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DS-10-264Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 135990 Permit Number: DS -2 -10 -264 Scheduled Inspection Date: June 06, 2011 Inspector: Bruhn, Norman Owner: OSUJI, CHARLES Job Address: 109 NW 110 Street Miami Shores, FL 33168 -4320 Project: <NONE> Contractor: R&M DESIGN CONCRETE CORP Permit Type: Driveways /Sidewalks /Slabs Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360030560 Building Department Comments STAMP CONCRETE DRIVEWAY Passed Failed ,<Of Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CC, June 03, 2011 For Inspections please call: (305)762 -4949 Page 1 of 26 o� Gf r51h a ` Miami Shores Village �\ g Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 ri Et? _� 71_1t BY: Ju — PermitNo.D5)0 -2(9 Master Permit No. Permit Type: BUILDING ROOFING. Owner's Name (Fee Simple Titleholde) ell/;901. 12I L ®® Phon "e3# c � 3 Z el Owner's Address /09 Z2 / "0 City 441ilr so' j/, State - Zip 3 /‘cf Tenant/Lessee Name Email Phone # Job Address (where the work is being done) /09 Zi //0 City Miami Shores Village County Miami -Dade Zip 3 3/4 FOLIO / PARCEL # IS � p e. ��' Vii!• �. ��� , 9 -� Is Building Historically Designated YES NO Flood Zone 7‘35- 2- `3_c) Coe' 1 4Zt_ Phone # 3nQ -9e0 3 ".46 c7/3-;01 Contractor's Company Name ° - Contractor's Address tV2_V7 e.e) /342 )404e City 4s ° State Zip /'6 Qualifier Name �_ :3 enof, /- .`J _ Phone # 3 I% 3 7 State Certificate or Registration No. Certificate of Competency No. c-//c? -Contact Phone 3 12e 9'8124 3 76' � ---- L 0 17 jeze/ c, Architect/Engineer's Name (if applicable) Phone # 1,o. 0� Value of Work For this Permit $ ®c? Type of Work: ❑Addition DAlteration Describe Work: 57A /.. Linear Footage Of Work: /tea ` W _ epair/Replace ❑ Demolition ;.7 * ** ** r * * * * * * * * * * * * ** * * * * * * * *** * * * ** ** *Fees******************************************** Submittal Fee $ Permit Fee $ Notary $ Training/Education Fee $ 0 "S.0 Scanning $ '70 0 Radon $ DPBR $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ 11S AO CCF $ ' Technology Fee $3ePIO CO /CC $ Bond $ See Reverse side -a 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 reinspection fee will be charged.. Owner or Agent / Contractor The foregoing instrument was acknowledged /fore me this / ' The foregoing instrument was acknowledged before me this e day of 6 ,20/0, by , day of 6 , 20/0 , by m who is personally known to me or who has produced /4-2.-.&' who is personally known to me or -who has produced ,x:2241® As identification and who did take . oath. as identification and\„yith _ Is O,;th. WY P EI6:ifi vex NOTARY PUBLIC: J'6 °�0 :. io s��O.. :Y�; Sign: Print:. My Commission Ex **************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY Ali Plans Examiner Sign: Print: My Commission Expires: • /4 d // P4ia��� /S �u a'1''' Ao\ **************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Engineer Clerk checked (Revised 07 /10 /07XRevised 06/10/2009) 10 -may . This Instrument prepared by: Name: fj Address: 7.14C grr" Permit #: — /D - Z.. _ Folio #: '� �! L ]) 7 11111 f1 11111111111111[111 �GIl= It+IE 2010804.16479 DR Bk 2 326 Fa 34661 (1Aa) RECOR ED 06/21/2010 12 ;13:3:3 HARVE RUVIN, CLERK OF COURT -MIAMI DADE COUNTY, FLORIDA LAST AGE STATE OF FLORIDA, oeuvre aitioADE 1 HER ,'i " 'FY ew OPIyIPiiti iii °ti !.`I G'll "' _ ':%� 3,3 /I D 20 i0 R ae r v)lJ' ofC11oN6nd ui. y%Cours ti NOTICE OF COMMENCEMENT State of Florida County of Dade The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice , of Commencement: 4 1. Property Legal Description: /0 9 N ! /t7 / a. ( ) Lengthy legal, please see description attached hereto Street Address (if available) 2. Description of Improvement: 3. Property Owner Name: 4. Mailing Address: 5. And interest in property: 6. Name of fee simple title holder if other than owner: Address: space above re:, 1 use of recording office 7. Contractor name: Address: 8. if Surety Bond, Name: And address of Surety: And amount of Bond: 9. Lender name: Address: Phone Number: Fax # :Q'"3�'L Phone Number: Phone Number: 10. Persons within the State of Florida (names and addresses) designated by Fax #: own other documents may be served as provided by Section 713.13(1)(A)7., Florida S atu eser upon whom Notices or Name: Address: Phone Number: 11. In addition to himself or herself, Owner'designates the followin Fax #: provided by Section 713.13(1)(B), Florida Statutes: g person(s) to receive a copy of the Lienor s Notice as Name: Address: 12.' Expiration date of this: Owner signature Owner signature: Printed name: we © -7-4% Printed name: •SWQ. , TO AND SUBSCRIBED before me this 2-- day of By: , Phone Number: Fax #: (expires one year from date recorded unless a different date is specified) :_._.. tome Notary signature Printed. name: Seal: ntification: My co • f Ve =° -might -of-`W % =_-- Center Line Monument Line CI = Clear ENC = E,acroachment (M) = Measured (C) = ; Calculated (CP) = Calculated from Plat U.E.= Utility easement Conc. = Concrete CBS = ;:oncrete block & Stucco C&G = Curb and Gutter PT = Pont of Tangency PC = Paint of Curvature PRC = F3int of Reverse Curvature 4.00= EXISTING ELEVATION (R°forieof. FIP = Found Iron Pipe SIP = Set Iron Pipe SND = Set Nail & Disc FND = Found Nail & Disc. FIR = Found Iron Rod SIR = Set iron Rod FN = Found Nail SN = Set Nail FDH = Found Drill Hole SDH = Set Drill Hole OUL = Overhead Electric PCP =Permanent Control Point PCC = Point of Compound Curvature M.E. = Maintenence Easement ID. = Identification Number B.O.B.. = Basis of Bearings LF.E.. = Lowest Floor Elevation NW. 110th STREET NW. 1109h STREET SCALE 1 "=20' LOCATION SKETCH (N.T.S.) - 2_0/0 SURVEY REPORT CERTIFIED TO: CHINWE OSUJI S: 1 FEDERAL REGULATIONS Y�� F.I.P. 1/2" (NO ID.) 554 68' {C &1 F.N. (NO ID.) BLOCK CORNER 5' CONRETE SIDEWALK •••• ••• • • ELEVATIONS: Elevation shown are based on National Geodetic Vertical Datum (N.G.V.D.) 1929. Benchmark Used. Miami —Dade County Bechmark N -567, with an elevation of 10.54'. • FLOOD ZONE INFORMATION: Property located at Flood Zone "X ", as per F.E.M.A. Flood Insurance Rate Map 12025C0182J, Community /Panel Number: 120652 0182J Revised /Effective Date: March 02, 1994. • Underground Encroachment and utilties, if any not located. • Fence Ownership by visual means only. • Legal ownership not determined. This Land may be subject to other recorded easements not shown on record plat. Ths is a residential property. The minimum reltive distance accuracy for this type of boundary survey was exceeded. • Bearings as shown hereon are based upon the Centerline OF NW. 11 Oth Street, with an assumed bearing of N90'00'00 "W, said line to be considered a well monumented line. Not valid without the signature and original raised seal of a Florida Licensed Surveyor Mapper. Additions or deletions to Survey Maps by other than the signing party are ptolViited without the written consent of the signing part. MICayeer CERTIFY THAT THE SURVEY REPRESENTED HEREON MEETS THE MINIMUN TECHNICAL 511ki*AORS SET FORTH BY THE BOARD OF LAND SURVEYORS PURSUANT TO SECTION 472.027, F.110P STATUES. •••••• 000000 .140441a. 0. EGBEBIKE, P.E., P.LS. fLORIDA REGISTERED LAND SURVEYOR NO. 5183 -FLORIDA REGISTERED LAND SURVEYING BUSINESS NO. 6559. "TED, THIS 29TH DAY OF DECEMBER, 2008 • ••• JOB NO: 07102 DRAWN BY: FP DATE: 02 -05 -2007 DATE: 02-05 -2007 SCALE: 1':20' LEGAL DESCRIPTION LOT 24, BLOCK 20 OF "MIAMI SHORES EXTENSION ", ACCORDING TO THE PLAT THEREOF, AS RECORDED IN PLAT BOOK 43, AT PAGE 40, OF THE PUBLIC RECORDS OF MIAMI —DADE COUNTY, FLORIDA. BOUNDARY SURVEY FOR CHINWE OSUJI 109 NW. 110th STREET MIAMI, FLORIDA 33168 P2520 N.W. 97th AVE., Suite 200 Miami, Florida 33172 Tel: (305) 715 -9090 (DADE) Fax: (305) 715 -9059 FLORIDA REGISTERED LAND SURVEYING BUSINESS. NO. 6559. PRECISION ENGINEERING & SURVEYING, INC. 1 Planning and Zoning Criteria Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 Folio Number:1121360030560 Owner's Name: CHARLES OSUJI Job Address: 109 110 Street Miami Shores, FL 33168 -4320 Owner's Phone: Total Square Feet: 1200 Total Job Valuation: $ 3,300.00 Contractor(s) Phone Primary Contractor Planning and Zoning Criteria and Comments Approved: Yes Date Approved: 6/8/2010 : Yes Comments: DIMENSION DRIVEWAY AND NEW SIDEWALK SIDEWALK CAN NOT EXCED 3 FEET IN WIDTH DRIVEWAY CAN NOT EXCEED 12 FEET IN WIDTH WITH 2 FOOT FLARES. DRIVEWAY MUST MAINTAIN 10 FOOT SEPARATION DISTANCE FROM SIDE LOT LINE 6/8/10 PLAN OK PROVIDED SIDEWALK DOES NOT EXCEED 3 FEET IN WIDTH. Permit No: 10j6r Job Name JOS- , 2010 Miami Shores Vivage Building Department Building Critique Sheet 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Page 1 of 1 ,R(5 - >> - 551-4330? Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 795 -2204 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RECEIPT PERMIT #: fiS 10 " DATE: aIdA A 900 Contractor ❑ Owner ❑ Architect up 2 sets of plans and Address: From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. Acknowledged by: )0 PERMIT CLERK INITIAL: RESUBMITTED DATE: 7` (2 R PERMIT CLERK INITIAL: farm an Zonhi Cry e11a Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 Folio Number:1121360030560 Owner's Name: CHARLES OSUJI Job Address: 109 110 Street Miami Shores, FL 33168 -4320 Owner's Phone: Total Square Feet: 1200 Total Job Valuation: $ 3,300.00 Planning and Zoning Criteria and Comments Approved: No Comments: DIMENSION DRIVEWAY AND NEW SIDEWALK SIDEWALK CAN NOT EXCED 3 FEET IN WIDTH Date Denied: 2/23 /2010 ,/DRIVEWAY CAN NOT EXCEED 12 FEET IN WIDTH WITH 2 FOOT FLARES. DRIVEWAY MUST MAINTAIN 10 FOOT SEPARATION DISTANCE FROM SIDE LOT LINE STATE OF (FLORIDA) COUNTY OF (DADE) FED 1 BY:o. Miami Shores Viiiage Building Department SURVEY AFFIDAVIT 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 The undersigned Affiant, ®4r -- - r , does hereby attest that (Property owner) The attached survey, performed by 4€C 'o.c® (Name of surveyor's company) For address: 4 99 /49 `.—f/ Performed on (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey Tess than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted.Gr.which 6666.. may violate zoning or building code regulations. The Affiant further understands that th2 exStence of any. such • structures may affect final inspections as applicable to this or other permits. ...... • • • • ...... •• Further, Affiant say eth naught ... Property Owner Signature SWORN TO AND SUBSCRIBED before me this Affiant is personally known to me, • • Property °wrier Print /? day of . • . • produced F-L - �. G. as id • dat;on. vsiv- 996099 Revised on 5/22/2009/ Re n °ii`"1" `I p� • • 6666.. • 6000 • ••. • • • .6666. • • 6666. • • 0..• .6666. • • • 6666.. • • 6.00.0 • • 711V 5Eli G � 1 2 \ 1' BY: - -- Miami Shores ViHage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY WHEREAS, L6/274)E of the following , hereinafter referred to as the Owner (owner) described property: ie)% s00 / / ®� � _S ire/ Legal description /folio#: Lot Block Subdivision /' -J r€r ii2nr�k ..r Tax Folio #: Requests permission t• ,stall: AsphaI , brick pavers Landscaping Other Within the public road right of way of (address) IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above- mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County •••• to make repairs or maintain said items within public right of way includh19,testorati ®iof• • • •. •••••• street by reason of the Owner's failure to do so, such expense shall be•pakhloy the OWher • • 0.00.. or shall constitute a lien against the above described property until paid.• • • • • •• •••••• • 2. The owner does hereby agree to indemnify and hold Miami Shores Village o r 1 3 b d e County : • •••••• harmless from any and all liability, which may rise by virtue of permitting the installation ®f. • • • • • . • • • •.•• •• • • • these items within the public right of way. •••••• • • • •••••• • • •••••• •••.• • • 0000• •.0000 • • • •0.00• • • 0000.. • • •....• • . • OOOOOO • • •.•.•. • • •.•.• • • • •••... • • • *•..• • • 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and /or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village (or his fully authorized representative). SIGNED, SEALED, EXECUTED AND A • EDGE on this /J day of ,0)-0i47 RODOLFO JUNCO o`� pu'e% War, Public - State of Sonde '` 4 °., on Expires Jut 15, 2011 $45.14 ,a Commission # CC N5 , ; .' Bonded Through National SIGNED, SEALED, AND DELIVERED in the presence of: a *,--;arrP •••• • • •••• • • • • • • • • • • • • ' OOOOOO •.•..• • • •.•• OOOOOO • • • • . ...... •••• • • ••.... • •- • • ••..•: • • • • •••• • • • • •• • r (Owfier's Signature ) Charlie Crist Governor Ana M. Viamonte Ros, M.D., M.P.H. State Surgeon General May 11, 2010 Rodolfo Junco 10251 SW 130 Ave Miami, FL 33168 RE: Contingency Letter Application Document No: AP964587 Centrax Permit Number: 13 -SC- 1135405 OSTDS Number: 109 NW 110 St Miami, FL 33175 Lot: 24 Block: 20 Subdivision: Dear Applicant: This will acknowledge receipt of an application dated 05/07/2010 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 : "DRIVEWAY INSTALLATION " 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 (305) 623 -3500. Enclosures cc: Sincerely, Jos - ngineer Specialist II Miami -Dade County Health Department 1725 NW 167 St, Opa Locka, FL 33056 Phone: (305) 623 -3500 Fax: (305) 623 -3645 R & M DESIGN CONCRETE CORP. Job No. R & M Design Concrete Corp. Ub Dr. • Miami, FL 33186 1Miami, S.W. llrida 33 86e (305) 386 -3721 PROPOSAL CONTRACT PROPOSAL SUBMITTED TO `y+ /41 G z (9S / STREET /' d e()4 1 10 s PHONE ZL,;1�qf)34; JOB NAME t STATE ZI O JOB LOCATION DESIGN COLOR We have read the foregoing proposed contract and accept the same` on the terms and conditions stated. Purchaser 80% to Pour 1 O% to Seal l r ✓)/ BN % � , C . r i• � r A 7? " 4 7/ I .. ti •: • • • • • • ems.• •• • • �. DADS & BROWARD NOTICE TO OWNERS COUNTY BUILDING CODE REQUIRES •••:•• •••••1 •'■ • •:••••••: TOTAL PRICE' :y . THAT ANY SIDEWALKS THAT ARE PART OF AN ENTRY WAY MUST BE 6 "INCHES OF THICKNESS. ANY SIDEWALK THAT IS NOT 6" INCHES THICK MUST BE REPLACED AND WILL ADD TO THE CONTRACT $100.00 DOLLARS FOR PERMIT AND $65.00 DOLLARS PER 5' FEET SECTION OF SIDEWALK REPLACED. IF YOU RESIDE IN CORAL GABLES IT WILL ADD $100.00 DOLLARS PER 5' SECTION REPLACED. ••el:: 6•1601.: :.I* • •� DEPOSIT $•••••5-69e9, ' • :0_ • • 3� • • ••� BALANCE.:$ . �.�-. -�•• • • • +.04 Balance $ �+ b'= A) '••• to be pdif•as follows: .••• 10% to Start COMPANY NOT RESPONSIBLE FOR DAMAGE TO UNDERGROUND PIPES THAT ARE NOT UP TO COUNTY CODES. We have read the foregoing proposed contract and accept the same` on the terms and conditions stated. Purchaser 80% to Pour 1 O% to Seal STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT '.Scale: Each biockre`rese ts 10 fe t and 1 inch = 40 feet, iiil12111 j` 111111111111111111111111101111111111011111111111111111 ■iii SiiM M�iiiiiiiiM iiiii�lEMEI iiii iii,1 ■iiiiiii ■ity1I, tii ■iiiriiii ■■ ■i.iilil iiiiri uii lii[tiiiiiiiliiii iiiiiii111iEMIMM 1I�Aiii'i�L� i EMME if iii �liiil�iiiii�,[fi�11ii����ii�!i ■iilIii UMEM NIME . aii iiii�liiitiii ■ ■i1liiiiiiiN11112 � EMEM lii ®Mi ■ii lilt 111�ii1>�1iiiiiiiiii11111ii'ii 111111 i ■iliiiii' a ii�iiiiiiiiii11iiii iiioliiilmiii ..iiilll.l.3i'!iiiii�Ii iii ■ ii11iiiit11iiiii ■iiiiiiiiii11,i1Iiiii iiirii�u uiiii � : ••u.. i• iiii ■ ■i �iiiILMEsiiLIiiMiNEIREM riiiiii ■ ■i11liiiiiiiiit SIMMIN i INEINIiiii ■ ■i liiiiiiiiiiii�MEMEN i iii11Iiiii ■iiiiiiiiiiiuumiii` `; ii�iiiiiiii ■111111111111111111'iiiii 1111111 �iiiiii� iiii I iiuliiiiiiiil ' ®1 • iii11iiiiiiIIiii■ iii liiiiii11iiiiiiil11i l 811.11 l����iiii ■iiiii�i'iiiii ®iiii BONE■ Notes: Site Plan ''submitted by Plan Approv By DH 4015, 10/96 (R (Stock Number: 5744- 002 - 4015 -6) )ate County Health Department ALLCH, GES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT (Replaces HRS -H Form Oi6 rich may be used) STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number - PART II - SITEPLAN - - - Scale: Each block= re•rese is 10 °f: -t and 1 inch = 40 feet. MMERMEMEMOMMEMEMMUMEMMEMMEMMME IMMEMMOMMEMEMMEMMERMEMMOMMUMMEM MMINIMMONEMMIMENAMMUNNMEMEMEMMEM MMOMMEMMEMMINISMEMMENUMMEMMEMOMM MMEMMEMMEMMEMMMEMUMMEMEMEMEMEM MOMMEMMMEMEMMOMMEMMMUMOMMEOMMEM ■■ ■I IMEMMEMHii N. ' MUIIIM000tiUIUUR ■OMMIMMI NIMMEMBEEMEMEEE ■UUNUE ■IMMUME } MIME •u•uia■aiuii ••u••• MEMEMMEMEMMINIMMINIMMEMMOMMINIMMEM MMIIMMEMMEMMEMMEMEMEMENIMEMMINIM MMEMEMMEMMEMMEMMEMMEMMIMMENIMEM MMEMEMMIIMMOMMINIENEMEMOMMEMOMME MMEMMOMEMEMMOMUMMEMENNEMENIMEM MOMMEMMEMMEMMUMMMINIMMEMEMEMEM NMEMMOMEMEMEMMINEMMEMENMEMOMEM MINIMMEMMEMEMOMEMEEMMEMMEMMEMOMM • MMEMEMmu ■ MEMINIMMME x z E 1mu®Mi Notes: Site Plan submitted by:.' Plan Approved By Title, if Sate / County Health Department ALLCHAN ES MUST BE APPROVED BY T1IE-COUNTY HEALTH DEPARTMENT DH 4015, 10/96 (Replaces HRS -H Form 016- n!hich:may be used) (Stock Number. 5744 - 002 - 4015.6) Page 2 of 4 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT APPLICATION FOR: [ ] New System [ Existing System [ ] Repair [ ] Abandonment APPLICANT: AGENT: 12c),Pc2 [ ] Holding Tank [ ] [ ] Temporary [ ] PERMIT NO. A e)1 DATE PAID: ), -- 1-- x-011,,;3 FEE PAID: RE,CEIR #: V° ‘n- Innovative TELEPHONE 00r) :) 3 MAILING ADDRESS: tQ -cf /-a4 E 0 AVE- -- 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. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION LOT: BLOCK: SUBDIVISION: . 44 PROPERTY ID #: �u -1 ° ' s5 ZONING: PROPERTY SIZE: ACRES WATER SUPPLY:.[ ] PRIVATE PUBLIC [f <= 2000GPD [ ] >2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y NJ) PROPERTY ADDRESS: 1 Lo LATTED: I/M OR EQUIVALENT: [ Y / N DIRECTIONS TO PROPERTY: 11 ai DISTANCE TO SEWER: FT BUILDING INFORMATION [ PRESIDENTIAL Unit Type of No Establishment 1 4-t 4 41 //e6a . 2 3 4 [ ] Floor/Equipment/ rains , SIGNATURE: ► ��� No of Building Bedrooms Area Soft 3 [ ] COMMERCIAL Commercial /Institutional System Design Table 1 Chapter 64E -6, FAC >O8& hf [ ] Other (Specify s DH 4015, 10/97 - Pag' 1 (Previous Editions May Be Used) Stock Number: 5744- 001 - 4015 -1 DATE: `$'0 Page 1 or 4 APPLICATION FOR: APPLICANT: AGENT: TELEPHONE: MAILING ADDRESS: LOT, BLOCK, SUBDIVISION: DATE OF SUBDIVISION: PROPERTY ID#: ZONING: PROPERTY SIZE: WATER SUPPLY: SEWER AVAILABIL PROPERTY ADDRESS: DIRECTIONS: BUILDING INFORMATION: TYPE ESTABLISHMENT: NO. B : BUILDING AREA: BUSINESS ACTIVITY: FIXTURES: SIGNATURE / DATE: Check type of permit, if "Other" specify type in blank. Property rs full Property 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, btock, and subdivision for or unrecorded subdivision). If lot is not inm� recorded subdivision, a copy of the lot legal description or deed must be attached. Official date of subdivis recorded — county plat (month/day/year) originally recorded. Dividing an approved lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the tot. 27 ch cter number for pro rty' CHD may require property appraiser ID # or oecr/mn/mownon/p/nange/parc»|numnomr. Specify zoning and whether or not property ioinKM zoning or equivalent usage. Net usable 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 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 dmy. Is sewer availa eonper381,OOO5.FkxhdaStotub*o.onddistonoetmoexmerinfeeL Street address for property. For lots without an assigned street address, address, indicate Street or road and locale incounty. Provide detailed instructions to lot or attach an area map showing lot location. Check residential or commercial. List type of estabtishment from Table ||. Chapter 64E-6, FAC. Examples: single family, single wide mobile home, restaurant, doctor's office. Count all rooms designed for sleeping and those areas expected to sleeping accommodations for occupants. Total square footage nfeno�aedhob�ab� area of excluding omrpo�. exterior storage shed, or open or fully ned patios or decks. Based on outside measurements for each story of structure. For commercial/institutional applications only. List number of employees, shifts, and hours of operation, or other information required by Table Chapter 64E-6, FAC. Mark Floor/Equiprnent Drains or Others and specify item or 'NA if not applicable. . ' Signature of appttcant or agent. Date application submitted to the CHD with appropriate fees and attachments. ATTACHMENTS: A site ptan drawn to scale, showing boundaries with dimensions, locations of residences or 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 orleatures 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