37 NE 101 St (6)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 1 3 trb Job Address 37 de . 16/ C 1 'Tax Folio
Legal Description / � Historically Designated: Yes No
Owner/Lessee / Tenant .V��' CA /e,-/- 1D" Master Permit #
Owners Address 37 /4 E. (01 ¢ - Phone 3 a 1 S 7 2 70 3
Contracting Co. /k t C 1 � � 13ra4 �;w Address `Z9 3 2- /V 0 - oz cj -C.
�j741PJ 6 � /
Phone ?AN' CV 21 .
State # Municipal # Competency # Ins. Co.
WORK DESCRIPTION
Square Ft.
odu L,
Signature of own and/or Condo President
Notary as to Owner and/or Condo President
My Commission Expires:
Date
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING ECHANICAL ROOFING PAVING FENCE SIGN
la l -w 00244/ .'ffd
Estimated Cost (value) i aG 6-0
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 perfonned 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.
APPROVED:
Zoning Building Electrical
Mechanical Plumbing
Signature o
Notary o Contractor or
My ommission Expires:
tractor or Owner- Builder
et)
FEES: PERMIT RADON C.C.F. /a NOTARY L> BOND 3 D V
TOTAL DUE
1/9/e7
Date
• - V
NOT . '•'S.rA
CLADY::
NC7rARY PUBLIC :: f : •
COMMISSION NO.
IAY COMMISSION EXP. MAR. ,,.:.d•
Structural Engineer
CONSTRUCTION PERMIT F'R:
[d] New System [ Existing System
[ Repair [ Abandonment
AP LICANT:
PROPERTY STREET ADDRESS:
LOT / BLOCK:
PROPERTY ID #:
A
N
K
0
T
H
[
[Z.-D J 'SQUARE
R [ ] SQUARE
A TYPE SYSTEM:
I CONFIGURATION:
N
F
1
E
L
D FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381,
FEET
FEET
1
DH 4016. 10/96 (Replaces HRS -H Form 4016 [page 1) whic
(Stock Number: 5744- 001- 4016 -0)
AGENT:
.ttec .) S s f C.
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. DEPARTMENT OF. HEALTH 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.
DE IONS
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SY TEM SI E
BOTTOM OF DRAINFIELD TO BE ( ro ] [
] [GALLONS / GPD] `_ ?' ,y EROBIC UNIT
1AGALLONS / GPD] •.
] GALLONS GREASE INTERCEPTOR CAPACITY
j GALLONS PER DOSE DOSING'TANK CAPACITY
PRIMARY DRAINFIELD SYSTEM
SYSTEM
[ ] STANDARD [ FILLED
[ J ) TRENCH [I BED
INCHES
-1'
FS Ell
) Holding Tank
Other(Specify)
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBERJ•,
TITLE:
TITLE:
CAPACITY
CAPACITY v M[TLTI -CHAMBERED / SERIES: [ 1
[MAXIMUM CAPACITY SINGLE TANK: 12
DOSE- RATE [ ] PER 24'HRS NO. OF PUMPS: [ )
[AB•VE /B' O' BENCHMARK /REFERENCE POI
S /FT] [ABOVE / ?�] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [.2s ] INCHES
n i ?i G
�i:�� xU r � �c�L�Ulluf6a
vz,zaTar.: EL[a?i•ATCi.' Stil)
PERMIT # ® 20-it 4
DATE PAID
FEE PAID $ ayr; 4
RECEIPT #
FAC
[ Temporary /Experimental
MOUND
P -a,<, 1
a:ask i ct TANG`` VALI - PTIREE AN A SOWS 1
FLECT 6t BEM MULLED ®bl THE Q LET ETA
Applicant '
MULTI- CHAMBERED /IN SERIES:[ )
• 1Wt a'iiEVE% (Li C,4c :Fa
CR Ma? 2.0 LONEE.D. 111E
R.CPOSED iaSORPTM EEO 073 CRIME WiEKCH •
EXPIRATION DATE:
. Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
•
• Scale: Each block represents 10 feet and 1 inch = 40 feet.
■ ■■■ ■■ ■■E02_ ' E k O'TIME
n iu i i uu'uuu _ e. • -_
111111111111111111 1111111
m� . _ e - ■■ I ■!IUD
■ om li.:_= �rl�!i 'l 1 film rf
otes:
ite Plan sub ` e•by.
Ian Approved
y
r
Date
oig
N
S
P
B
ALL CHANGES ' UST APPROVED BY THE COUNTY HEALTH DEPARTMENT()
J .
DH 4015,.10/96 (Replaces HRS -H Form 401 which may be used)
(Stock Number: 5744 -002 -4015 -6)
L
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT / /
Permit Application Number l or-2 L( f
J
PART 11 - SITEPLAN
Not Approved
/ � �e
County Health 1 epartment
�
Page 2 of 4
APPLICANT: 2 /5,4 04,eg /f(J /v
AGENT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
lye. as -4=e„ *C
PROPERTY ADDRESS: ,57 ,4 / 0 / j 't
LOT: /6 BLOCK: / ( SUBDIVISION 4/7/API/ SO4e
= === = =x= = == = = = ==== == ====tea
CHECKED (X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR
1
l
l
]
l
FILL
[
[23]
[
(25]
[26]
TANK INSTALLATION �� ::;t--1-.571-4.. CI
[01] TANK SIZE [1] [ [
(02] TANK MATERIAL 4°. [
[03] OUTLET DEVICE
[04] MULTI - CHAMBERED[ Y t2 [
[05] OUTLET FIL
ALA_
[06] LEGEND /1f 1
[07] WATERT ��
[08] LEVEL (09 ] DEPTH LID 21(
DRAINFIELD INSTALLATION
(10] AREA [1,126X &.1,[ 2 ]3 QFT
(11] DISTRIBUTION BOX
[12] NUMBER OF DRAINLINE
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE I
[15] DEPTH OF COVER/
[16] ELEVATION [ABO
[17] SYSTEM LOCATION
[18] DOSING PUMPS AY
(19] AGGREGATE SIZ
[20] AGGREGATE EXCESSI
(21] AGGREGATE DEPTH/3e(
/ EXCAVATION MATERIAL
FILL AMOUNT O'(
FILL TEXTURE 61'
EXCAVATION DEPTH 3'
AREA REPLACED!' X 27 d
REPLACEMENT NATERIALJ
EXPLANATION OF VIOLATIONS / REMARKS:
FINES t9vt
DH 4016, 10/97 (Previous Editions May Be Used)
SETBACKS
[
[
[29]
[30]
[31]
(32]
[33]
[34]
[35]
Applicant
PROPERTY ID i: /t -3�o6
RULE AND MUST BE CORRECTED.
SURFACE WATER
DITCHES
PRIVATE WELLS
PUBLIC WELLS
IRRIGATION WELLS
POTABLE WATER LINES
BUILDING FOUNDATION
PROPERTY LINES
OTHER
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED
(41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AG
[44] BUILDING AREA
[45] LOCATION CONFO
[46] FINAL SITE
[47] CONTRACTO
[48] OTHER
PERMIT NO. a ' c 2 7
DATE PAID:
FEE PAID: 7 J(/
RECEIPT 1: `?t`' y/"
=x=-- =
[ 44 9 41 ] ABANDONMENT PUMPF / `3 / ��
[50] TANK CRUSHED & FILLED � / ( �j
CND DATE:
CED DATE:
Page 2 of 3
Permit 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 comply with, wh er 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 /or E
Employing Plumber's Name_
Location and Legal Description Lot_
Street and Number where work is to be performed —No
Size Septic Tank_--__- ------------ o --
Feet of Drain Tile_ ______ c2
Nature of Water Supply: City—Well.
Amount of Permit $_
STATE OF FLORIDA, }
COUNTY OF DADE.
State work to be performed and purpose of building (By Floors)_
New Building _ -- Remodeling _-- ____ -- Addition
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
�.
....... No._ /l/G _-- Street
Block � L` � / col - -- ----- - - - - --
7 C ) Street !e
_Type of Tank
_ _Dist. Feet of Tank or Drain Field from Well .
Date__
----- -----�-- -- -- -- --
No. /ca✓ Street..,1
Repairs No. of Stories. _ _._._' ...... .......
(Signed a
Capacity Gals
__Size of Soakage Pit
7
(Signed)_ -.1
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his oblig .ns as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permane 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.
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
Master Plumber.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspt ' m, or faulty
materials and /or worinnanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA.
TORIES
NK
SINKS
SLOP
SINKS
LAUNDRY
TUBS
UR
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
-
SEPTIC
TANK
SEWER
CONN.
DRAIN
PI ELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWIM'G
POOL
LIST
CHECK
Permit 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 comply with, wh er 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 /or E
Employing Plumber's Name_
Location and Legal Description Lot_
Street and Number where work is to be performed —No
Size Septic Tank_--__- ------------ o --
Feet of Drain Tile_ ______ c2
Nature of Water Supply: City—Well.
Amount of Permit $_
STATE OF FLORIDA, }
COUNTY OF DADE.
State work to be performed and purpose of building (By Floors)_
New Building _ -- Remodeling _-- ____ -- Addition
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
�.
....... No._ /l/G _-- Street
Block � L` � / col - -- ----- - - - - --
7 C ) Street !e
_Type of Tank
_ _Dist. Feet of Tank or Drain Field from Well .
Date__
----- -----�-- -- -- -- --
No. /ca✓ Street..,1
Repairs No. of Stories. _ _._._' ...... .......
(Signed a
Capacity Gals
__Size of Soakage Pit
7
(Signed)_ -.1
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his oblig .ns as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permane 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.
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
Master Plumber.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspt ' m, or faulty
materials and /or worinnanship.
Work done by
Address of work
Owner
srwr.
Sertic Tank
Drainfiold
Plumbing - Final
When ready
Received b
..e2/
Date
Time
PLUAG - INSPECTION
TL
6 7, Permit No.
/L1,e
/a 1
Rough \ TOD out
AM
PM
Work done ly
Address of work „Wez j
Owner
Septic Tank 07 Sower
Drainfield Gas
Plumbing - Final
When ready
Received by
Date
Time
7;
Pt ITMBING - IITSPECTION
Permit No . 4— V 1 0
RoueD.
Top out
PM
Permit No. —SA
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 - -, -. No . 7 Street_____Y___
Registered Architect and /or Eligieleer
Employing Plumber's Name
Location and Legal Description Lot
Nature of Water Supply: City —Wett'
Amount of Permit $_
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
My Commission Expires
MIAMI SHORES VILLAGE
No
_Block /
Street and Number where work is to be performed —No St reet_____ 1 f__
State work to be performed and purpose of building (By Floors)
New Building r Remodeling Addition Repairs —____ No. of Stories
Size Septic Tank Z Type of Tank
Feet of Drain Tile 6 O Dist. Feet of Tank or Drain Field Ere ir...Weli∎
Size of Soakage Pit
_(Signed)
(Signed)
Date
-------- - - � —
Nt __ Street 71i�_ — ___
Subdivision
Capacity Gals 9 YL
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligatidns 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. 4
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary pubic, 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
aster Plumber.
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
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWIM'G
POOL
CONTR.
LIST
/
CHECK
Permit No. —SA
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 - -, -. No . 7 Street_____Y___
Registered Architect and /or Eligieleer
Employing Plumber's Name
Location and Legal Description Lot
Nature of Water Supply: City —Wett'
Amount of Permit $_
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
My Commission Expires
MIAMI SHORES VILLAGE
No
_Block /
Street and Number where work is to be performed —No St reet_____ 1 f__
State work to be performed and purpose of building (By Floors)
New Building r Remodeling Addition Repairs —____ No. of Stories
Size Septic Tank Z Type of Tank
Feet of Drain Tile 6 O Dist. Feet of Tank or Drain Field Ere ir...Weli∎
Size of Soakage Pit
_(Signed)
(Signed)
Date
-------- - - � —
Nt __ Street 71i�_ — ___
Subdivision
Capacity Gals 9 YL
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligatidns 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. 4
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary pubic, 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
aster Plumber.
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.