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PL-12-436Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 171049 Permit Number: PL -3 -12 -436 Scheduled Inspection Date: March 23, 2012 Inspector: Hernandez, Rafael Owner: FEINBERG, HOWARD Job Address: 1410 NE 103 Street Miami Shores, FL Project: <NONE> Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Drainfield Phone Number (305)754 -4000 Parcel Number 1132050310020 Contractor: EDDIE ROJAS PLUMBING INC Phone: 305 -944 -6788 Building Department Comments INSTALL 300 SQFT DRAINFIELD Passed 1E Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS IN FILE March 22, 2012 For Inspections please call: (305)762 -4949 Page 14 of 15 DIVISION OF Environmental Health Florida Department of Health Miami -Dade County Health Department OSTDS/Well Division 1 805 SW 26 St. • Miami, FL 33175 4 its,s Inspector ---- -- Date 3 —12 ;/ Address % �� � IV' (:: 1O : /- ©SIDS # A,/04 25- %% Cot/intents. Signature STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL PERMIT NO /41 2/0 DATE PAID. FEE PAID RECEIPT #• APPLICANT: AGENT: PROPERTY ADDRESS: LOT: /_ BLOCK: SUBDIVISION. ��' - -�•: e.� L PROPERTY ID it)) S';40 -03I- Qc'a 0 CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. - = = = = = = = = =- TANK INSTALLATION �^ ---�� SETBACKS [ 0"1- mo' / [ ] [27] SURFACE WATER FT [ - -Z,:. [ ] [28] DITCHES FT [ ] [29) PRIVATE WELLS FT [ ] [30) PUBLIC WELLS FT [ ) [31] IRRIGATION WELLS - FT [ o]' [32) POTABLE WATER LINES 6 S FT [ f-] [33] BUILDING FOUNDATION % .a- FT [ ibdr [34] PROPERTY LINES / 0 FT [ 1 [35] OTHER FT FILLED / MOUND SYSTEM [36] DRAINFIELD COVER [37] SHOULDERS [38] SLOPES [39] . STABILIZATION [01] TANK SIZE [1] /ems 113[2].-> 0 0 [02] TANK MATERIAL [03] OUTLET DEVICE., [04] MULTI- CHAMBERED [Y /to [05] OUTLET FILTER [06] LEGEND [07] WATERTIGHT [08] LEVEL , [09] DEPTH TO LID DRAINFIELD INSTALLATI_ O}N AREA [1] /CKo [2) '- OSQFT DISTRIBUTION BOX HEADER NUMBER OF DRAINLINES DRAINLINE SEPARATION iZ DRAINLINE SLOPE DEPTH OF COVER j ELEVATION [ABOV ELO M SYSTEM LOCATION DOSING PUMPS Ik /4 [10] [111 [12] [13] [14] [15] [16] [17] [18) [19] [20] [21) AGGREGATE SIZE jY ) AGGREGATE EXCESSIVE FINES AGGREGATE DEPTH J./ /.4 FILL / EXCAVATION MATERIAL [22] FILL AMOUNT I '' [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL EXPLANATION OF VIOLATIONS / REMARKS: [�1 [� [ 3] [ -r [44] [ .-J- [45] [ �]- [46] [ [47] [ 1 [48] ADDITIONAL INFORMATION [40) UNOBSTRUCTED AREA [41] STORIv1WATER RUNOFF [42] ALARMS MAINTENANCE AGREEMENT BUILDING AREA LOCATION CONFORMS WITH SITE PLAN FINAL SITE. GRADING CONTRACTOR kit-t4--4a OTHER [ 1 [ ] ABANDONMENT [49] TANK PUMPED TANK CRUSHED & FILLED % CONSTRUCT FINAL SYST DIVISION OF Environmental Health Florida Department of Health Miami -Dade County Health Department A OSTDS /Nell Division *Ii 11805 SW 26 St.. Miami, FL 33175 Inspector vZ Date DH 4016 (Page 2), 10/97 (Previov Stock Number 5744 -002- 4016 -4 Address I uii e5 , , , L Id OSTDS # /� /'/ (i L 2 5 %/ a Miami Shores Village 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 PERMIT APPLICATION Permit Type: PLUMBING /- 9 /ii'( / JOB ADDRESS: d 1"/ (.% / / G City: Miami Shores County: Miami Dade Zip: 33 )3 Folio/Parcel #: Is the Building Historically Designated: Yes FBC 247Z) Permit No. Master Permit No. c — (43( OWNER: Name (Fee Simple Ti eholder): Address: 4J C f City: Tenant/Lessee Name: Email: i1e�- c7 ,i NO 7 Flood Zone: O-WAAP Zr L'., //4( 1 Phone #: —7. 9$ CdState: Phone #: CONTRACTOR: Company Name: /,C/JO7(( 0/p.95- ?II/la' hone #: g os- 9L/ 6%1e Address: 4g ig. 0 City: ill / S e: / Zip: 3 3/67 O ( Qualifier Name: �/%f/ 6 ,p/ 7 S' Phone #: 2O.) q : /c /�p ?cr. State Certification or Registration #: C Fe. e2 L,/g4/3J Certiyate of C etency #: l (2, 2)2 Contact Phone #: Z�/ �L,y 6 7 E r Email Address: ��C e ® "% �' e b %/�% /" DESIGNER: Architect/Engineer: Phone #: au cam' J// ' T Value of Work for this Permit: $ Type of Work: ❑Address Description of Work: `7-- Square/Linear Footage of Work: ❑New ' URepair/Replace ❑Demolit'.n * * * * ** * * * * * * ** *** * ** * * * * ** * * * **** ** r *** Fees************* * * * * * * * **** * * * ** *** * * ** ** * * ** ** Submittal Fee $ 5Z5 . 4 to Permit Fee $ 45-0 ' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ & 9. 5' 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 bsence o such posted notice, the inspection will not be approved and a re spection fee will be charged. r Signature �� &h'I —Signature tcaner or Agent Contrac The foregoing instrument was acknowledged before me this 13 The foregoing instrument as acknowledged before me this / 3 day of %'1'1 , 20 K2, by �l G &-v -a AC: /4(4 day of in4Y4)-41 , 20 /2, by C/ 2.7 who is personally known to me or who has produced A'l 0 who is personally known to me or who has produced re..4 v As identification and who did take an oath. as identification ands:: ho did take an oath. NOTARY PUBLIC: ��li„iiti,u���� NOTARY PUBLIC: ";1���0�� ..et Sign: po��' . Sign:�.,,� • Print: 11 d ���l0l1, Print: 01 �1o� : s �1 g`0b190l�0;:a My Commission Expires: �,�'•a�� Ax EO � 1. sea ��'�• • ►...'••'.a . 6SA lssiiu�o My Commission Expires: APPROVED BY 4f 3 /`Y' /� Plans Examiner Zoning Structural Review Clerk (Revised3 /12/2012XRevised 07 /10 /07XRevised 06 /10/2009XRevised 3/15/09) From: 03/13/2012 23:49 #615 P.001/001 __ __ CERTIFICATE OF LIABILITY INSURANCE DATE(MMUDD/YYY1') — 03/13/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. the poI._...(es) must be If SUBROGATION IS WANED, sub)ect to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Accurate 8300 West Flagier Suite 114 Miami, FL 33144 Phone J305)226 -8727 INSURED Edward Rojas Plumbing Corp 880 NE 111 St Biscayne Park, FL 33161- Fax (305)226 -8767 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CONTACT Lucia Estrella • i PHOMN .(�Afigalq. 4.0,..... (305)226 -8727 305226 -8767 MAIL- - -.. .. .....;_1�C'`,.M� �... � ...............__.._ .. • ADDRESS• Iuciaestreila ©bellsoulh.net • INSURER(SLAFFORDING COVERAGE INSURER A : American Builders Insurance INSURER B - INSURER C : INSURER D : INSURER E : INSURER F : NAIL F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • !ADD Eg- POLICY -- - - -- :INSIIIV8611 POLICY NUMBER .MIDD E F1!IPOUCYryEXPi! UNITS D I EACH OCCURRENCE _ $ 500,000.00 _ DAMAGE TO RENTED ■ 100,000O I PREMISES I€.amie:IDA° L $ 100,000.00 ! —MED EXP (any one Berson) I $ 5,000.00 � 107/28/2011 .07/2812012 II PERSONAL &ADVINJURY • $ 100,000.00 1 I GENERALAGGREGATE $ 500,000.00 -, i PRODUCTS - COMP/OP AGO! $ 500,000.00 I t TYPE OF INSURANCE i GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY A ❑ ❑ CLAIMS -MADE ® OC CUR ❑ i 1 i GE•IML AGGREGATE LIMIT APPLIES PER: POLICY_- D,sgej- ❑ we AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ONED SCHEDULED ❑ AUTOS W ❑ AUTOS NON -OWNED AUTOS I ❑ HIRED AUTOS ❑ ❑ UMBRELLA LIAB ❑ LQ EXCESS LIAR ❑ CLAIMS -MADE I • ❑ DED ❑ RETENTIQN$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNER/EXECUTivE / N I OFFICER/MEMBER EXCLUDED? ---'N/A: (Mandatary in NH) if yes, describe under _DESCRIPTION OF OPERATIONS below. i OCCUR 012487857 MBINED SINGLE LIMIT . BODILY INJURY (Per person) 1 $ - - BODILY INJURY (Per aoddenl} $ LP OPER ppMpGE ((�r acdaeltt ..... _. �. $� AGGREGATE EACH OCCURRENCE WCSTATUU. OTH -I $ RY LINtiTS ❑ ER_...i_ _ —... • E.L BACH ACCIDENT 1 $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT] $ - .. • DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space le required) CERTIFICATE HOLDER Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138 305- 758 -8972 ACORD 25 (2010/05) QF The ACORD name and logo are registered marks of ACORD CANCELLATION --- - - SHOULD ANY OF THE ABOVE D SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THER • , ')TICE WILL BE DELIVERED IN ACCORDANCE WITH THE P.6 j OVISIONS. tAUTHORIZEDREPRESENTAT� / Lucia Estrella ®1888 -2010 ACORD CORPORATION. All rights reserved. MIAMI -DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 1st FLOOR MIAMI, FL 33130 517565 -8 2011 LOCAL BUSINESS TAX RECEIPT 2012 MIAMI -DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2012 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 THIS IS NOT A BILL — DO NOT PAY RENEWAL 237125 -0 STATE WtW,9431 * * ** Butgan RUjjgTIPtUMBING CORP 880 NE 111 ST 33161 BISCAYNE PARK DWJIARD ROJAS sec 1T9W 91 @llBil'MG THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUAUFICA- TIONS. PAYMENT RECEIVED MIAMI -DADE COUNTY TAX COLLECTOR? O / 11 /2 011 02230012001 000049.50 SEE OTHER SIDE FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 PLUMBING CORP WORKER /S CONTRACTOR 1 DO NOT FORWARD EDWARD ROJAS PLUMBING CORP EDWARDO ROJAS PRES 880 NE 111 ST MIAMI FL 33161 l tl �Itt i�tett�itl�ttttt} �ittt�tt�t�tet��3�t ft�tt4!}Zttt}ttlt� THIS DOCUMENT HAS A COLORED BACKGROUND ^ MICROPRINTING . LINEMARKT"' PATENTED PAPER STATE OF FLORIDA. DEPARTMENT OF BUSINESSAND PROFESSIONAL REGULATION CONSTRICTION INDUSTRY LICENSING BOARD DATE BATCH NQDMBE: SEQ# L11092704915 LICENSE NB 09/27/2011'110110131 CFC0494:31 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter Expiration date: AUG 31, 2012 ROJAS, EDWARDO EDWARD ROJAS PLUMBING CORP 880 NE 111TH ST BISCAYNE PARK FL•33161 RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Feinberg Howard PROPERTY ADDRESS: 1410 NE 103 St Miami, FL 33138 LOT: 11 BLOCK: 5 PROPERTY ID #: 11- 3205 -031 -0020 PERMIT #: 13-SC-1394242 APPLICATION #: AP 1062571 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR867829 SUBDIVISION: Miami Shores [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ 1,050 ] GALLONS / GPD Septic 0 1 GALLONS / GPD 0 ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY D [ 300 ] SQUARE FEET R [ 0 l SQUARE FEET A TYPE SYSTEM: [x] STANDARD I CONFIGURATION: [ ] TRENCH N F LOCATION OF BENCHMARK: F.F.E.: 8.40' I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: 0 T H E R [ 0.00J. CAPACITY CAPACITY (MIl4XIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ SYSTEM SYSTEM [ ] FILLED [ ] MOUND (x] BED [ ] [ 36.00 ] [) INCHES k FT ] [ ABOVE A BELOW b BENCHMARK /REFERENCE POINT 58.00 1 [I INCHES r FT ] [ ABOVE /) BELOW b BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 22.80 1 THIS PERMIT IS FOR THE _ SIDE SYSTEM # 1 ONLY.1— Existing 1050 gal. septic tank certified by "Armstrong of America "on 02/14/2012 to remain. 2- Install 300 sf of drainfield in bed configuration. 3- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. 4- Invert elevation of drainfield to be no less than 4.00' NGVD. 5. Bottom of drainfield elevation to be no less than 3.50' NGVD.6. East Side septiosystem to remain. INCHES THIS PERMIT IS NOT FOR ADDITION(s). SPECIFICATIONS BY: APPROVED BY: RAIR Pedro N Ospina DATE ISSUED: 02/24/2012 DH 4016, 08/09 (Obsoletes Incorporated: 64E- 6.003, all previous editions FAC v 1.1.4 Dade CHD lOV "b ;9IRATION DATE: 05/24/2012 which ma18�tbi, !.1 as 9 ,wlSug!! page 1 of 3 ow le AP1062573a (/ ayla 01 a ��' a004.500 t� aQ Iihi J� ooa g 4/ tp rra� J Pel4 1.At 00 OW �� / is /411 e wloliaC p� Aed /fib!! � p �!d vo�ael4j da��Q� �# �SB� a! ,v ,,. 4/ v/ 4010, ' 0 n"- Qo STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL PERMIT NO 1400 6 2 c 3 J DATE PAID. FEE PAID. RECEIPT #• APPLICANT. F-Q J AGENT: / PROPERTY ADDRESS. / // (d N. L JO 3 LOT: —/ BLOCK: SUBDIVISION. PROPERTY ID #1)"' 0 Ce3 1 -- co 2. CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION [01] TANK SIZE [1] /VS'a[2]J © 0 [02] TANK MATERIAL [03] OUTLET DEVICE [04] MULTI - CHAMBERED [Y /J [05] OUTLET FILTER [06] LEGEND [07] WATERTIGHT [08] LEVEL [09] DEPTH TO LID SETBACKS [ ] [27] SURFACE WATER FT [ ] [28] DITCHES FT [ ] [29] PRIVATE WELLS FT [ ] [30] PUBLIC WELLS FT [ ] [31] IRRIGATION WELLS _ , FT (' [ �]' [32] POTABLE WATER LINES 6 S FT O 7 [ —.] [33] BUILDING FOUNDATION / . t FT ��- [ ✓J [34] PROPERTY LINES I FT [ ] [35] OTHER FT DRAINFIELD INSTALLATION [10] AREA [1] /S%[- [2] `3(3 OSQFT [11] DISTRIBUTION BOX HEADER [12] NUMBER OF DRAINLINES 6 , [13] DRAINLINE SEPARATION 1_2. /, [14] DRAINLINE SLOPE [15] DEPTH OF COVER [16] ELEVATION [ABOV ELO M [17] SYSTEM LOCATION [18] DOSING PUMPS --1[19] AGGREGATE SIZE fy) A [20] AGGREGATE EXCESSIVE FINES [21] AGGREGATE DEPTH "/ FILL / EXCAVATION MATERIAL [22] FILL AMOUNT ,% ,2 ' [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL EXPLANATION OF VIOLATIONS / REMARKS: 'Ile FILLED / MOUND SYSTEM [36] DRAINFIELD COVER [37] SHOULDERS [38] SLOPES [39] STABILIZATION ADDITIONAL INFORMATION UNOBSTRUCTED AREA STORMWATER RUNOFF ALARMS MAINTENANCE AGREEMENT BUILDING AREA [45] LOCATION CONFORMS WITH SITE PLAN [46] FINAL SITE GRADING G�c� [47] CONTRACTOR iCk- 14h'r-t+� [48] OTHER ABANDONMENT [ ] [49] TANK PUMPED _./ [ l [50] TANK CRUSHED & FILLED/ , CONSTRUCT APPROV /DISAPPROVED]• %r - --P QP FINAL SYST D /DISAPPROVED] • DH 4016 (Page 2), 10/97 (Previous Editions May Be Used) Stock Number: 5744-002-4016-4 CHD DATE., '" .2--/ 2 , CHD DATE. 3 Page 2 of 3 PT 1: Applicant PT 2: Installer /Contractor PT 3: Building Department PT 4: Health Department Ru Ord G Pupa