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PL-17-147 1 DIVISION 0f r � j �/ •°' Environmental Health Florida Health O Miami-Dade County 91�A QQ OSTDS/Well Division 11805 SW 26th Street•Miami,FL 33175 �O Inspector Jcr*tAkx ._ Jho Date 2/13.117 Address /2 to 3 tVE Zft OSTDS# APPZ70360 � Comments: i Signature 1 1 + S C • Permit NU. PL-1-17-147 s�!OREs y� Miami Shores Village Pei nit Type: Plumbing-Residential 't 10050 N.E.2nd Avenue NE ' Work Classification:Septic Miami Shores,FL 33138-0000 Per Permit Status:APPROVED '�. Phone: (305)795-2204 LORiDp' Issue Date: 212/2017 Expiration: 08/012017 Project Address Parcel Number Applicant 1263 NE 92 Street 1132050270270 Miami Shores, FL 33138- Block: Lot: MARTA J PACHECO BOBONIS Owner Information Address Phone Cell MARTA J PACHECO BOBONIS 1263 NE 92 Street (786)531-9479 MIAMI SHORES FL 33138- 1263 NE 92 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,400.00 MIAMI DADE ENVIROMENTAL 786-251-4099 ... ��. Total Sq Feet: 0 Type of Work:REPLACE A DOZIN TANK Available Inspections: Type of Piping: Inspection Type: Additional Info:REPLACE A DOZIN TANK HRS Approval Bond Return: 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-1-17-62660 CCF $1.80 DBPR Fee $2.25 02/02/2017 Check#:500 $618.30 $50.00 DCA Fee $2.25 01/19/2017 Credit Card $50.00 $0.00 Education Surcharge $0.60 Bond#:3302 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $668.30 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 foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zonin ut I authorize the above-named contractor to do the work stated. February 02, 2017 A orized Signature:Owner / Applicant / Contractor / Agent Date B ilding Department Copy February 02,2017 1 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,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. ASignatur Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this T foregoing instrument was acknowledged before me this day of ZY;4-V 20�J by � -7day of 7,4�— 20 / r by iii pn.r who is personally known to (tea :�4,E, ,who is personally known to me or who has produced �'(/�� ., as me or who has produced;,r(lam--l�".& as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: L Sign:\ ' Print: �/4— �l-(r��Q �Ci�fl J G-'� Print:�� Cel Seal: �►a+;�u Seal: �Nn�pue� TAWMAWWLES TARSHAIJI KNOWIJ?S * 'COMMISSION t FF 059152 * * MY COMMISSION t FF 059152 EXPIRES:January31,2018 EXPIRES:January 31,2018 Bm&dTin Budge NoWySeevioes *; � BondedThniBudgetNoterySerricee :j**************************************** APPROVED BY 1�/ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) t !■■■■■■■■■■■■■■■■■■■■■■!■■■■■■■ ■!■■■■■■■■!■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■m.•■■■■■■■■■■■■■■■ !■■■■■■■■!■■■�,�so.■■■■■■■■■■■m■■ !!■■■■■■■■■..o.o■■■■■■■■■!mo.o■ ■■■■■■■■■■■moom■■■m■■■■■mummo■■ ■■■■■■■■■■■i■■!■■■■■■■■ _;:'�■■■ ■ ■■■■■■■■■■II■■�"■fav■�►�■i�!`�►�i�■■■ Lfd ■■■■■!■SCI■■��..� �►��_�_�_�_in__!■�■■■■ ■■■■�i`/■■!■■■■■■■■f1i�rFf�l'�1�"f'�l9�I��I!�I��[l�I�■■ ■■■�■■■■■■■■■■Iii ■��,T��Yiii�iii��}L�illL:1111L1/!�■ ■■■■■■■■■■■■■■�■■■�LL �'1�]�II111.'irl! 1Jril��■!■ • 1 • Af)1 c V&diz viro PERMIT #:13-SM-1731396 STATE OF FLORIDA APPLICATION #:AP1270300 DEPARTMENT OF HEALTH DATE PAID: `lar ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID: CONSTRUCTION PERMIT RECEIPT #: VL DOCUMENT #:PRI 044969 CONSY'RUCTION PERMIT FOR: OSTDS Repair APPLICANT: CRISTOS TZAUANAS PROPERTY ADDRESS: 1263 NE 92 St Miami, FL 33138 LOT: 16 BLOCK: 2 SUBDIVISION: Bay Lure PROPERTY ID #: 11-3705-027-0270 (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 EXLMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. n SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD EXISTING Septic tank to remain CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] �>,rQ?0 K [ 225 ] GALLONS DOSING TANK CAPACITY [50.00 ]GALLONS @[ 6 )DOSES PER 24 HRSt,-,0t'WPuJhps,�•(a? D [ 300 ] SQUARE FEET Existinq drainfield to rema SYSTEM �C,}C\A`r�f.�ttr\ �{tC'\..�?y\tl'•'\1��,-,. \\t t;v\5 R ( 0 ] SQUARE FEET SYSTEM �;�g \ya A TYPE SYSTEM: [ J STANDARD [ ) FILLED [x] MOUND [ ] ,p\u°j?\\C,,?t?`at\C'.�.;!t tC? I CONFIGURATION: [ ] TRENCH [xJ BED F LOCATION OF BENCHMARK: FFE................5.7UNGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 12.00 ] [ INCHES FT ] I ABOVE BELOWIBENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 24.00] [ INCHES FT I r BELOW]BENCHMARK/REFERENCE POINT L D FILL REQUIRED: (30.00] INCHES EXCAVATION REQUIRED: ( 0.00 ] INCHES PUMP TANK INSTALLATION ONLY O T The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total jesbd, H of 300 gpd. Performing Lift Dosing. E INSTALL A 225 GAL DOSING TANK Pumps must be certified as suitable for distributing sewage effluent. - R SPECIFICATIONS BY: Ger L hilizair TITLE: Engineering Specialist IZ APPROVED BY: TITLE: Engineer Supervisor III Dade CHD d VEdwar DATE ISSUED: 1/11/2017 EXPIRATION DATE: 04/11/2017 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, EAC Page 1 of 3 V 1_1A AP1270300 SE1019069 Miami Shores Village RECF'1�TED- ' Building Department JAN 19 2017 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:_ _ Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2014 2 BUILDING Master Permit No. — ' PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ®PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP jCONTRACTOR DRAWINGS JOB ADDRESS: Cb 'R U E - 9 9 S 7- City: City: Miami Shores County: Miami Dade Zip: A-4 jk Folio/Parcel#: 11- 70.j-0 2-7 -D 2 70 Is the Building Historically Designated:Yes NO 0�_ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder)�S I Qq=4 0 A U M, S' Phone#: Address: /2/o a W F - g 2 S 7- 3kTenCity:HI, " I S Qn11 e State: IrzZip: 3 3 -2,3k:- Tenant/Lessee ant/Lessee Name: Phone#: Email: {� CONTRACTOR:Company Name: �� A R` DA-b e- U OU l rW V keQ Q Phone#: 786-2 S I-ID Address: 82C1©•Lbl-e bin, 5 331-a-tta � t✓GW--S3((9(0 City: State: ipZip: 3 tb& Qualifier Name (Dc'e OkO'No' Phone#: 796 2S/-Y0 11 State Certification or Registration#:IES R09 -7 12.7& Certificate of Competency#:0='14W9 ffa 1:7 — DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work:' Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: p lVe _ 1 U Specify color of color thru tile: Submittal Fee$ JPermit Fee$ CCF$ CO/CC$ Scanning Fee$ 1,571Radon Fee$ �• DBPR$ Notary$ Technology Fee$ 2 ' Training/Education Fee$ Gd Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ I �� (Revised02/24/2014) Q ♦SNORES Gid s� Irl iami shores Village "" Oil Building Department L�VRNr��OvPi 10050 N.E.2nd Avenue �l0R1Up' Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt i£ 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: �_L_ Owner State of Florida . County of Miami-Dade The foregoing was acknowledge before me this day of �J�/� ,20A By 1Hjq(1:1 jo "ACJ k(-C r) who is personally known to me or has produced as identification. Notary: SEAL: * * MY lxNF d1Mti8ude�1WY311,201s Miami-Dade Environmental Services, Inc. 8290 Lake Drive Suite 334 Doral, Florida 33166 (786) 251-4099/ Fax (305) 513-9200 MiamiDadeEnvironmental@msn.com January,18, 2017 State of Florida County of Dade Before me this day personally appeared Jose Bolanos who, being duly sworn, deposes;and says. That he will be the only person working on the project located at 1263 NE 92 ST Miami Shores FLA. Sworn to (or affirmed) and subscribed before me this.. ��..day of jnn.2011by,:G.Q,�!:, e)01nnQ5 . Personally know...................... XOr produced Identification.2 Type of identification.zv.s Azc)- 5.� MAHARAIK.GONZALEZ W COMMISSION#GG 044602 =� EXPIRES:November 2,2020 o; .......................................... ''':;;or i��P' Bonded Thru Notary Public Underv+riters Drint Tvnc nr Ctnrnr%Klnmc of Aintzry REGISTERED SEPTIC TANK CONTRACTOR JOSE BOLANOS 8290 LAKE DRIVE, SUITE 334 DORAL, FL 33166- MIAMI DADE ENVIRONMENTAL SERVICE, INC. SR8971276 Business Authorization: SA0091617 Registration Expires on September 30, 2017 7 ® DATE(MWDD/YYYY) ACORUCERTIFICATE OF LIABILITY INSURANCE 1/19/2017 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject 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 UUNIAGI NAME: ADVANTAGE INSURANCE OF AMERICA PHONE A/C.No. o Ext: (305) 649-5566 A/c No:(305) 649-5559 4520 NW 7th St -ADDRESS: 749@hotmail.com Miami, FL 33126 DDDRINSURER(S) AFFORDING COVERAGE NAICa INSURER A:GRANADA INSURANCE INSURED MIAMI DADE ENVIRONMENTAL SERVICES,INC INSURER B: INSURER C: 8290 LAKE DRIVE STE 334 INSURER D: MIAMI, FL 33166 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. IEFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MWDDNYYY MWDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000, 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100, 000 CLAIMS-MADE D OCCUR MED EXP(Any one person) $ 51000 X PERSONAL&ADV INJURY $ 1, 000, 000 0185FL00091528 01/19/17 01/19/18 GENERAL AGGREGATE $ 2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PE OT LOC $ AUTOMOBILE LIABILITY Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PdenAMA $ AUTOS Pero accit $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS I ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEI,: If yes,descr be under IDESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Septic Tank Systems Cleaning/Installation/ Servicing or Repair CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2 AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES, FL 33138 ACC DANCE WITH THE POLICY PROVISIONS. AUTHO IZ ZRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registe d marks of ACORD v , JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 10/24/2016 EXPIRATION DATE: 10/24/2018 PERSON: BOLANOS JOSE R FEIN: 820553271 BUSINESS NAME AND ADDRESS: MIAMI DADE ENVIROMENTAL SERVICE,INC 8291 LAKE DR S#334 DORAL FL 33166 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...appy only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 006573 Local Business Tax Receipt Miami-Dade County, Statepf Florida THIS IS NOT A BILL-DO NOT PAY 4882578 EXPIRES BUSINESS NAME/LOCATION RECEIPT NO. SEPTEMBER 30 2017 MIAMI DADE ENVIRONMENTAL SERVICE INC RENEWAL 8290 LAKE OR 334 - � 6096144 Must be displayed at place of business Pursuant to County Code DORAL FL 33166 Chapter BA-Art.9&10 SEC.TYPE OF BUSINESS PAYMENT RECEIVED OWNER OR `AIAMI DADE ENVIRONMENTAL SVS INC 196 9 P02 CI LTY PLUMBING CONTRACTOR BAYS o�07/13/2016 ��2016 Worker(s) CHECK21-16-084655 This Local Business Tax Receipt only coefirms payma t of the tnal Blainess Tax.The Receipt is am a licem. �o li icadoas.to do bosilms Holder Seat comply with any governmental permit or a cerbRcatioa of the lava M q re which app to the business or nongovenirnental regulatory laws aa�regnrromemts The RECEIPT NH.above�be displayed on aH�erc'al vehicles-Miami-0ads Code Sac 1te-276 a a-....vRaxcollector For mere ratormoa.atlvisit w�-