PL-17-632 Permit NO. PL-3-17-632
Miami Shores Village o ' Permit Type:Plumbing-Residential
10 Mi N.E.2nd Avenue e 'Penni Work Classification:Drainfield
- Miami Shores,FL 33138-0000 Permit Status:APPROVED
Phone: (305)795-2204
CORIDp'
Issue Date:3/15/2017 Expiration: 09/1112017
Project Address Parcel Number Applicant
215 NW 111 Street 1121360010660
Miami Shores, FL 33168- Block: Lot: PASCAL&MARIE FLEURIMONE
Owner Information Address Phone Cell
PASCAL&MARIE FLEURIMOND 215 NW 111 Street
MIAMI SHORES FL 33168-3301
Contractor(s) Phone Cell Phone Valuation: $ 2,000.00
JOE LEWIS SPECIALTY SEPTIC (305)662-7979 (786)343-9958
Total Sq Feet: 150
Type of Work:REPAIR DRAINFIELD Available Inspections:
Type of Piping: Inspection Type:
Additional Info:REPAIR DRAINFIELD HRS Approval
Bond Return: Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Owners Bond $500.00 Invoice# PL-3-17-63243
CCF $1.20
DBPR Fee $2.25 03/15/2017 Check#:137 $500.00 $166.70
DCA Fee $2.25 03/09/2017 Cash $50.00 $ 116.70
Education Surcharge $0.40 03/15/2017 Cash $ 116.70 $0.00
Permit Fee $150.00 Bond#:3342
Scanning Fee $9.00
Technology Fee $1.60
Total: $666.70
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,PLUMBIN ,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify t all the fore g information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhe ore, I author' the above-named contractor to do the work stated.
March 15, 2017
Authorized Sign re:Owne / plicant / Contractor / Agent Date
Building Department Copy
March 15, 2017 1
r �
Miami Shores Village � ,�
Building DepartmentMAR 9 2011
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 [BW:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC -210 2
BUILDING Master Permit No. P[ I 'f wJz
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
]PLUMBING ❑ MECHANICAL [-]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:—2- /S l✓ J l -St ('
City: Miami Shores County: Miami Dade Zip: b
i
Folio/Parcel#: 2-/3 l'bo l- OG 6 0 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: > F[F,E: q
OWNER:Name(Fee Simple Titleholder): G4
Phone#: ���/ V ?-75 w
Address:
A/ 0 ///
City: M/d`"z S hd r'es State:_/' o zip: 3,316 ? dc1 n/
Tenant/Lessees Name: Pl9S'G*z- �� u �_� /�t 0 04 Phone#: 306-W1, -O'F/
Email: ��/eurlN-,oncC c�� C Qma (' L•Cohn
CONTRACTOR:Company Name: /5 o2e-c `Se/ Phone#: � G
Address: 2.3 2-5 U SY t
3/ y
City: State: � Zip: .3 -7
Qualifier Name: S1,90- le-.L I)--S// Phone#: 7�4
State Certification or Registration#: L& its.r,Jo, Certificate of Competency#: -S�00 /S 9 Q
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip::
Value of Work for this Permit:$ 4;'10 OD Square/Linear Footage of Work: /&0 -sq/��
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace_ ❑ Demolition
Description of Work: Oro, /N krei d y
Y
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ Zj CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary.$_
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
I. T
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 Wermit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature 44-6a A1,19 / 1119 Ol1wl— Signature
OWNER or AGENT . CONTRACTOR
The foregoing instrument was acknowledged before me this Theforegoing instrument was acknowledged before me this
Of -
20 17 by 1 day of I- t��� 20 , by
rnl who is personally known to ICS tS who is personally known to
me or who has produced _as me or who has produced 6=-Cf asDF_
identification and who did take an oath. identification and who did take an oath. Idr�q
NOTARY PUBLIC: NOTARY PUBLIC:
KILLICK JOSEPH
Sign: Notary Public-State of Florida
Commission#GG 069770 _
Print: M Comm.Expires Feb 5,2021 Print:
Fl Bonded through National Notary Assn. t
F
Seal: —'—'MPWWVW04 Seal: _ MY COMMISSION#GG 044602
AP; EXPIRES:November 2,207.0
Bonded Thru Notary Public Underwriters!
************************************************************************************************************
APPROVED BYPlans Examiner Zoning
Structural Review Clerk
(RevisedO2/24/2014)
INVOICE
LEWES SEPTIC
UMPOU'TS DRA.INFIFIIDS
7196-263-1723
Date:
State of f 10 Yid
County of Q�A E
Before me this day personally appeared jut. Le&-is w]io,"being=cluly sworn,deposes and
says:
That he or she will be the only person working on the project located r: .1-5 N w /1/ S f
Sworn to(or affirmed)and subsen`hed before me f.is �Y of No Y 20� -by
Personally know
OR Produced Identification L Z00`U 203�Z O
1
Type of Identification Produced
. . t �`cerSe-.
Print,Type or Stamp Name of Notary
R�s Gr
�c
s Miami Shores Village
Building Department
10050 N.E.2nd Avenue
�Lpg`xpp► Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner- Workers' Compensation Insurance Exemption
Florida Law r6quires 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 if.
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: /'lam cd r le _rl 1220-0166-
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this -7 day of da yc4 2aLl 7 .
By Eu.
% )au r i mys't(� who is personally known to me or has produced
as cation.
KILLICKJOSEPH
Notary:
Notary Public-State of Florida
My Comm.Expires Feb 5,2021
SEAL: Bonded through National Notary Assn.
1
fir^
STATE OF FLORIDA
DEPARTMENT OF HEALTH r .
APPLICATION FOR CONSTRUCTION PERMIT
Permit Application r
------- - -------------------PART II -SITEPLAN---------------------------
3cale: Each block represents 10 feet and 1 inch =40 feet.
4,0 741
Try
t
� e, a
dotes:
;ite Plan-submitted by:
'Ian Approved Not Approved Date
ly I County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
< t
4 Z►tE STATE OF FLORIDA PERMIT #: 13-SC-1742885
f DEPARTMENT OF HEALTH APPLICATION #: AP 1277885
ONSITE SEWAGE TREATMENT AND DISPOSAL
DATE per;
SYSTEM
'�. FEE PAID
CONSTRUCTION PERMIT
RECEIPT #:
WE DOCUMENT #: PR1051381
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: (Pascai Flevrimovd)
PROPERTY ADDRESS: 215 NW 111 St Miami, FL 33168
LOT: 18 BLOCK: 3 SUBDIVISION:
PROPERTY ID #: 11-2136-001-0660 [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 [ 900 ] GALLONS / GPD Existina Seotic Tank to Remain CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @( ]DOSES PER 24 HRS #Pumps [ ]
D [ 150 ] SQUARE FEET New Trench Conf. Drainf. SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE: 11.95'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE ( 16.50 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 56.50 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 52.001 INCHES
0 EXISTING SEPTIC TANK TO REMAIN, REPLACE DRAINFIELD ONLY
T 1.-EXISTING 900 gal.septic tank with and approved filter TO REMAIN.
H 2.- Install 150 sf.of drainfield in TRENCH configuration.
E 3.-Install 12"of slightly limited soil at the bottom of the drainfield.
4.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or trench.
R (Comments Continued on Page 2.)
SPECIFICATIONS BY: Joe Lewis TITLE:
APPROVED BY: TITLE• ENGINEERING SPECIALIST I Dade CHD
Yvenel Clermont
DATE ISSUED: 02/28/2017 EXPIRATION DATE: 05/29/2017
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FACPage 1 of 3
v 1.1.4 AP1277885 SE1024748
DOCUMENT #; PR1051381
5.-Invert elevation of drainfield to be no less than 7.74'NGVD
6.-Bottom of drainfield elevation to be no less than 7.24'NGVD
THIS PERMIT IS NOT FOR ANY ADDITIONS.
The system is sized for 2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimated flow of 300
gpd.
Required drainfield area based on rule 64E-6.015(6)(c)2.
Install a new drainfield to achieve Drainfield size requirement.
The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s.
64E-6.013(3)(0, FAC.
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entalHealth
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Florida Health on O"�
Miami-Dade County O
0� pSTDS s(�'ell rAj mi FL 331" .
�Q� iigos s Z3 47.
Date ry
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inspector yv �� OSTDS#
Insp
Address
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Comments:
Signature -
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