PL-12-1697Miami Shores Village s E P>
g 7
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 No. 2 ( 9 ---4—
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): ",one*:
Address:
City:
State:
Zip:
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS:
City: Miami Shores County: Miami Dade _zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: Phone#: ;� Z
Address:
City: State:
Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ square/Linear Footage of Work:
Type of Work: OAddress OAlteration ❑New ❑Repair/Replace
Description of Work: 1 y -P z r,ti e 0
Submittal Fee $ Permit Fee $_ �'C'� ` ' CCF $ CO/CC $
Scanning Fee $
Radon Fee $
DBPR $ Bond $
Notary $ TraininWYAucation Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
❑Demolition
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 coni ncement must be posted at the job site
for the first inspection which occurs seven (7) days after the building pennit is issued.I i rhe absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature _ / i U Signature _ --47
Owner or Agent Contractor
foregoingThe instrument strument was acknowledged before me this The foregoing instrument was acknowledged before me this --LL
L
day of20� , by
; day of ' � t , 20 i c', by
who is personally known to me or who has produced 1� who is personally known to me or who has produced ? y
Ls %ma=r As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:\,--,/
My Commission Expires:
***************
APPROVED BY
rERESq J SOLOMON
ir MY COMMISSION # EE131935
EXPIRE, ni_.. _
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
l� Plans
Structural Review
NOTARY PUBLIC:
Sign:L.
Print:
My Commission My o66A j SOLOM
a.' MM'S66A
ON
IgN St
�tl3l3 'o�ss EXPIRES Nov E 37935
FyrldaAlo ember 08,2
Zoning
Clerk
I
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAb SYSTEM
.�yCONSTRUCTION INSPECTION AND FINAL APPROVAL
in ow
APPLIC
AGENT:
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
PROPERTY ADDRESS: , C
LOTS BLOCK:_ SUBDIVISION: ROPERTY ID #:
CHECKED [X] ITEMS E'NCr IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
EXPLANATION
[ l _
CONSTRUCTION [APPROVED ISAPPROVED] MDATE:
FINAL SYSTE AP RO /DISAPPROVED] := CHD DATE:��L�� l Z
OF VIOLATIONS / REMARKS:
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
(30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES FT
[33] BUILDING FOUNDATION _ FT
[34] PROPERTY LINES FT
[35] OTHER FT
FILLED / MOVND SYSTEM
[36] DRAINFIELD COVER
[371 SHOULDERS
[38] SLOPES
[39] STABILIZATION
61
ADDITIONAL INFORMATION
[40] UNQBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS Q A-
[431 MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTORi/2,C/ri S •
[48] OTHER
ABANDONMENT
[ 4 9 ] TANK PUMPED
[50] TANK CRUSHED & FILLED
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
•
Page 2 of %#
TANK INSTALLATION
[ -:-1
1011
TANK SIZE [1 ] I21 J-0 0
[ ]
1 /]
[02]
TANK MATERIAL
[ /]
[03]
OUTLET DEVICE[
]
I
[04]
MULTI-CHAMBERED [].
[ ]
I ]
[05]
, OUTLET FILTER �'
]
[
[06]
LEGEND
✓j'
[
[07]
WATERTIGHT
[ �j
1
[08]
LEVEL
[
[09]
DEPTH TO LID
[ ]
EXPLANATION
[ l _
CONSTRUCTION [APPROVED ISAPPROVED] MDATE:
FINAL SYSTE AP RO /DISAPPROVED] := CHD DATE:��L�� l Z
OF VIOLATIONS / REMARKS:
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
(30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES FT
[33] BUILDING FOUNDATION _ FT
[34] PROPERTY LINES FT
[35] OTHER FT
FILLED / MOVND SYSTEM
[36] DRAINFIELD COVER
[371 SHOULDERS
[38] SLOPES
[39] STABILIZATION
61
ADDITIONAL INFORMATION
[40] UNQBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS Q A-
[431 MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTORi/2,C/ri S •
[48] OTHER
ABANDONMENT
[ 4 9 ] TANK PUMPED
[50] TANK CRUSHED & FILLED
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
•
Page 2 of %#
DRAINFIELD INSTAI LNTIQN
L
[10]
AREA [1] [2] SOFT
I -T
[ 1
[11]
DISTRIBUTION BOX HEADER �
[12]
NUMBER OF DRAINLINES
[ ✓]
[
[13]
DRAINLINE SEPARATION
[d�
[ �]�
[14]
DRAINLINE SLOPE
[ y
[
[15]
[16]
DEPTH OF COVER '��' ,.,
ELEVATION N� iy ELOW] BMJ
[ �-']•
[ _}-
[17]
SYSTEM LOCATION
I
[18]
DOSING PUMPS
[j
✓]
[19]
AGGREGATE SIZE
I
[20]
AGGREGATE EXCESSIVE FINES
[�}"
I IT'
[21]
AGGREGATE DEPTH /
FILL
/ EXCAVATION MATERIAL
[�
[ ✓1-
[22]
FILL AMOUNT/
[-IT
[23]
FILL TEXTURE
[ T
[24]
EXCAVATION DEPTH
[-1
[25]
AREA REPLACED
(G
I �]
[ 2 6 ]
REPLACEMENT :MATERIAL
EXPLANATION
[ l _
CONSTRUCTION [APPROVED ISAPPROVED] MDATE:
FINAL SYSTE AP RO /DISAPPROVED] := CHD DATE:��L�� l Z
OF VIOLATIONS / REMARKS:
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
(30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES FT
[33] BUILDING FOUNDATION _ FT
[34] PROPERTY LINES FT
[35] OTHER FT
FILLED / MOVND SYSTEM
[36] DRAINFIELD COVER
[371 SHOULDERS
[38] SLOPES
[39] STABILIZATION
61
ADDITIONAL INFORMATION
[40] UNQBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS Q A-
[431 MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTORi/2,C/ri S •
[48] OTHER
ABANDONMENT
[ 4 9 ] TANK PUMPED
[50] TANK CRUSHED & FILLED
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
•
Page 2 of %#
a.
•. DIVISION Of
Environmental Health
Florida Department of Health
Miami -Dade County Health Department 10�
OSTDS/Well Division
11805 SW 26 St. • Miami, FL 33175
G"`„ `{�/ �-•� Date ��
Inspector — 2
Address ,Lo /5� C = �-��- - -'�� OSTDS #6fI-Q YES 4 51 Al
Comments: _
--�Signature
AP
89111/2917 89;IW 9549678433
PAGE 81/02
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