PL-16-2860 Permit NO L. �- -2
Miami Shores Village it Type Plultrtb�ng•-ResiderE�i. }
�.� 10050 N.E.2nd Avenue NE ,r SIS SI H{7t?C1 D' Id
Miami Shores,FL 33138-0000
Phone: (305)795-2204 � - 171
tatus:A IPR,
10126/2016 Expiration: 0 017
Project Address Parcel Number Applicant
909 NE 99 Street 1132060340230
JOHN DOLL
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
JOHN DOLL 909 NE 99 Street
MIAMI SHORES FL 33138-2568
Contractor(s) Phone Cell Phone Valuation: $ 6,000.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082 Total Sq Feet: 200
Type of Work:REPLACE BROKEN TANK&DRAINFIELD.I Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
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-10-16-61731
CCF $3.60 10/20/2016 Check*5170 $50.00 $777.60
DBPR Fee $4.50
DCA Fee $4.50 10/26/2016 Check#:125 $777.60 $0.00
Education Surcharge $1.20 Bond#:3236
Permit Fee $300.00
Scanning Fee $9.00
Technology Fee $4.80
Total: $827.60
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 EL ICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNER:,A IDA IT: I certify that all the oing information is acc that all work will be done in compliance with all applicable laws regulating
constructio , zoning uthe�re,I a orize a above-named c ,actor to the work stated.
0 October 26, 2016
Authorized Signature:Owner / Applicant / ontractor / Agent Date
Building Department Copy
October 26,2016 1
�. DIVISION OF
Environmental Health
o��Q Florida Health
Miami-Dade County
OSTDS/Well Division
Q11805 SVV 6th Street-Miami,FL 33175 �O
L Inspector Y °? /tz� Date to _; 0
�l
Address C� /� C S� OSTDS # r
1
Comments:
Signature
Scanned by CamScanner
�10_
Miami Shores Village RECEIVED
Building� Department OCT 2 0 1016
10050 N.E.2nd Avenue,Miami Shores, Florida 33138
/XJ Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 —7-t F
FBC 20 04 GG
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
K( PLUMBING F-] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
771 CONTRACTOR DRAWINGS
JOB ADDRESS: C1 'NJ 5 01cl St
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: I f ®� Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): 'j%J I-)>-% ,' Da ll Phone#:
Address: 1�®) C 9
City: �A I C4 rq"�N IS"10rrS State: Zip:
Tenant/Lessee Name: Phone#:
Email: }y�� b
CONTRACTOR:Company Name: �� a 11 ° " )� Phone#: ' 66 e- 6r-,-3.3
Address: 6,F)pP41N 10
City: (D pa oc, c, State: Ft Zip: 3301f
Qualifier Name: T� .�t;. '�� '�'(`���`� Phone#:
State Certification or Registration#: �� �,,(Z6 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work: 2-00
Type of Work: ❑ Addition ❑ Alteration ❑ New K Repair/Replace E] Demolition
ti
Description of Work: " l aC o b r-j f� lam+°'1 r— Vn en-R-elicl
ST�Irl tQ e W 200 __61vi
��'c ►� ���-, fi'-c�( �-
lco -2
Specify color CPru. �
Submittal Fee$ lJ s, _ Permit Feb$ �00--f CCF$ J VJ CO/.CC$
•e'IA� 0.l•B�s
Scanning Fee$ R,•`B,yF� �,w •• i.•ti a8:0 �ee$ G rDBPR$ 0 • � Nota /$
Technology Fee$ ( Training/Education Fee$ a • Lo Double Fee$ //\\-®'
Structural Reviews$ Bond$ G�y • r
TOTAL FEE NOW DUE$ �L a 0
(Revised02/24/2014) rr0
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.
`"'Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
�I - ° y rA" .20
day of � 20 by .by
`u � —� , � da of �_
i"
"��= (��i who is personally known to � � �`���� who is personally known to
me or who has produced r-0�-N- (,f as me or who has produced ���-� I� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: r Sign: AI
Print: Print:
UJZ�m (Den3EamwJ
Seal: Seal:
.•'� ��'• JE##ICA L.ARMSTRONG ,•o:' N
JERRICA L.ARMSTRONG
Notary Pudic-State of Florida Notary Public-State of Floft
* * * $emmwfhyo*fP1eti�*'�
��•.,F
Re
My Comm.Expires Fcb 9.2019 ?�a;� �• My Com.Exphn fab 9.2019
nn
APPROV Plans Examiner Zoning
U
Structural Review Clerk
(Revised02/24/2014)
00
OR
C-193
� Miami shores Village
"" ""'l" Building Department
o�� 10050 N.E.2nd Avenue
N, 0RYvA 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 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:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this �i day of �' f ,20
By who is personally known to me or has produced
as identification.
otary: C,
SEAL:
o�•v MWA L.ARMSTRONG
barn r+ -ao of FWWa
gonvansm 4V N,lurovy
My Can.Isms Feb 9.2019-
PERMIT #: 13-SM-1709760
STATE OF FLORIDA APPLICATION #: AP1257218
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
SYSTEM FEE PAID:
.� CONSTRUCTION PERMIT
RECEIPT #:
DOCUMENT #: PR1035358
CONSTRUCTION PERMIT FOR; OSTDS Repair
APPLICANT: (John&Carmen Doll)
PROPERTY ADDRESS: 909 NE 99 St Miami,FL 33138
LOT: 13-14 BLOCK: 170 SUBDIVISION: Miami Shores Sec. 8
PROPERTY ID #: 11-3206-034-0230 [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 l GALLONS / GPD Septic CAPACITY
A [ 0 l GALLONS / GPD CAPACITY
N [ 0 7 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 200 1 SQUARE FEET BED CONFIGURATION SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [xl BED [ ]
N
F LOCATION OF BENCHMARK: 13.2'NGVD TOP OF BOTTOM FLOOR.
I ELEVATION OF PROPOSED SYSTEM SITE [ 15.60 ] [ INCHE3 FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 49.601 [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 46.00 ] INCHES
0 1.-Install a 900 gal.septic tank with an approved filter
2.-The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
T with s.64E-6.013(3)(f)FAC.
H 3.-Install 300 sf.of drainfield in BED configuration.
4.-Install 12"of slightly limited soil at the bottom of the drainfield.
E 5.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed abso tion bed or trench.
R (Comments Continued on Page 2.)
SPECIFICATIONS BY: Yvenel Clermont TITLE: ENGINE RING Ste, IST Q6
sae
a
APPROVED BY: TITLE; Professional Engineer ' ` O�t� CHD
RJ.cr,ard H Rojas
DATE ISSUED: 10/13/2016 aa�` 01/11/2017
DH 4016, 08/09 (Obsoletes all previous editions which may not be usedQ'
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1257218 SE 0404
. ° DOCUMENT #: PR1035358
(Comments continued on Page 2)
6.-Invert elevation of drainfield to be no less than 9.57' NGVD
7.-Bottom of drainfield elevation to be no less than 9.07' NGVD
8.-This permit includes the abandonment of the existing septic tank.
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)(f), FAC.
NA VW
STATE OF FLORIDA
DEPARTIVIEN-I" OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
we's
Permit Application Number ,--.----------_
_-----------.------, PART 11 - SITE
kale: Each block represents 5 feet and 1 inch 50 feet.
da
417';A�
4;
5 Fft
Z
. ...... .. . ....
7
00,
.... ...... ...... .....
............
+
.'7
34
f
C
4 (.4
There are no pertinent featu
... .... .... res across:
the street or adjacent to;the property
that may affect septic system.
otes: (D
t`o
12f Cl( el 10\J 6.y- r-,
C
-4-
1(33 z: Aj
2
00
to Plan submitted by:
Signature
Title
an Approved Not Approved Date
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
1015,10/96(Replaces HRS-H Form 4015 which may be used)
:k Number:5744-002-4015-6) Page 2 of 3