PL-15-2647 (2). a
Miami Shores Village
10050 N.E.2nd Avenue NE � ££
n
Miami Shores,FL 33138-0000 r
Phone: (305)795-2204 ' ,. .... "
Expiration: 04119/2016
Project Address Parcel Number Applicant
1350 NE 101 Street 1132050230020
Miami Shores, FL Block: Lot: DIRK&ELIZABETH PETERSON
Owner Information Address Phone Cell
DIRK&ELIZABETH PETERSON 1350 NE 101 ST
MIAMI SHORES FL 33138-2611
Contractor(s) Phone Cell Phone
STATEWIDE SEPTIC CONNECTIONS (954)963-0082 Valuation:
WI6,000.00
Total Sq Feet: 60
Type of Work:REPLACE DRAIN FIELD AND SEPTIC Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
HRS Approval
Bond Retum: Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Contractors Bond $500.00
Invoice# PL-10-15-57464
CCF $3.60 10/192015 Check#:1000 $50.00 $684.90
DBPR Fee $3.15
DCA Fee $3.15 10222015 Check#:1004 $684.90 $0.00
Education Surcharge $1.20 Bond M 2890
Permit Fee $210.00
Scanning Fee $9.00
Technology Fee $4,80
Total: $734.90
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoin information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore,I authorize th bov med contractor to do the work stated.
Cc October 22,2015
Authorized S nature:9wrier / Applicant / Contractor / Agent Date
Building Department Copy
October 22,2015 1