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246 NE 102 St (2)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date O (o Job Address v? � /t/, ,� . /O , S %,Tax Folio Legal Description Historically Designated: Yes 3 No Owner/i essee / Tenant /y,, A /fit e � Master Permit # 3 q2 3 7 Owner's Address .(, / r d , o? S / Phone 7,5 /69 7 Contracting Co. Co� 241I f4 % S S /� P7 Q S [)/ e - 'foe 'Address `' 80 /- 6 ,4' „(,tJs O , /, w De, Qualifier (` /M,{ e W'WV 0/f f SS# - P) 6 - / y /f State # q 6 0 3 7 Municipal # Competency # eoo o o 3,, 71s. Co. 6,0f-, 9 D Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL ' LU' ECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION 3 ©d 5 Q , 11 Square Ft. ©(9 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 done in compliance with all applicable laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated. o President Date Ndtary as to Owner and/or Condo President My Commission Expires: Date FEES: PERMIT 3 RADON C.C.F. APPROVED: Zoning Building Electrical Mechanical Plumbing Engineering Estimated Cost (value) //So ®C' Signature of Contractor orLS ( ner- Builder nw�P Date Notary as to Contractor or Owner- )6-”' •014CP/P )wild 1 Date My Commission Expires: � Peje OFFICIAL NOTARY ;EA.L 2 ; M � BARBARA ANN FUGAZZI N o >l * COMMISSION NUMBER y f m \ � CC360191 MY COMMISSION EXP. of I O i' Q 1398 NOTARY TOTAL DUE 4// APPLICANT: AIR. L . oa/V C & AGENT: ;4; PROPERTY STREET ADDRESS: / 71 1 ® 2::11 .- D R A I N F I E L COI)TSTRUCTION PERMIT FQ,1� [ � // New System [ fl [I�'J [Repair Abandonment [ Other(Specify) LOT: PROPERTY ID #: ! 44 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,D SP F A2'IONS 0 T H E R a ®0 [ J TYPE SYSTEM: CONFIGURATION: 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 isting System 0 olding Tank BLOCK: SUBDIVISION: GPD] EPTIC TANKJAEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] A [ ] [ Ww •NS / 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: [ ] LOCATION OF BENCHMARK: / / ELEVATION OF PROPOSED SYSTEM SITE [ BOTTOM OF DRAINFIELD TO BE [ SQUARE FEET PRIMARY DRAINFIELD SYSTEM R•F}�F`EET SYSTEM ( ] STANDARD [ ] FILLED [ ] TRENCH [ 1 - 1 J BED D FILL INEffp9. [ .a c1C L N4 l 't ! g jTION REQUIRED: [ T ���rp�p NDE;.' E� O . y> r���A `ati` ,�41 . p S BM7 DLNCIIM �i� I 131,701113 l c.rPEC � ION THIS ;R,`Lan:: IS NOT r C a iTICN(3) RA 2,1-IL 3LEtlA1Y M SPECIFICATIONS BY: TITLE: HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001- 4016-0) APPLICANT PERMIT # r6k-oz DATE PAID a- " 1 FEE PAID $ LL O. c_ RECEIPT # Temporary /Experimental [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] [ ] MOUND [ ] [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT ] INCHES TITLE: - i � c CPHU EXPIRATION DATE: P THE 6:PTltt T.;EJI( $W M F77'. 7Z Eii'. 25,2.E DEFLECTION DE'A:i Iii8TALLEO QA TEE C'CZT "aC' Page 1 of 2 INSTRUCTIONS: PERMIT 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 # or section/township /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 10D-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 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. s I APPLICATION FOR: [ ] New System 0 Repair APPLICANT: e /j //f , / ?/0J AGENT: % 690e/ .S 3 /c; / 4 54 4t / & /i MAILING ADDRESS: / -lJ /, . .), so, ,/ _/ d'e OK- •,� /7? TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] LOT: BLOCK: SUBDIVISION: DATE OF SUBDIVISION: �j .rU PROPERTY ID #: [Section /Township /Range /Parcel No.] ZONING: PROPERTY SIZE: // 1 ACRES [Sgft /43560] PROPERTY STREET ADDRESS: e //( �J , DIRECTIONS TO PROPERTY: BUILDING INFORMATION / nit Type of/ , No .- Establ h 3 4 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 ei [ ] Garbage Grinders /Disposals [ ] Ultra -low yorume Flush Toilets APPLICANT'S SIGNATURE: C4- ] Existing System [ ] Holding Tank [ ] Temporary /Experimental ] Abandonment [ ] Other+'(Specify) y�C] RESIDENTIAL . of Bedrooms HRS-H Form 4015, Mar 92 (Obsoletes previous edition (Stock Number: 5744 - 001 - 4015-1) °..); PROPERTY WATER SUPPLY: eti PRIVATE [ PUBLIC ] COMMERCIAL PERMIT # DATE PAID FEE PAID $ RECEIPT # TELEPHONE: /0 6 _ 14/ O Building # Persons Business Activity Area Sgft Served For Commercial Only [ ] Spa's /Hot Tubs ] Floor /Equipment rains [ ]/ Other (Specify) t A DATE: x(723 whiy rb�, 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: Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, o copy of the lot legal description or deed must be attached. DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing on approved lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot. PROPERTY IDs: 27 character number for property. (CPHU may require property appraiser ID # or section/township /range /parcel number. PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved arras end 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 10D-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. APPLICANT: /7 , ( / ,7A/(24- ... . LOT: PROPERTY ID #: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: SUBDIVISION: 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 : 06 YES [ ] NO NET USABLE AREA AVAILABLE: /XI ACRES TOTAL ESTIMATED SEWAGE FLOW: r'.. 0 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] AUTHORIZED SEWAGE FLOW: i GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: ( O SQFT UNOBSTRUCTED AREA REQUIRED: 6/249 SQFT SOIL PROFILE INFORMATION SITE 1 SITE EVALUATED BY: SITE SUBJECT TO FREQUENT FLOODING: [ ] YES lnJ NO Munsell # /Color Texture Depth 6X / y _sA) i n7 /7 to to to to to to to to USDA SOIL SERIES: /D / PERMIT # 05 1 AGENT : 6,,e, -S S t ? 77 [Section /Township /Range /Parcel No. or Tax ID Number] BENCHMARK /REFERENCE POINT LOCATION: CEO d nee 4 / D/(? / AL /,..) , ,5" � a 6 /'( ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] 40y BELOW] ENEHMARK/)REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE P 0 OSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: FT DITCHES /S ALES: � FT RMALLY WET? [ ] YES ` NO WELLS: PUBLIC: FT LIMITED USE: FT P IVATE: FT NON - POTABLE: X/ j- FT BUILDING FOUNDATIO S: /0 FT PROPS Y LINES: S FT POTABLE WATER LINES: / /e2 FT 10 YEAR FLOODING? [ ] YES 06 NO 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: / MSL /NGVD SOIL PROFILE INFORMATION SITE 2 Munsell #,Color Texture Depth. 67,r 5/1/P /7 to 6' USDA SOIL SERIES: to to to to to to to to OBSERVED WATER TABLE: p Y INCHES [ABOVE / ;] EXISTING GRADE. TYPE: RCHED / ESTIMATED WET SEASON WATER TABLE ELEVATION: e) INCHES [ ABOVE / LOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES Lki NO MOTTLING: [ ] YES [. NO DEPTH: 4---- INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: //o?, 6 I.Y)i DEPTH OF EXCAVATION:--2 INCHES DRAINFIELD CONFIGURATION: [ ] TRENCH [,x] BED [ ] OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE: O ' HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) Page 3 of 3 (Stock Number: 5744 - 003 - 4015 -1) INSTRUCTIONS: PERMIT' 0: Permit tracking number assigned by CPHdU. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY IDI/: 27 character number for property. (property appraiser ID 0 or section/township/range/parcel number) PROPERTY SIZE: Check if property size at site conforms to submitted site plan. Record net usable area available -Eat area exclusive of all paved areas and prepared road beds within public rights -of -way or easements and exclusive of etr cma, 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 1 (residences) or Table 2 (noi - sesidentic!), C :apt r 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area cnd water c:pply (7500 3alionr per day per acre for private water supplies and 2.500 gpd per acre for public water cuppliea). �f authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be de:lied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at !earl 2 times as large as the drainfield absorption area and at leant 75 percent of the unobstructed area must meet minimum setbacks in Chapter 10D -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 roil 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 1 SITE 2 SITE 3 1 +) SHOT: H.I. s H.H. 11 1. H.H. [ -] SHOT [ -I SHOT [ -I SHOT STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION IT U _r5 j Permit Application Number Scale: Each block represents 5 feet and 1 inch = 50 feet. ■ ■ .■ ■■ ■ • • ■ ■ ■■ n■ ... • :mu•......••.. ;:':■.'::Cm:::::::...... .....::U7 nni Inv �: G ■■■. ■■■■■■■■C■UU U■■■ ■■ • ■IU■ snug t ■n ■■CI■_ ■� U ■■■■ ' UU■.■■■■■■.■.U C ■..■.. l ■ U ■■ .■■1 ............. + .U .U■ ■ l ■..■. .■.■■■■■■ ■■■ �■■ ■■ ■■■■■ U ■ ■ ■■ ■ . ■. ■■■■ ■ ■■ 1■I .■ _ ■minim ■I.■■11111minu I nimmma ..�� �.'�': ■�: ■ ■ ■■ ■ ■■ ■■ U ■■■. ■ ■ ■■ 1■ .■: .■...■Ulin ■■■■■. ••U •1 ■ I ■ ■ ■ ■ ■ � . 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Plan Approved By Site Plan submitted by: /A FP Pak = T-ptl#Tio /J, pi? if /IV ,� PART II - SITE PLAN IGNATURE Not Approved v ALL CHANG UST 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) TITLE Date 2.' County Public Unit Page 2 of 3 pp In ae WOrk't° , e pe.xforrned! • uinderth s Perini !t: • .ee0o daa,r tithe i grante peta it done 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 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 ' - •ti ' Registered Architect and /or Engineer Employing Plumber's Name 2 a . - No 7 S 1 L___f _J& &I f' , LF--" r Location and Legal Description Lot Y 1 7 Block _ Su bdivision 2 i'e� - : <_46t.__.4_, ' / Street and Number where work is to be performed —No ..J ___Y__ft,__ f Street 4/0 . sL _1= State work to be. performed and purpose of building (By Floors) New Building 1/ Remodeling Addition 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 Nature of Water Supply:' City —Well Amount of Permit $__ / �� ss. • MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT (Signed) ( Signed) Date `� / No Street 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. STATE OF FLORIDA, 1 COUNTY OF DADE. 1 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 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 / �. 4.2 114 .t }hN.'r, CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL. SPRKLR. SYSTEM SWIM'G POOL CO LIST / 1 3° L� � /_% °iF- � .="'t L}�^ }-/ 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 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 ' - •ti ' Registered Architect and /or Engineer Employing Plumber's Name 2 a . - No 7 S 1 L___f _J& &I f' , LF--" r Location and Legal Description Lot Y 1 7 Block _ Su bdivision 2 i'e� - : <_46t.__.4_, ' / Street and Number where work is to be performed —No ..J ___Y__ft,__ f Street 4/0 . sL _1= State work to be. performed and purpose of building (By Floors) New Building 1/ Remodeling Addition 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 Nature of Water Supply:' City —Well Amount of Permit $__ / �� ss. • MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT (Signed) ( Signed) Date `� / No Street 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. STATE OF FLORIDA, 1 COUNTY OF DADE. 1 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 such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship.