
Street
Date... 6-- I .. ' S
My Commission Expires Notary Public, State of Florida
Plupnbin3 Inspector
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as on a n ;Moyer of 13ho
undt:r the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Permanent /.,i lenient, and tlas , can..
t.lie:d with the provisions thereof, and will require similar compliance from all contractors or s .contracts employe: 1 y him in r 's., rk r b.
performed under this permit; and will post or cause to be posted' for inspection on th - • to works ch :' I rl' notice r no icer •rs ar
required by the Act. The undersigned agrees to employ only such sub - contract s, on . k to be r . ed ?a this
licensed by Miami Shores Village.
Mast./ Plumber.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, per,orr: ; , ppear•x,
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 t all acts
therein by hin, stated are true.
NOTE: A re- inspection fee of ;1.00 will be made when such rs.inspeetlon V mede•neoeaaary by improper notice for inspection, tr tsuil,
materials and /or workmanship.