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PL-16-3494
Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Date: 11312017 'PROVED .,. Expiration: 07/02/2017 Parcel Number Applicant 10618 NE 11 Avenue Miami Shores, FL 33138- 1122320280630 Block: Lot: BENJAMIN JOHN & KRISTINA R Owner Information Address Phone CeII BENJAMIN JOHN & KRISTINA ROGERS 10618 NE 11 Avenue -- -- — - — -- MIAMI SHORES FL 33138- (786)390-8835 10618 NE 11 Avenue MIAMI SHORES FL 33138- Contractor(s) Phone STATEWIDE SEPTIC CONNECTIONS (954)963-0082 CeII Phone Valuation: Total Sq Feet: Type of Work: REPLACE COLLAPSED SEPTIC TANK. TANK Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $0.00 $2.25 $2.25 $0.20 $150.00 $3.00 $0.80 $159.10 Pay Date Pay Type Invoice # PL -12-16-62501 01/03/2017 Check* 6219 12/30/2016 Check #: 6217 Amt Paid Amt Due $ 109.10 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: HRS Approval Final Review Plumbing 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 • Futhermore, I thorize the above-named contractor to do the work stated. January 03, 2017 Authorize, Si. .ture: Owner / Applicant / Contractor / Agent ate Building Department Copy January 03, 2017 1 o ‘ tlfr‘c‘14a BU I LDtNS: a. PERMIT APPLICATION BUILDING ❑ ELECTRIC [,PLUMBING ❑ MECHANICAL Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305)1756-8972 INSPECTION LINE PHONE NUMBER: (305),762;4949 ❑ ROOFING Master Permit No. Sub Permit No. ❑ REVISION ❑ EXTENSION 21,RENEWAL r, 51 i,EL 30 ?Ii1.6 4.4i'I -i Fsc LA pc 1c0-3(-Iqg ▪ PUBLIC WORKS ❑ CHANGE OF CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: \0(7 r e NO O '' °' City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: tI, 2"-.,®2g - ®6 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: 3-3110 OWNER: Name (Fee Simple Titleholder): Y) Crniner �Y I 0O01"Pl e#: \W6 la NC-7 City: ot S� State: Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: G iA5\GLeJ Address: kr))G ve)© V. i lot /'Ckei *t City: 0 POl LOC- 1 r, I State: A Na. Name: TeA-CSG, t` yat' 4 Phone#: State Certification or Registration #: �V O- I ►1 Z(' Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: Value of Work for this Permit: $ Square/Linear Footage of Work: M P Type of Work: ❑ Addition ❑ Alteration �j 1'� Description of Work: ' Tc._ t� ) C ± r10 CAtapketu- Phone#: 3 16621-433 Zip: ✓NJ State: Zip: New tgi. Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ S DBPR $ 2. 0 2.5 Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 1 OP. (Revised02/24/2014) 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 approved and • reinspection fee will be charged. Signatur NER o GENT The foregoing instrument as a knowled 23 day of Dr C (?;.,,iz_o , who is me or who has produced FLA- identification L-identification and who did take an oath. NOTARY PUBLIC: ged before me this ,20 I6 •by personally known to (h as Sign: 0z -tiara • e 4 r .' crx L � Prin Seal: APPR (Revised02/24/2014) JERRICA L. ARMSTRONG .E Notary Public - State of Florida • My Comm. Expires Feb 9, 2019 Signature j4 ort dQO- CONTRACTOR The foregoing instrument was acknowledged before me this 2e day of Dec , 20 6 , by T,c S k Y'Vo is personally known to me or who has produced -A— ( ,% identification and who did take an oath. NOTARY PUBLIC: Sign: Prin Seal: Q as ******** JERRICA L. ARMSTRONG Notary Public - State of Florida **OnitifirtfutAfg'Fft'q'9'P88'9'* My Comm. Expires rnF 9 Plans Examiner '' ' Zoning Structural Review Clerk \L_ Environmental Heattr Florida Health Miami -Dade Count OSTDS «Veil Division 11805 5 \ 26th `1treet • Miami. Fl 33 7. Inspector Eft,.. -r ---s;,( �c net Address lb" l rNi fc,e4-c.r /22 .s Signature e I( Scanned by CamScanner 1,40,0t4tv--?-14<t--- f -13 3! sArs -ct• CSNPRI. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATIONFL- BUILDING 0 ELECTRICI IROOItr6il:ELL- PLUMBING JOB ADDRESS: FBC20/c Master Permit No. Sub Permit No. I c'/33 / JEVISION ❑ EXTENSION ❑ RENEWAL ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS 1 06 8 NSE I. iv ,rice City: Miami Shores County: Folio/Parcel#: ) d " 2-2,3 Z_ ^ 0 `c' oGG `" Occupancy Type: Load: Miami Dade Zip: Is the Building Historically Designated: Yes NO Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):_ x'1)64 (rr'1 i r, k) 01'1 r d- trick VIC\ R0 Wone#: 2>C' Y ' ((-'82-3 'Ci6� g A,, _ City: M I Q v✓) I 'J rt? S State: Fl— Zip: 5 1 1 f3 e Tenant/Lessee Name: Phone#: Email: Address: CONTRACTOR: Company Name: u� Address: ( 640 N 4-� Phone#: -3 feel_663-; ', C -� City: O �.ti C �0 State: T L Zip: �.� Qualifier Name: TSS 6 vC't 0 ,-ictO r") Phone#: State Certification or Registration #: S'1 0fl i Zk 2 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Type of Work: ❑ Addition ❑ Alteration Description of Work: re- Ck C' . C Cw \t ›S -C'01 Square/Linear Footage of Work: Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ LipsoFee $ ls�y T CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ ee Structural Reviews $ Bond $ \ `f " t 9-- lt� G TOTAL FEE NOW DUE$ IO 1, 10 (Revised02/24/2014) i 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 OWNER or AGENT Signature CONTRACTOR The foregoing instrument was acknowledged before me this The aforegoing instrument was acknowledged before me this I �' day of M 0� , 20 1S. , by V \ day of MOD , 20 i S , by 1Lr‘<-:4.,,- , who is personally known to €'3 who is personally known to me or who has produced FL c I D as me or who has produced kri 6� Ip identification and who did take an oath. NOTARY PUBLIC: Sig Print. Seal: o�var < "+Diary Public State of Florida J equaiin Rodriguez t ommission E. 11 APPROVED BY (Revised02/24/2014) identification and who did take an oath. NOTARY PUBLIC: Sig as Print Seal: ?o�w' Notary public = -: of Florida 1; • ' Jscqualin Rodriguez ?oh, Cvmmiseion EE115407 Feine +iai::'m:07/25/2018 ************************************************************ Plans Examiner Zoning Structural Review Clerk Notice to Owner — Workers' Com p Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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: State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of `l ;20 . l By i� th No SEAL: r,b 'e, Notary PublicoFlorida da fly Jacquelin Rodriguez lr o'y abMr Commission i:EI 15407 Expires 07'25/2oi who is personally known to me or has produced as identification. STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Benjamin John PERMIT #: 13 -SC -1585160 APPLICATION #: AP1174940 DATE PAID: FEE PAID: RECEIPT #: DociMENT #: PR974837 PROPERTY ADDRESS: 10618 NE 11 Ave Miami, FL 33138 LOT: 13 BLOCK: 4 SUBDIVISION: PROPERTY ID #: 11-2232-028-0630 [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 [ A [ N [ K [ 1,050 ] GALLONS / GPD New septic tank 0 ] GALLONS / GPD CAPACITY CAPACITY 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 202 ] SQUARE FEET Existing drainfield to rema SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [x] BED [ ] N F LOCATION OF BENCHMARK: F.F.E., 6.50' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 14.401[ E L D FILL REQUIRED: INCHES BOTTOM OF DRAINFIELD TO BE [ 35.40][ 0 T H E R [ 0.00 ] INCHES / FT ] [ ABOVE / / FT ] [ ABOVE / INCHES EXCAVATION REQUIRED: [ BELOW BELOW BENCHMARK/REFERENCE POINT BENCHMARK/REFERENCE POINT ] INCHES Tank replacement only. (an approved outlet filter shall be installed.) Inspector to verify the existing septic tank is properly abandoned before final approval. The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with sec. 64E -6.013(3)(f). F.A.C. "THIS PERMIT IS NOT FOR " ADDITION(s) ". The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of 400 gpd. SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: Teresa J Solomon Carlos M Icaza 05/15/2015 TITLE: TITLE: Master Septic Tank Contractor Dade CHD EXPIRATION DATE: 08/13/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC v 1.1.4 AP1174940 SE960722 Page 1 of 3 STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR CONSTRUCTION PERMIT Permit Application Number PART II - SITEPLAN Scale: Each block represents 10 feet and 1 inch = 40 feet. .9� -1 c;. --e no s;f i -i n &Yt- c. SSk S--tv-ee ?p ivt Pt -1 2)0 6r 0 0rela (4/N Cr" S i 0 Notes: sled .QUA- iecd p‘SS c( v C M‘tam1 Skoref 331.56? Qvr,n p tPcv,dAp.-.. ee 1 Qce t ker/cxp 1 is pd GG Site Plan submitted by: Plan Approved Not Approved 3 Is c•irra Date By County Health Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 2 of 4 (Stock Number: 5744-002-4015-6)