69 NE 102 St (3)r
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address C9 de
�• X 13 O� htT ) D
• /aZ s Tax Folio
Legal Description S , R ik Historically Designated: Yes No
M
•
4 4x 16 D ce e.q g . 2. Master Permit #
Owner's Address to e/ n/ /4 ?. CI 1 Phone
Contracting Co. 1 ' 11. C l S XFio7, dro.. ` :address
Owner/Lessee / Tenant
Qualifier Op ss# Phone 3 "‘C/ 71.E
State # Munici # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
Square Ft. o215Z)
1 A 1 !,}(x_2. Tot.., h_ ea,„ J /e %(
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 AF1 I ify th 1 the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction . s d zonin • /' urth ore. authorize the above -named contractor to do the work stated.
A s: cTFPHEN E. COCKING
a �: ' : 1ON # DD 031747
• '0, 2005
44' ' ' UndsrntNem
lir 17 9c0/
tgnature of er an or President Date
Notary as to
My Commissio
FEES: PERMIT
APPROVED:
Zoning Building
Mechanical
� z, 17-`a✓
STEPHEN '
MY COMMISSION a ?! f;:'• • . 1
9
EXPIRES: �, fuD9cUndetwdtere
ate
Estimated Cost (value) � ( C7
Sign e of Contrac
Own e ...:wilder
•
r Contrac or •wner- Builder
My Commission Expires:
C.C.F. NOTARY �� , (� (� BOND
Electrical
TOTAL DUE
Dat
Structural Engineer
i
STATE OF FLORIDA CENTRAX #: 13 -SG -11345
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID : $
▪ CONSTRUCTION PERMIT RECEIPT
, OSTDSNBR : 01 -3916- -R
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System [ ]Holding Tank
[ X ]Repair [ ]Abandonment [ ]Temporary
IN ]
APPLICANT: Suarez, Mario AGENT: SR0931119, COCKING MSTEPHEN
PROPERTY STREET ADDRESS: 69 NE 102 St Miami FL 33138
LOT: 20 BLOCK: 12 SUBDIVISION: Miami Shores Sec N 1
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3206 - 013 -1680 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 750 ]Gallons SEPTIC TANK MULTI - CHAMBERED /IN SERIES: [Y ]
A [ 0 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 200 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [� ]STANDARD [ N ]FILLED [ N ]MOUND [ N ]
I CONFIGURATION: [ ]TRENCH [']BED [ N ]
N
F LOCATION TO BENCHMARK: Fin. F1. Of Existing Res Elev. 13.5' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 2.3 ] [ FEET ] [ BELOW BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 4.5 ] [ FEET ] [ BELOW BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 26.0 ] INCHES
OTHER REMARKS:
Existing 750 Galls Septic to remain.
Install 200 Square feet drainfield to remain.
Invert Elevation of the drainfield to be no less than 9.54' NGVD
Bottom elevation of the drainfield to be no less than 9.04' NGVD
This permit is not for addition.
SPECIFICATIONS BY: Andre, Paul
TITLE: F, U=
APPROVED BY: Andre, Paul TITLE:,. PFOfes 1,44.1 Engin Dade
DATE ISSUED: 12/24/01 Zlie j L 17."',J ud ti> s ��J� X PIRATION DATE: 3/24/02
DH 4016, 03/97 (Obsoletes prey editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) fostds_cons_4016 -11
Innovative Other
CHD
Page 1 of 2
Scale: Each block represents 10 feet and 1 inch = 40 feet. L4L W 9 °
1
tvt
I
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT_
Permit Application Number (/ -
Site Plan submitte ) by:
Plan App
PP
By
ALL CHANGES
Notes: C0 ti ir,e, >c y ,,,o
DH 4015, 10/96 (Replaces HRS -H Form 4015 JVhich may be used)
(Stock Number: 5744 -002 - 4015 -6)
PART II - SITEPLAN
o
Not Approved
1.64 z .45a.
6f° C i l e �
UST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
(IL ol
Date / 2/0,
County Health Department
Page 2 of 4
•T1
PAY
TO THE
ORDER OF
MR. C'S SEPTIC & DRAIN, INC.
OPERATING ACCOUNT
P.O. BOX 693239
MIAMI, FL 33269-0239
q14 S k,,4 V ` l/a
L_'AI 4. -414 A 4.A //. ■ � _ /. . 41 --A—I
Q49
Washington Mutual
Washington Mutual Bank, FA
Miami/199th Street Financial Center 1719
175 NW. 199th Street 1.800- 788.7000
Miami, Ft. 33169
BUILDING O
ELECTRICAL ❑
PLUMBING
ROOFING ❑
ECH ❑
er of
uilding
24 Sour Customer Service
FOF :PeA 5 T U-3 (-/-3 tP
00048 5411' ; 1 : 26 7084 1 3 LI: 38 31110 308 4 21"011'
MIAMI SHORES VILLAGE, FLORIDA
305- 795 -2204 ,
PERMIT N_ - 5
PERMIT CARD MUST BE AVAILABLE FOR ALL INSPECTION
Work to be performed under this Permit
rchitect
Contractor
o? Buide
Legal
Description
Address of
Building
DATE
6Z/ v4 /C /
1r
•
6OLLARS a
4854:
63- 8413/2670
3830308420
Date
Contractor's
License No.
6- 013 - Ibo
Subdi-
vision
Sq. Ft.:
Value of
Project 1 a 40 a
200
Permit: T/ 0. 0 C),
Notary: S o V .;. >.:.
Bond:
Radon:
Amount of )
Permit: bot S _ (7 ()
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 applica-
tion 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 specificationp that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any itime if the work is not done in com : fiance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that he contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and .,
regulations pertaining to the work covered 'ereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, e a s or employees.
Sign d• ` r f . I - / A - (INSPECTOR) BY
In consideration of the i a. 1 .w. a of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict co r with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this ermit 1 assu'r - responsibility for all work done by either, myself, my agent, servant or employee.
� ,/(.9 : �" V -z • /� �. -.dam
•
BUILDING ❑
ELECTRICAL , ❑
PLUMBING
ROOFING V ❑
ECH ❑
(
„ildh of
f B Td ing
Architect
Contractor
or Builder
Legal f l
0 Description
�ddress of / '( - Building 1 - ) 0 �•
\ —
1�.
MR. C'S SEPTIC & DRAIN, INC.
OPERATING ACCOUNT
P.O. BOX 693239
MIAMI, FL 33269 -0239
Ai)
/_./tea . i . /. / //. . • _
PAY
TO THE
ORDER OF •
11
1806789 -7000
Miem1, R 33169 24 now Customer Smrke
FOR 57 S J C P Y 3
11'0048 5411' •I: 26 7084 L 3 L1: 38 31110 3084 21110”'
Washington Mutual
Washington Mutual Bank FA
MIami/199th Street Financial Center 1719
175 NW. 199th Street
4?nZlu,.:w,..,�• ' -�—__, , r<a „peG;�ti:,,n�w... —, f n_a T - _�� . �_,1�. �.e.
sibility for work done by his agents,
Sighed-
In consideration of the is
ertaining thereto and in strict c9
n accepting this permit I assumte
.
. 305 - 795 -2204
PERMIT N? 50482,E ^
ants Ar employees.
DATE
' 6
t 3- 8413/2670
v / - 3830308420
I $: ` 9( - . �
1
6Oi LARS lJ
MIAMI SHORES VILLAGE, FLORIDA
Date
PERMIT CARD MUST BE AVAILABLE FOR ALL INSPECTIONS
Work to be' performed under this Permit
Contractor's
License No.
\- - 403 o
Solidi=' � 10-7
Sq. Ft.:
Value of
Project $ f 0 Q
J
4854
Permit: 1' s 0 0
-6c)
CCF:
`Notary: .5._ t) C7
Bond: j _ O C�
Radon:
Amount o£—,
Permit:
- 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 applica-
�l tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
— \ (\ N drawings, statements or specifications may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
-J _ t 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
- 4.permit is granted is the understanding that the/contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
egulations pertaining to the work .c verpd he by whether shown on the -plans or drawings or in the statements or specifications and that be assumes respon-
(INSPECTOR) BY
t e of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
irni with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
eslfonsi for all work done by either, myself, my agent, servant or employee.
_PROPERTY OWNER NE
New Construction
Name l�� F ( E ' (N j
e
/
Address
UM ms. /1a.
Repair
Alteration Interior
Home Telephone
Relocation of Structure
Business Telephone
Shell Only
Fax
Add'I Attachment
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'I Detachment
Other
Job Address:
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Step 1.
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICA'T'ION
6 N
Address
pt. City
Folio Number 1 / l / L3 i(08 )Description of Work
Lot Block
Subdivision PB PG
Current Use of Property
Proposed Use of Property
Tenant Information
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
PERMIT APPLICATION
Master Permit No.
Subsidiary Permit No.
//- 33/3
State Zip
A /�e-c. s3,h4- T7 i4
7 • 2 •• . r��.
Linear Feet
Zoning
Square Feet Units Floors
Value of Work Bldg Value
O v i
Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
Name
License No.
Address
Telephone
Fax
Qualifier Name
Page 2
1N1PORTAN'l' NO'T'ICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
A Fri DAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1°' Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORIDA, COUNTY OF MIAMI -DADE
Signature of Owner
Print Name
Sworn to and subscribed before me this
Si/mature of Notary Public - State of Florida
day of
SEAL: SEAL:
STATE OF
Signature of Contractor / Qualifier
Print Name
to aik d subscribed before me
Signature of
Lary Public
PERMIT APPLICATION
IDA, COIJNTY OF MIAMI -DADE
tate of
orida
day ofi� __ ,
L.
Personally known OR, Produced Identification Personally Imow4✓ OR, Produced Identification
Type of Identification Produced: Type of Identification Produced:
ELECTRICAL
Tvi,I,
Minimum Fee
QTY.
'i'YI'E
Dryer
QTY.
TYPE
Outlet, Appliance
QTY .
TVI'I:
Service Repair
QTY.
A/C Central 1 -3 Ton
Heating Strips, each
Fan
Outlet, Wall
Service, Temporary
- Paint Booth
A/C Central 4 -7 Ton
Fire Pump
Outlet, Switch
Piping, Flammable Liquid
Signs
A/C Central 8 -15 Ton
Fixture - Fluorescent
Process/Pressure Piping
Oven
Space Heater (kw)
A/C Central 16 -20 Ton
Pressure Vessel
Fixture Light
Parking Lot Lights
Spas/Hot Tubs
A/C Central 20+ Ton
Flood Lights
Plugmold/Strip
Subfeeds, No. of Amps
A/C Window
FPL - Load Central
Posts
Swim Pool, Commercial
Air Conditioners
Garbage Disposal
Range/Range Top
Swim Pool, Residential
Chiller
Generators, etc.
Receptacles
Switchboards
Clear Violations
Heat Recovery
Refrigerator, Comm. (p/PH)
Temp Serv., Construction
Compactor
Low -volt, Burglar
Refrigerator, Domestic
Temp for Test - 30 days
Deep Freezer
Low -volt, Fire
Renew - Temp Service
Water Closet
Demolition
Low -volt, Intercom/Teleph.
Repair Circuits
Water Heater
Dishwasher
Low -volt, Television
Service, Number of Amps
Water Heater New
MECHANICAL
TYI'1:
Minimum Fee
QTY.
Tl'1'I;
Condensate Drain
QT1'. TYPE
Generator
Q'I'Y. TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
Q"IV.
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
- Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Pump and Abandon'
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
Gas - Appliance
PLUMBING
TYI'I•:
A/C Condensate
QTY.
TYPE:
Drains, Roof
QTY.
mg.::
Miscellaneous Fixture
QTY.
'INIT.
Soakage Pit
Q"IV.
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon'
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
L OFFICE USE ONLY
CHECKLIST
J OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi - family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
❑ PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
$ o
Metropolitan Dade County (C.C.F.) $ ( sq.ft. = x/I000
x (1.60)
Inspector State Educational Fund $ (¢.005 /sq.ft.)
State DCA (Radon) $ (¢.01 /sq.ft.)
Code Enforcement Fine $
Zoning Review
REVIEWED AND PREPARED BY:
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
PERMIT APPLICATION
LI CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $
DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLSCATION FOR PLUMBING PERMIT
P e r m i t No / r5 3 Date._ -_ -._ A 7 /l
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the budding 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.
Street_
Owner's Name and Address � _ _. No.
Registered Architect and /or Engineer______ �? ___ _�_ •
Employing Plumbers Name _ � G+ .t. • `- = !i__ No. _ - - - - -- Street_ — _. S
Block
Street and Number where work is to be performed —No /12 Str
State work to be performed and purpose of building (By Floors) _ -_ -_- -Q _. 4 a c
Location and Legal Description Lot___
Subdivision...- ___ -_ --
New Building-------- _ -__ -- _ -- Remodeling Addition._ -_ Repairs No. of Stories... .. ......
Size Septic Tank
Feet of Drain Tile__
Nature of Water Supply: City — Well..__---__ ___- ..... of Soakage Pit
Amount of Permit $
Type of Tank_
_Dist. Feet of Tank or Drain Field from Well
Capacity Gals.
(Signed) _
mbing In.. •.ctor.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations . s an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent S •plement, and bus com-
plier with the provisions thereof, and will require similar compliance from all contractors or sub - contractors emplo ' . him in the work to be
performed under this permit; and will post or cause to be posted for inspection on • : the work such c notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contract . s, on wor to be per as are
licensed by Miami Shores Village.
STATE OF FLORIDA,
COUNTY OF DADE. j
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 insp m, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
UR
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHICK
... -
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE'
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
CHECK
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLSCATION FOR PLUMBING PERMIT
P e r m i t No / r5 3 Date._ -_ -._ A 7 /l
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the budding 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.
Street_
Owner's Name and Address � _ _. No.
Registered Architect and /or Engineer______ �? ___ _�_ •
Employing Plumbers Name _ � G+ .t. • `- = !i__ No. _ - - - - -- Street_ — _. S
Block
Street and Number where work is to be performed —No /12 Str
State work to be performed and purpose of building (By Floors) _ -_ -_- -Q _. 4 a c
Location and Legal Description Lot___
Subdivision...- ___ -_ --
New Building-------- _ -__ -- _ -- Remodeling Addition._ -_ Repairs No. of Stories... .. ......
Size Septic Tank
Feet of Drain Tile__
Nature of Water Supply: City — Well..__---__ ___- ..... of Soakage Pit
Amount of Permit $
Type of Tank_
_Dist. Feet of Tank or Drain Field from Well
Capacity Gals.
(Signed) _
mbing In.. •.ctor.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations . s an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent S •plement, and bus com-
plier with the provisions thereof, and will require similar compliance from all contractors or sub - contractors emplo ' . him in the work to be
performed under this permit; and will post or cause to be posted for inspection on • : the work such c notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contract . s, on wor to be per as are
licensed by Miami Shores Village.
STATE OF FLORIDA,
COUNTY OF DADE. j
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 insp m, or faulty
materials and /or workmanship.