DS-09-322Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 111626 Permit Number: DS -3 -09 -322
Scheduled Inspection Date: August 17, 2009
Inspector: Bruhn, Norman
Owner: OSTENDORP, THOMAS AND REBECCA
Job Address: 261 NE 102 Street
Miami Shores, FL
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Driveways /Sidewalks /Slabs
Inspection Type: Final
Work Classification: New
Phone Number
Parcel Number 1132060134960
Building Department Comments
REDO EXISTING PATHWAY
Passed Wer91:9?
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP- 107736. Work exceed permits.
Walk on side and rear not permitted /revise plan NB
Ain-met 14 ')nno
For Inspections please call: (305)762 -4949
Patio 1 of 19
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
L Permit No. 3:2.2
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type (circle):
Building
Roofing
Owner's Name (Fee Sirtple Titleholder) - Phone #
Owner's Address
/
City I ` ! 1 . ate S L— Zip
Tenant/Lessee Name
-71591. 5Y
91U2 56
Phone #
Job Address (where the work is being done) '1 r .is 1 CYL k
City Miami Shores Village County Miami -Dade Zip '�'■
FOLIO / PARCEL # 1 (— 7-%'m — 0 1/4 ' `'t C11 to Z
Is Building Historically Designated YES NO /
Contractor's Company Name ri" ""v 01U14-9
Contractor's Address
Phone #
City State Zip
Qualifier Name Phone #
State Certificate or Regi tration No.
Architect/Engineer's Nam
Value of Work
Square / Linear Footage Of Work:
Type of Work..'. dition DAlteration ['New ❑ Repair/Replace ❑ Demolition
n..
*********** * * * * * * * * * * * * * ******** *** **** Fees *** * *** * * ** * * ** * * **** . ** **** * * *** ** * * **
Submittal Fee $
Notary $
Scanning $
Bond $
Structural Review. $
Permit Fee $ CCF $
Training/Education Fee $ Technology Fee $
Radon $ DPBR $ Zoning $
Code Enforcement $ Double Fee $
Total Fee Now Due $ � ti9 )-2"
See Reverse side —�
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
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.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reins. M fee will be charged.
�•
Signature
Owner or
The for-.:oing i .trument as a owledged be ore
1 C u - ` .
day of �. I,¢ s , 20 O by � �� 'v � y of , 20 , by
who is pe .o ally known to me or who has produced 1 1 I who is personally known to me or who has produced
• (9801ntification and who did take an oath. as identification and who did take an oath.
NOT ' PUBLIC: ®NOTARY PUBLIC:
nature
Contractor
The foregoing instrument was acknowledged before me this
Sign:
Print:
My Commission Expires:
I, 45401%
3
CN9c,40 cam' 4ioGOPrint:
My Commission Expires:
**************************** * * * * * * * * * ** * ** * * * * * * * * * * * ** ** **
APPLICATION APPROVED BY:
(Revised 07/10/07)
V, 0 g-4-/
Plans Examiner
Engineer
Zoning
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795-2204 Fax: (305)756-8972
Permit NO. DS-3-09-322
Issue Date: 3/12/2009
Expires:3/1212009
Folio Number:1132060134960
Owner's Name THOMAS AND REBECCA OSTENDORP Owner's Phone:
Job Address: 261 102 Street Total Square Feet:
•
Miami Shores, FL
Total Job Valuation: 1:1
50
$ 750.00
Contractor(s) Phone PrimaryContractor
HOME OWNER Yes
„•
Planning and Zoning Criteria and Comments
Approved: Yes Date Approved: 8/5/2009 : Yes
Comments: 8/5/09
NEW PLAN OK
.NGE
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SCALE:1 " =20'
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— X — X — DENOTES FENCE LINE
— ,/,— i,_ DENO WOOD
PENCE OLINE
— 1 — 1 — DENOTES OVERHEAD
CABLE = SHED
DENOTES ELEVATION
SITE
A - ARC LENGTH OVER HEAD CABLE .(
ASP - ASPHALT OFFICIAL RECORDS- -
HU - ADJACENT UNIT BOOK •
BP/ - BUILDING CORNER ON /NEAR PL FROM PLAT -
C - CENTRAL ANGLE PROPERTY UNE -
- CENTER UNE POINT OF CURVATURE -'
- C/C - CLOSING CORNER
CC - COVERED CONC (PORCH) POINT OF COMPOUND - F
CF • CALCULATED FROM FIELD MEASURE CURVATURE
CONC - CONCRETE . PARKER KALON NAIL -
CR - CALCULATED FROM RECORD DATA
CTV - CABLE TV RISER POINT OF BEGINNING - 1
A - CENTRAL ANGLE (DELTA) POINT OF -F
DE - DRAINAGE EASEMENT COMMENCEMENT
EASE - EASEMENT POINT OF REVERSE - :
EOW - EDGE OF WATER CURVATURE
FP - FENCE ON / NEAR PROPERTY LINE POINT OF TANGENCY -
FF - FINISHED FLOOR CENTERLINE OF PARTY i
.,FIP FOUND IRON PIPE " • WALL
FIR FOUND IRON ROD RADIAL -
FN FOUND NAIL RIGHT -OF -WAY - I
FND FOUND BELL SOUTH RISER -
FM FLORIDA POWER $,_LIGHT UTILITY EASEMENT -
L - FROM LEGAL DESCRIPTION VALLEY GUI !tit -
PW. PARTY WALL WIRNESSCORNER -%
M MEASURED WATER METER -
ME' MAINTENANCE EASEMENT WING WALL -
NR '' NON - RADIAL UTILITY POLE -
S
LOT Nt
BLOCK
NOTES:
1.THIS SURVEY IS BASED UPON RECORD INFORMATION AS PROVIDED I
CLIENT. NO SPECIFIC SEARCH OF THE PUBLIC RECORD HAS BEEN MAI
BY THIS OFFICE.
2. UNDERGROUND IMPROVEMENTS HAVE NOT BEEN LOCATED EXCEP
SPECIFICALLY SHOWN.
3. ELEVATIONS ARE BASED UPON NATIONAL GEODETIC VERTICAL DA1
(N.G.V.D. 1929).
4. FENCE TIES ARE TO CENTERLINE OF FENCE.
5. IN SOME CASES. GRAPHIC REPRESENTATIONS HAVE BEEN
EXAGGERATED TO MORE CLEARLY ILLUSTRATE MEASURED RELATIONSI
- DIMENSIONS SHALL HAVE PRECEDENCE OVER SCALED POSITIONS.
6. ALL DIMENSIONS SHOWN ARE FIELD MEASURED AND CORRESPONC
RECORD INFORMATION UNLESS SPECIFICALLY NOTED OTHERWISE.
7. CORNERS SHOWN AS "SET' ARE IDENTIFIED WITH A CAP MARKED LB
(LICENSED BUSINESS) # 6799.
SURVEYORS CERTIFICATION:
I HEREBY CERTIFY THAT THIS BOUNDARY
SURVEY MEETS THE MINIMUM TECHNICAL STANDARDS FOR SURVEYS./
SET FORTH BY THE FLORIDA BOARD OF SURVEYORS AND MAPPERS IN
CHAPTER 61G17 -6 OF THE FLORIDA ADMINISTRATIVE CODE. PURSUAN
TO SECTION 472.027. FLORIDA STATUTES.
ELEVATIONS SHOWN - IF APPLICAELE ARE EASED UPON _ _
BENCH MARK:
ELEVATION = ' N.G.V.D: 1929
DATE- ///' G� -Z'0'
ANDREW SNYDER PROFESSIONAL SURVEYOR AND MAPPER FLORIDA
REGISTRATION No. 5639 (NOT VALID WITHOUT THE SIGNATURE AND TH
ORIGINAL RAISED SEAL OF THE FLORIDA LICENSED SURVEYOR AND
MAPPER SHOWN ABOVE)
REVISION SCHEDULE:
•
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•■••
• .
• ••
•
SIGNED:
••
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0000
•
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••• ANDTEC •
s N &••IOJSPEC.• T;ONS
ProvIdIngel. nt Surrlying & Hnm• jryr'p c on Services to Soi lorida
• • ..arw.aetomaii/if'•�tel
•••i
1500 NW 62NDZSr EEiSUITE S11 0000
FORT LAUDERDALE, FLORIDA 33309 g
(954) 776 -6766 - FAX: (954) 776 -4660 T t ' y
PERMIT #: OS09 -tea
APPROVED
Miami Shores
DATE
ZONING DEPT
BLDG DEPT
SUBJECT TO COMPLIANCE WITH ALL FEDERAL
STATE AND COUNTY RULES AND F- n'JLAT!O'iS
a
0000
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• f PAGE OF
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LEGAL DESCRIPTION • •
LOT 18 ,19 ,WEST 1/2 2 0 , BLOCK 36, MIAMI SHORES
SECTION NO.1, ACCORDING.‘110 :11-1e•PnIDTFefHE.F.EOF AS
RECORDED IN PLAT BOOK 10!• rnGt CS ;•; Q OF 'HE PUBLIC
RECORDS OF DADE COUNTY, •r.,OR:LM. • •
• • • • • •
• • ' ••
•
• • •
• ••
PROPERTY ADDRESS
261 NE 102ND STREET
MIAMI, FL 33138
INVOICE NUMBER: 31817
DATE OF FIELD WORK: 11/19/2004
CERTIFIED TO
THOMAS J,AND REBECCA JO OSTENDORP
CAPSTONE TITLE PARTNERS, LLC
ATTORNEYS' TITLE INSURANCE FUND
HSBC MORTGAGE CORPORATION, USA, ITS SUCCESSORS
AND /OR ASSIGNS AS THEIR INTEREST MAY APPEAR
FLOOD ZONE: X - 120652 - 0093 -J
02
101
100
100
99
98
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATIO
FBC 2004
Permit Type (circle): Building Roofm
Owner's Name (Fee Simple Titleholder) 1e%J +f4 6 f Phone #
Permit No. 09, Al-
Master Permit No.
Owner's Address i D h. 1. SD-
City 11 Y1k J.A.J/1,1 t 'it i4 S t (® Zip 3 3 i3
Tenant/Lessee Name
7SC
Phone #
Job Address (where the work is being done) •'
City Miami S#►ores Village County Miami -Dade Zip 7 S
FOLIO / PARCEL #
Is Building Historically Designated
Contractor's Company Name
Contractor's Address
City State
Qualifier Name Phone #
State Certificate or Registration No. Certificate of Competency No.
YES
NO aX
Phone #
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $5l?
I
Type of Work: ['Addition ['Alteration QNew a Repair/Replace ❑ Demolition
Describe Work: ee°TSt 14 °351 N -= ?® '
Phone #
Square / Linear Footage Of Work: 63 S F
C,(— ZD4 * * * * * ** **** **: x**+x*** ******** ******* ** Fees * * **** * *** * * ** * * * *** ** * **************:x*****
Submittal) Fee $ O h ./ Permit Fee $ 00 Ov CCF $ r(00 C
Notary $ 0)1 Training/Education Fee $ •)'ao Technology Fee $ a 0
Scanning $ t . Radon $
Bond $ Code Enforcement $ Double Fee $ ^u ,; `y
Structural Review. $ Total Fee Now Due $ CPI ' ( )
DPBR $
Zoning $
See Reverse side
C.6 4 "2-
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) .-! A )C tir\tr
Mortgage Lender s Address 2_4
City ° ' 4 U 1\ State tom'
Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
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.
"WARNING` TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will , s be approved and a reinspection fee will be charged.
Signatur- _ , -, � v i ' C ,..S gnature
Own: r or ^gent Contractor
The foregoing instrument was _ b owledged before me this c4 The foregoing instrument was acknowledged before me this
day of re,b , 20 041 , by 41444/0 J 17,E 2i'I JOT , day of , 20 _, by
who is personally known to me or who has produced % l w4r1S who is personally known to me or who has produced
ir C. "J -3-3-6 4.-° As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expir
**** ***** * ****** ****
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
*********************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY:
(Revised 07/10/07)
•
Plans Examiner
Engineer
Zoning
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit NO. DS -3 -09 -322
Eft
Issue Date: Not Issued
Expires: Not Issued
Folio Number:1132060134960
Owner's Name: THOMAS AND REBECCA OSTENDORP Owner's Phone:
Job Address: 261 102 Street Total Square Feet: 50
Miami Shores, FL Total Job Valuation: $ 750.00
•
Contractor(s) Phone Primary Contractor
HOME OWNER Yes
Planning and Zoning Criteria and Comments
Approved: Yes Date Approved: 3/5/2009 : Yes
Comments:
NAME:
ADDRESS:
VILLAGE OF MIAMI SHORE
RECEIVED
MAR •0 4 2.?
OWNER BUILDER DISCLOSURE STATEMENT
DATE: 1)50c1-1322
7-61 r` tot 144
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws
of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure
statement, which entitles me to work as my own contractor; I further understand that I as the
owner must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a
permit under an exception, to the law. The exemption allows you, as the owner of your property,
to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one - family or two- family residence. You may
also build or improve a commercial building at a cost of $25,000.00 or less. The building must be
for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a
building you have built yourself within one year after the construction is complete, the law will
presume that you built for sale or lease, which is a violation of this exemption. You may not hire
an unlicensed person as it contractor. It is your responsibility to make sure the people employed
by you have licenses required by state law.and by county or municipal licensing ordinances. Any
person working on your building who is not licensed must work under your supervision and must
.be employed by you, which means that you must deduct F.LC.A and with - holdings tax and
provide workers' compensation for that employee, all as prescribed by law. Your construction
must comply with all applicable laws, ordinances, .buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I hold title to the above property and I am planning on doing this cons
Myself.
Initial
2. I understand that as an owner - builder I must abide by all zoning ord. v ances and
building regulations in effect at the time of permit application. Inactive
permits for a period of over 180 days will become null and void (e
and a new permit will be required to be issued for reinstatem
permit.
Initial
3. I have an understanding of the 2004 FBC & FRC and understand that this
department and its inspectors are there to help enforce and interpret t
There is a copy of the code in this office for review.
4^ I. understand that the building official and inspectors are not there to
alter or give advice on how to meet code — only if the structure
minimum code.
Initial
5. I understand that as an owner - builder, that any contractor disputes /ith sub-
contractors and myself must be handled in a civil court with the adv. • - of au)
attorney. The department will not mitigate any contract disputes.
Initial
6. I understand that if I compensate any person or company for work erformed
they are requited to have a business license in the county. If for any ` eason
do not posses a business license I will be responsible and liable for
doing from this unlicensed company or person.
Initial
dA
WV
/they are
7. I understand that if any person gets injured on my construction proj
entitled to workmen's compensation. And if they do not posses a
policy I could be held liable for all doctor and related cost which co
loss of wages during recovery from injury.
Initial
or en's
include
8. I understand that under state and local laws I can not do any
Plumbing, Heating, Air & Roof work on my property with out
the proper permits by licensed contractors.
Was acknowledged before me this 2 41 day of Ft
By Ts OTTO *1
Initial
lectri =a
t obt 'rm
, 20
who was personally known to me or who has
Produced there License or (Torte F7 5333 4t
as identification.
Charlie Crist
Governor
Ana M. Viamonte Ros, M.D., M.P.H.
State Surgeon General
Thomas Ostendorp
261 NE 102 St
Miami, FL 33175
RE: Contingency Letter
Application Document No:
Centrax Permit Number:
OSTDS Number:
261 NE 102 St
Miami, FL 33175
Lot: 18 -19 Block: 36
E ECEV D
MAR 0 4 • �:
AP913122
13 -SC- 972603
March 03, 2009
Subdivision: Miami Shores Sec
Dear Applicant:
This will acknowledge receipt of an application dated 02/27/2009 for a permit to use an existing
onsite sewage treatment and disposal system located on the above referenced property.
1. -There is no increase in sewage flow, change in characteristics compromising the integrity or
function of the system installation.
2. -This project entails : " RE SURFACE OF A CONCRETE WALKWAY ONLY "
From a review of your completed application, it has been determined that your existing system is
adequate for the proposed use : " APPROVED ".
G/P
If you have any questions on this matter, please call our office at (786) 315 -2444.
Enclosures
cc:
Sincerely,
Miami -Dade County Health Department
1725 NW 167th St, Opa Locka, FL 33056
Phone: (786) 315 -2444 Fax: (786) 315 -2090
APPLICATION FOR:
New System
Repair
APPLICANT:
[ ]
[ ]
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ON -SITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
AGENT: r
/X,,l/1;. f i✓ �e =
(,)1 Existing System
[+ Abandonment
I it =,
PERMIT NO. k ; - ! 1
DATE PAID: , I ' -u'' `a
FEE PAID: 'I ' C
RECEIPT #:
[ ] Holding Tank [ ] Innovative
[ ] Temporary [ ]
TELEPHONE: `rte
MAILING ADDRESS:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
PROPERTY INFORMATION
LOT yc 113L BLOCK: ''q . SUBDIVISION: �i\„/\0'44-1, <,.'; .r ' -, :`kJ'"- : t, PLATTED:
C' :.-, b 1 [
PROPERTY ID #: 'N 't- � ='-_, `. � ^AJ ZONING:
PROPERTY SIZE: _ "< ° -,`.'? ACRES WATER SUPPLY: ( 1 PRIVATE PUBLIC [ ] < =2000GPD [ ` ='7 >2000GPD
I/M OR EQUIVALENT: ( Y / N )
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / N 1
PROPERTY ADDRESS:
DIRECTIONS TO PROPERTY: ,3=
DISTANCE TO SEWER: FT
BUILDING INFORMATION [vI RESIDENTIAL
[ ] COMMERCIAL
Unit Type of No. of Building Commercial /Institutional System Design
No Establishment Bedrooms Area Sq Ft Table 1, Chapter 64E -6, FAC
1
2
3
4
1
[ ] Floor /Equipment Drains [ ] Other (Specify)
jr
SIGNATURE:
DH 4015, 10/97 - Page 1 (Previous editions may be Us
Stock Number: 5744- 001 - 4015 -1
DATE:
Page 1 of 3
APPLICATION FOR:
APPLICANT:
AGENT:
TELEPHONE:
MAILING ADDRESS;
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
PROPERTY ID#:
ZONING:
PROPERTY SIZE:
WATER SUPPLY:
SEWER AVAILABILITY
PROPERTY ADDRESS:
DIRECTIONS:
BUILDING INFORMATION:
TYPE ESTABLISHMENT:
NO. BEDROOMS:
BUILDING AREA:
BUSINESS ACTIVITY:
FIXTURES:
SIGNATURE / DATE:
Check type of permit, if "Other" specify type in blank.
Property owner's full name.
Property owner's legally authorized representative.
Telephone number for applicant or agent.
P.O. box or street, city, state and zip code mailing address for applicant or agent.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a
recorded subdivision, a copy of the lot legal description or deed must be attached.
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.
27 character number for property. CHD may require property appraiser ID # or
section/township /range /parcel number.
Specify zoning and whether or not property is in I/M zoning or equivalent usage.
Net usable area of property in acres (square footage divided by 43,560 square feet)
exdusive of aU 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 non - compacted road rights -of -way
and easements with no subsurface obstructions may be included in calculating lot area.
Check private or public <= 2000 gallons per day or public > 2000 gallons per day.
Is sewer available as per 381.0065, Florida Statutes, and distance to sewer in feet.
Street address for property. For lots without an assigned street address, indicate street
or road and locale in county.
Provide detailed instructions to lot or attach an area map showing lot location.
Check residential or commercial.
List type of establishment from Table II, Chapter 10D-6, FAC. Examples: single family,
single wide mobile home, restaurant, doctors office.
Count all rooms designed primarily for sleeping and those areas expected to routinely
provide sleeping accommodations for occupants.
Total square footage of endosed habitable area of dwelling unit, exduding garage,
carport, exterior storage shed, or open or fully screened patios or decks. Based on
outside measurements for each story of structure.
For commercial/nstitutional applications only. List number of employees, shifts, and
hours of operation, or other information required by Table II, Chapter 10D-6, FAC.
Mark Floor/Equipment Drains or Others and specify item or "NA" if not applicable.
Signature of applicant or agent. Date application submitted to the CHD 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.