941 NE 91 Terr (2)Permit No. ie,t4 Date
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith s emitted for'the building or othei
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 Divisior
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept al
building during progress of work.
r ° C ' II- / / r A ,
Owner's Name and Address 1 '� No i_. Street ., t
Registered Architect and /or Engineer
it i r
Employing Plumbers Name. . ' ' ° ' :. - = - ' - -- - - ' " No. - __ - Street
Location and Legal Description Lot_.._ Block__ ______________._____. Subdivision F ___ y ,
7
Street and Number where work is to be performed —No _ ` _ F __ � ___ Street l' 01 a _
t- r . 1
State work to be performed and purpose of building (By Floors)__ � __ ..__ . 1 t__ ! -- : ' 1, _ __
New Building Remodeling Addition Repairs
Size Septic Tank Type of Tank__ Capacity Gals
Feet of Drain Tile ..
Dist. Feet of Tank or Drain Field from We1L
Nature of Water Supply: City —Well .
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Size of Soakage Pit__
(Si
No. of Stories
Plumb g Inspector.
The undersigned a cant for this buildi - •ermit does hereby certify th e understands and accepts his obligations as an ployer of labor
under the Florida Workmen's Compensation Act, • g Section 5966, Co » . ed General Laws of Florida Perinanent Supplem t, and has com-
plied with the provisions thereof, and will require s complian om all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)-------- .__-
My Commission Expires Notary Public, State of Florida
Master Plumber.
STATE OF FLORIDA, }
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare
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 fay
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faul
materials and /or workmanship.
CLOfET!
BATH
Tuns
SHOWERS
LAVA-
TORIES
SINKS
INK
SLOP
SINKS
LAUNDRY
Tuns
URINALS
U
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURE!
CONTR.
LIST
-_
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWI hi' G
POOL
CONTR.
LIST
CHECK
Permit No. ie,t4 Date
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith s emitted for'the building or othei
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 Divisior
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept al
building during progress of work.
r ° C ' II- / / r A ,
Owner's Name and Address 1 '� No i_. Street ., t
Registered Architect and /or Engineer
it i r
Employing Plumbers Name. . ' ' ° ' :. - = - ' - -- - - ' " No. - __ - Street
Location and Legal Description Lot_.._ Block__ ______________._____. Subdivision F ___ y ,
7
Street and Number where work is to be performed —No _ ` _ F __ � ___ Street l' 01 a _
t- r . 1
State work to be performed and purpose of building (By Floors)__ � __ ..__ . 1 t__ ! -- : ' 1, _ __
New Building Remodeling Addition Repairs
Size Septic Tank Type of Tank__ Capacity Gals
Feet of Drain Tile ..
Dist. Feet of Tank or Drain Field from We1L
Nature of Water Supply: City —Well .
Amount of Permit $
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Size of Soakage Pit__
(Si
No. of Stories
Plumb g Inspector.
The undersigned a cant for this buildi - •ermit does hereby certify th e understands and accepts his obligations as an ployer of labor
under the Florida Workmen's Compensation Act, • g Section 5966, Co » . ed General Laws of Florida Perinanent Supplem t, and has com-
plied with the provisions thereof, and will require s complian om all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)-------- .__-
My Commission Expires Notary Public, State of Florida
Master Plumber.
STATE OF FLORIDA, }
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeare
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 fay
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faul
materials and /or workmanship.
f
i
BUILDING ❑
ELEC
PL
ROO
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
❑ PERMIT N? 13465
This permit granted to the contractor or b er named above
herefor in strict c pliance with all ordinances pe mning thereto
drawings, statements or specifications that may have been submitte
time if the work is not-doge inl:6mpliance with such ordinances or if
granted is the understanding thhat the contractor or builder named abov
pertaining to the work coverethue1p vlei, shown on the plans or dra
done by jlis agents', strriants or employees.
N
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
be performed under
Sign
In consideration of CTi nce to me of this permit I agree to pe..rm th
pertaining thereto and in strict con o sgihh the plans, drawings, eta nts or
In accepting this permit I assume responsibilarfor-aaitqa • , • er, my
Permit
Value of
Project $
Contractor's
License No
BY
II Amt. of
Permit $
a
AUTHORITY
5 4
onstruct the building or to install the equipment or device described in the ap lan
e understanding that the work will be performed in compliance with any plans,
by the proper municipal authorities. This Permit may be revoked at any
ged without authorization. A further condition upon which this permit is
pon ility for a thorough knowledge of the ordinances regulations
e s ents sp ' ications and that he assumes respo . 1 ' 'ty for work
INSPECTOR
ork covered hereunder in pliance with all ordinanc and regulations
ecifications submitted to proper authorities of Mia Shores Village.
servant or . . oyee.
APPLICANT:
AGENT: ,
PROPERTY ADDRESS:
LOT: __ BLOCK: , SUBDIVISION:
:sss:::: :::ICIMEM: :s :s:WMW
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND NUM iisCOlSICTED.
sssssaassssssasssassssassssssss
l
1
l
1
l
1
1
1
1
l
1
TANK
[01]
[02]
[03)
[04]
[05]
[06]
[07]
[
(09)
FILL
[22]
[23]
[24]
[25]
[26]
STATE OF FLORIDA PERMIT 110/ -a.
DEPARTMENT OF HEALTH DATE PAID: -
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM FEE PAID:
CONSTRUCTION INSPECTION AND FINAL APPROVAL NIONIPT #r.;; - " s; ..,
INSTALLATION
TANK SIZE (lye \ [ [
TANK MATERIAL /I_
OUTLET DEVICE
MULTI - CHAMBERED ['
OUTLET FILTER �,,,.-
LEGEND - . • - +.-
WATERTIGET
LEVEL
DEPTH TO LID ' --
DRAINFIELD INSTALLATION
(10) AREA [ 1 1 / (21 :_SOS t
[11] DISTRIBUTION BOX _ MEADER (
(12] NUMBER OF DRAXIQ.INES [
[13] DRAINLINE SEPARATION [
[14] DRAINLINE ELOPE
[15] DEPTH OF COVER f.
[16] ELEVATION (ABOVE ,BM
[171 SYSTEM LOCATION _
[18) DOSING PUMPS A'
[19) AGGREGATE SIZE '
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPT* 11
/ EXCAVATION MATERIAL
FILL AMOUNT
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
[
1
[
1
l
l
1
1
1
1
1-
)
[ 1 (-40)
[ 1 (411
[ 1 (
[ 1 1
[ l 1441
[ 1 (
[ 1 [
[ 1 [
[ l (
l
CONSTRUCTION (APPROVED /DXSAPPROVID]y'.
FINAL SYSTEM [APPROVED /DISAPPROVED] :'
DH 4016, 10 /971(Pruvious Editions May Be Used)
BUILDING DEPARTMENT
PROPERTY ID #e
sss
s
SETBACKS
(27) SURFACE WATER !T
(28) DITCESS;✓ FT
[29] PRIVATE WELLS 11 FT
(30) PUBLIC WELLS' p.1 . / '' •FT
(31] IRRIGATION MU i FT
[32] _POTTABLE Naas LIB !T
(33) BUILDS POWIDATI FT
(34] VISOPERTI LIARS FT
(35) OTH R
FILLED f MOUND ETETIMI
(34 ) B/Mai'` R
(371 s3ONLDER*
( 'Mona
(39) s?ABILIMTI0fT
ADDITIONAL IsvOlOoktiour
OTHER
fAMOBWMM C'TIMP AMMI
STDRK:NAM ROMOFF
ALARMS
MAIETENANCE AGEMINMIT
IUYLDING ARIA
LOCATIAI Micron's NITS sirs PLAN
FINAL sITS =spins
ABANDONMENT
[49)_ TANK PUMPED L/ Cr'
[50] TANK CRUSHED A FILL16 f //_
CND DATES
CND DATE*
Page 2 of 3
• . .
PERMIT NUMBER: Permit tracking number assigned by CHD.
APPLICANT: Property owners full name.
AGENT: Property owners legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS: Record item number, explanation of violation, and required
CONSTRUCTION APPROVAL: Circle approved or disapproved, CHD signature and date.
AS BUILT INSTALLATION SKETCH
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed that buikiing construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
[ +] SHOT H.I. H.I. H.I.
H.I. [ -] SHOT [ -] SHOT [ -] SHOT
ELEVATION