950 NE 100 St (6)Owner/Lessee / Tenant
Owner's Address 950 NE 100 STREET
Contracting Co. NORTHDADE SEPTIC TANK
FEES: PERMIT
APPROVED:
Zoning
Mechanical
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 2/1/96 Job Address 950 NE 100 STREET Tax Folio
Legal Description Historically Designated: Yes
SYDOW
Qualifier DENNIS NEVILLE SS# Phone 754 -3375
State # 025836 -8 Municipal # Competency # 12842 Ins. CoTRAVELERS /ESTF
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): Il[IDEBENGXEDEMR) L : P.TJUMBIN { MEIC ]JNAL}BQO NAK X l9RX
WORK DESCRIPTION INSTALL DRAINFIFT,D
Square Ft. 200
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 a ork will be done in compliance with all applicable
laws regulating constructi., and z. ing. Furthermore, I authorize the above -name. . actor o do the w
Date
iq 6
Not ,ds to Owner an e r (Condo President ate
My Commission Expi
c«<<<<<, <c<<<<n <<<ttt<<c. « «aWe5
cz. PUB Teresa J. Felder
* Q Commission Public State of Florida
:,. o Conission No. CC 480 307 <e
` rt.e My Commission Expir;,s 07/16/99 :,
1- 200- 3•1∎OTARY. Fla. Nc:ary re vjc. & aorcGng Co.. c
RADON C.C.F.
Estimated Cost (value) $1000.00
M
Building
Plumbing 4
Master Permit #
Phone
751 -3949
No
3 cq
7
Address 800 NW 111 STREET, MIAMI 33168
to Contractor,
mmissio t E t xn
) t tt
i p,pY PV
NOTARY
ilder Date
,c-edeA ji#
uilder Date
wttttatttt« %mtm%st tt4
Teresa J. Felder
Notary Public, State of Florida
3 31 ‘,14 Commission No. CC 480307
+'oF FLO My Commission Expires 07/16/39 .;
1.8CO.3. OTARY - Fla. No & northing Co. �<
TOTAL DUE 3—L'
Electrical
e
Engineering
CONSTRUCTION PERMIT FOR:
[N ] New System [ N ] Existing System
[ Y ] Repair [ N ] Abandonment
APPLICANT: SYDaW
PROPERTY STREET ADDRESS: 950 NE 100 STREET, MIAMI SHORES 33138
LOT: N/A BLOCK: N/A SUBDIVISION: N/A
PROPERTY ID #: 950 NE 100 STREET 33138
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
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
EXISTING
T [.750 ] [GALLONS / 0: SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:( ]
})^_, .; [GALLONS / 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: [
D [ 200 ] SQUARE FEET ' DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: EX ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [X] BED [
F LOCATION OF BENCHMARK: F..F_F_:9om„G.1.
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 30 ] INCHES
DATE ISSUED:
O INSTALL 12" OP LOAMY COARSE SAND TINDER BOTTOM
T OF DRAINFIELD SUBMIT BENCHMARK BEFORE INSPECTION
H THIS PERMIT TS NOT FOR AT)DTTTON(S).
E INVERT ELEVATION (MTNTMTTM) ! /4 1. T d 1. 1 ,94 g_ 4
R BOTTOM OF DRAINFIELD ELEVATION tfMTNTMTTM) : , 5 s
SPECIFICATIONS BY: TITLE:
APPROVED BY: - , r TITLE:
. U
TM SEPTIC TANK DEFLECTION DEVICE !METALLED ON THE ADD A
OUTLET SOLID
TI E.
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 $
RECEIPT #
[N ] Holding Tank [N] Temporary /Experimental
[N ] Other(Specify)
AGENT: NORTH DADE SEPTIC TANK
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
EXPIRATION DATE:
CPHU
Page 1 of 2
INSTRUCTIONS:
P,E'Wse 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.
BLOCK, SUBDIVISION or
:.'ROPER T Y Mt!: 27 character id number for property. (CPHU may require property appraiser ID (1 or section /township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 10D -6, FAC.
DRAINFIE D: 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 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.
APPLICATION FOR:
[
N ] New System [ N ] Existing System
[ Y ] Repair [ ] Abandonment
APPLICANT: SYDOW
AGENT:
MAILING ADDRESS: 800 NW 111 STREET, MIAMI 33168
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:
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS: 950 NE 100 STREET, 33138
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of No. of
No Establishment Bedrooms
1
2
3
4
NORTH DADE SEPTIC TANIC
SFR
BLOCK:
[N ] Garbage Grinders /Dispo
[N] Ultra -low Volume Flus
APPLICANT'S SIGNATURE:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
SUBDIVISION:
ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [XX] PUBLIC
CX ] RESIDENTIAL [ ] COMMERCIAL
2 BEDROOMS
ets
HRS -H Form 4015, Mar 92 (Obsoletes previous editions � whicr!ay not be used)
(Stock Number: 5744 - 001 - 4015 -1) @ �?
[ Holding Tank [ Temporary /Experimental
[ ] Other(Specify)
b
DATE OF ORE 72
SUBDIVIS
[Section /Township /Range /Parcel No.] ZONING:
Building # Persons
Area Scift Served
[N ] Spas /Hot Tubs
N ] %ther (Specify)
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
90-.
s 4 0Pe,z)
TELEPHONE: 751 -3949
754 -3375
DATE:2 /2/96
Business Activity
For Commercial Only
[N ] Floor /Equipment Drains
Page 1 of 3
INSTRUCTIONS:
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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY MP: 27 character number for property. (CPHU may require property appraiser ID 11 or section/township /range /parcel number.
PROPERTY SIZE:
Lot, block, and subdivision for lot (recorded or unrecorded aubdivision). If lot is not in a recorded subdivision, a copy of the lot
legal description or deed must be attached.
Net usable area of property in acres (square footage divided by 43,560 square feet) 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. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 1OD-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table II, Chapter I0D -6, FAC.
FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application one day submitted to the CPHU with appropriate fees and attachments.
ATTACHMENTS:
A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANTS SYDOW AGENT: NRTH DADE SEPTIC TANK
LOT:
BLOCK: 1 .4 p SUBDIVISION:
PROPERTY ID #: 950 NE 100 STREET, 33138
A
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 P • [ ]YES [ ] NO NET USABLE AREA AVAILABLE: 9401 ACRES
TOTAL ESTIMATED SEWAGE FLOW: -4 -G 0 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: ,.4 00 SQFT UNOBSTRUCTED AREA REQUIRED: 4 0 0 SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS ` i) [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: 100+ FT DITCHES /SWALES: — FT NORMALLY WET? [ ] YES [ NO
WELLS: PUBLIC: 100 FT LIMITED USE: "- FT PRIVATE: FT NON - POTABLE: ! FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: ID FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [xl NO
10 YEAR FLOOD ELEVATION FOR SITE: wZ 3 . 0 FT MSL /NfW
'SOIL'PROFILE INFORMATION SITE 1
Munsell # /Color Texture
brown saady
USDA SOIL SERIES: Sandy
Depth
0 to 72"
to
to
to
to
to
to
to
to
SITE EVALUATED BY:
[Section /Township /Range /Parcel No. or Tax ID Number]
10 YEAR FLOODI G?
SITE ELEVATION:
SOIL PROFILE INFORMATION SITE 2
PERMIT # 7 4e 4 . 31 6
YES F NO
FT MSL/Piglff
Munsell # /Color Texture Depth
brown sndy U" to /2„
USDA SOIL SERIES:
Sandy
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: .. INCHES [g180Y71 / BELOW] EXISTING GRADE. TYPE: [D / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 108 INCHES [ A'KIIt1I5 / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [X] NO MOTTLING: [ ] YES [X4 NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: 1.25 DEPTH OF EXCAVATION: 30 INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH X[ X4 BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:2 /2/96
HRS -H Form 4015, Mar 92 (Obsoletes previous edi ons which may not be used) Page 3 of 3
(Stock Number: 5744- 003 - 4015 -1)
PROPERTY SIZE: Check if property 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 creams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
INSTRUCTIONS:
PERMIT 1): Permit tracking number assigned by CPHU.
APPLICANT: Property owner's full name.
AGENT: Property owner'° legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID/I: 27 character number for property. (property appraiser ID 11 or section/township /range /parcel number)
SWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimated sewage flow for the establishment from Table 1 (residences) or Table 2 (non - residential), Chapter
I0D -6, FAC. Record the authorized sewage flow fo• the la1 based on net unable area and water oupply (1500 gallons
per day per acre for private water supplies and 2500 gptJ per acre for public water cupp1ies). f authorized a ;wage flow
does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed rise available and the amount required. Unobstructed area muct be ct least 2
times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must net minimum
setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the dreinfield.
BENCHMARK INFORIMMATION: Record the location of the benchmark. if using a cterveyor'o 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 er °NA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot muct be meceured. 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 Iota subject to flooding record 10 yecr flea elevation for cite and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal ter,. required. Soil
identification will use USDA Soil Classification methodology (Musical! colors and USDA coil textures). Refusals meet
be clearly documented. Provide USDA coil series if available, record 'UN(' if the eerier) 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 bared on site evaluation, USDA coil mapa, 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 drainfieid 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 1 SITE 2 SITE 3
[¢] SHOT: H.I. H.I. i9.11.
H.I. [ -] SHOT [ -] SHOT [ -] SHOT
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Notes SYDOW: 950 NE 100 STREET, 13138
OLD SYSTEM OVRRPT,OWTNC. e [J t OCAS (ltO / K%4-1.C, C.f. T S (/�/J e a ;j9
OA/ 0,- io el ( c iTg
Site Plan Submitted by
SIGNATURE
Plan Approved I;/
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION IT,/
6
Permit Application Number l J
PART I1 - SITE PLAN
,9/
KUM
m_t.mr
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6) .
7S8
TITLE
_ I
Not Approved Date J /
County Public Unit
Page 2of3
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Notes SYDOW: 950 NE 100 STREET, 13138
OLD SYSTEM OVRRPT,OWTNC. e [J t OCAS (ltO / K%4-1.C, C.f. T S (/�/J e a ;j9
OA/ 0,- io el ( c iTg
Site Plan Submitted by
SIGNATURE
Plan Approved I;/
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION IT,/
6
Permit Application Number l J
PART I1 - SITE PLAN
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KUM
m_t.mr
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6) .
7S8
TITLE
_ I
Not Approved Date J /
County Public Unit
Page 2of3
BUILDING
ELECTRICAL
PLUMBING
Owner of
Building
Architect
Contractor
or Builder
Legal
Description.
Address of
Building
Lot
e" ere)
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
DATE I�"'�
PERMIT N° 10461
Work to be performed under this Permit
en
Bl.
Subdi-
vision
6
Signed • — liPhriari.....imaisit BY
INSPECTOR
BY
/3
Contractor's
License No
-tio • -140a,,
Value of Amt. of
Project $ Permit $
t
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 the st ment . specifications and that he assumes responsibility for work
done by his agents, servants or employees.
195
In consideration of the issuance to me of this permit I agree .erform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings tements or specifications submitted to the proper authorities of Miami Shores Village.
In ac epty this permit I ass_, e responsibility f.. all ork dpne'.y either, myself, my agent, servant or employee.
AUTHORITY
°'r te
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Permit No./ 0 4
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 /or Engineer
yy
Employing Plumber's NameL._ ��� , " • "�____ No
Location and Legal Description Lot Block Subdivision____
Street and Number where work is to be performed —No r % 2 • Street
STATE OF FLORIDA,
ss.
COUNTY OF DADE.
t
No - Street
Street
'' /
My Commission Expires Notary Public, State of Florida
Date
State work to be performed and purpose of building (By Floors)
New Building Remodeling Addition Repairs No. of Stories
Size Septic Tank 2 -' Type of Tank Capacity Gals
Feet of Drain Tile _-_Li Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City —Well Size of Soakage Pit
Amount of Permit $ (Signed)
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 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 undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
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.
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
SW IM'G
POOL
.--
CONTR.
LIST
CHECK
°'r te
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Permit No./ 0 4
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 /or Engineer
yy
Employing Plumber's NameL._ ��� , " • "�____ No
Location and Legal Description Lot Block Subdivision____
Street and Number where work is to be performed —No r % 2 • Street
STATE OF FLORIDA,
ss.
COUNTY OF DADE.
t
No - Street
Street
'' /
My Commission Expires Notary Public, State of Florida
Date
State work to be performed and purpose of building (By Floors)
New Building Remodeling Addition Repairs No. of Stories
Size Septic Tank 2 -' Type of Tank Capacity Gals
Feet of Drain Tile _-_Li Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City —Well Size of Soakage Pit
Amount of Permit $ (Signed)
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 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 undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
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.
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.