370 NE 101 St (4)bate ly ‘/- fl`' Job Address 3y0 Tax Folio // < 7,2 .0/ U<y 5 C )
Legal Description
Owner/Lessee / Tenant £/z4 .
Owner's Address 3 76 '1 f fin/ f Phone
Contracting Co. lam# - $ -' / o Address
g‘;,/ - f -7 1/7p
Qualifier
State # Municipal # '" x) 6 y i/
Architect/Engineer
Bonding Company
Mortgagor
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION Or, g-, 7 ' f 'PS 1
Square Ft. 3 c
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
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 pennit to do work and installation as indicated above, and on the attached addendum (if applicable). I certify that all wRrk
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELEC'IRI,C ,
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
AVIT: I certify that all the foregoing information is accurate and that all work will be done in compli
g. Furthermore, I authorize the above -named contractor to do the work stated.
4 At
Notary as to
My Conunissio
er and/or Condo President Date
• sWm. MARK WOODARD
i
,�, <� COMMISSION # CC 625712
� EXPIRES MAR 2, 2001
^`� BONDED THRU
9 4. OF V ATLANTIC BONDING CO., INC
FEES: PERMIT , RADON
APPROVED:
Zoning Building
Mechanical
Historically Designated: Yes
ss# / Phone
Competency #
Address
Address
Address
Estimated Cost (value),
C.C.F. / NOTARY
No
Master Permit # 9 g(O 2
(90D
Ins. Co.
ce with all applicable laws regulating
Date
/ — r
Signature of Contra
Notary as to Contractor or Owner- Builder
My Commissio ,f 1 Wm. MARK WOObAkb
a ,u r , COMMISSION # CC 625712
^ i-51 c EXPIRES MAR 2, 2001
ONDEDTHRU
9 �OF F\ ATLANTIC B BONDING CO., INC.
Electrical
BOND
Datf
TOTAL DUE 3 3
Structural Engineer
CONSTRUCTION PERMIT, OR:
(J ] New System [ Existing System [P] )6l ding Tank [V] Temporary /Experimental
( \ Repair L '] Abandonment [/ Other(Specify)
APPLICANT:
EL / z i) . 7 s [ Cfdf hicryD AGENT : A 44, o z
PROPERTY STREET ADDRESS: 37c) v F ®,) p' .f -
y
LOT: BLOCK:
PROPERTY ID #:
SYSTEM MUST BS ,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 SPF�C
T [#' a ] GALLOj1IS
A [ ] [GALLONS
N [ ] GALLONS
K [ ] GALLONS
D [t'» SQUARE FEET PRIMARY DRAINFIELD SYSTEM
] SQUARE FEET SY
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [ ] TRENCH [,4 BED [
R [
N
F
I
E
L
D
0
T
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
LOCATION OF BENCHMARK: /f. P4 4 /_ � ) p
ELEVATION OF PROPOSED SYSTEM SITE Air ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ O , 'C 1 ] NCHE FT [ABOV1 B� ENCHMA' /REFERENCE POINT
FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: L,3 ] INCHES
SUBDIVISION:
r3 sz;?
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
�" [OR OR TAX I D NUMBER ]
IFICATIONS
/ GPDEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
/ GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
TITLE:
TITLE y_
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
APPLICANT
PERMIT #
DATE PAID
FEE PAID $ 2 e
RECEIPT #
si d' eY (.zz s
EXPIRATION DATE:
T
� CPHU
Page 1 of 2
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTj4N,ERMI
, w d u
Permit Application Number
PART 1I - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
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f ( :) / f
I '-'•"""* "."."4.1).... 4.4.
1
1
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1
1.
1
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1
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Notes:
Site Plan submitted by:
4 c
o ,
SIGNATURE
,
•
TITLE
Plan Approved Not Approved Date`
By � �, � � �!�� y ,.y j,`-` ( County Public Unit
ALL CHANGES MUST BE AR PROVED P VED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not befused) Page 2 Of 3
(Stock Number. 5744 -002- 4015 -6) -.
/
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