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PL-17-2958Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -12-17-2958 Permit Type: Plumbing - Residential Work Classification: Drainfield Permit Status: APPROVED Issue Date: 12/2612017 Expiration: 06/24/2018 Parcel Number Applicant 141 NW 98 Street Miami Shores, FL 33150- 1131010240100 Block: Lot: JULIAN & ROSE BAPTISTE Owner Information Address Phone Cell JULIAN & ROSE BAPTISTE 141 NW 98 Street MIAMI SHORES FL 33150-1738 Contractor(s) Phone A SUPER SEPTIC & DRAIN FIELD INC CeII Phone Valuation: Total Sq Feet: $ 3,500.00 200 Type of Work: INSTALLING 200 SQFT BED DRAINFIELD Type of Piping: Additional Info: INSTALLING 200 SQFT BED DRAINFIELD Bond Return : Classification': Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $2.40 $2.25 $2.00 $0.80 $150.00 $9.00 $3.20 $169.65 L Pay Date Invoice # 12/15/2017 12/26/2017 Pay Type PL -12-17-65926 Credit Card $ 50.00 $ 119.65 Cash $ 119.65 $ 0.00 Amt Paid Amt Due 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 a = ing. Futhermo uthorizee above-named contractor to do the work stated. t� / Cotttfactor / Agent Building Department Copy December 26, 2017 Date December 26, 2017 1 BUILDING PERMIT APPLICATION Miami Shores Village �v~1rve1J Building Department DECE1 20 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �� Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 gt1 FBC 20( c Master Permit No. P L\1 _. Z 1 sU Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL El PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: /T/ A4 9 8 Sr r City: Miami Shores County: Miami Dade Zip: 3 3 /S O Folio/Parcel#: /1.- 3 /01- 0.21/- 0/00 Is the Building Historically Designated: Yes NO X Occupancy Type: fee g a Load: Construction Type: rt - OWNER: Name (Fee Simple Titleholder): i : ,' Phone#: e•---- Address:�n /1/ 1 it/. 9$' �1 f2�e•o1'-�" City: t `t. Am: - , karbtS State: {----t o MI dr A Zip: 33 k5--0 Tenant/Lessee Name: ---------Phone#: -"- Email: Flood Zone: BFE: FFE: CONTRACTOR: Company Name:/i &pat. ��e�57T C Av,J 1147 ( c+. Phone#: 0-6-- -36 s-0'& 77D/ v i8 A09/20 -- Address: City: /7/./.424/3 4 State: 7771�o C7/.t Zip: 33 0/Ay Qualifier Nam.. aw ;J- -o Phone#: 3 05-36 a(- o! 1 2 State Certification or Registra on #: S 4 d / Qp / 9'4702.Certificate of Competency #: S /Q. o i d J 7yo2,. DESIGNER: Architect/Engineer: �'� Phone#: Address: City: � State: Zip: Value of Work for this Permit: $ 9 �-' L/ Square/Linear Footage of Work: ca/40 v S,g r . Type of Work: ❑ Addition ❑ Alteration ❑ New L✓J Repair/Replace ❑ Demolition Description of .61? 4 4) pla c1e. P L 1-7 6R4 Specify color of color thru tile: d / Submittal Fee $ SJ P fro 1 Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ 2 • CD DBPR $ 2.25 Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ WI. • G (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 be approved and a reinspection fee will be charged. Signatur OWNER or AGENT The foregoing instrument was acknowledged before me this day of 7D 2 jQ�- , 20 (7 , by 3r144-1 ���-- �-/Wh is ersdhaiTy known to me or who has produced P ( Ldk, as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: I NIIII1I NiS Simi/i ,arch 6 ,g1/1... moo• 4•'• �. 954260 : * = '..•„ .g.� �YthN � • •�OQ� Signature The foregoing instrument was acknowledged before me this 1.5 day of -�' 1 S crt-rY\ V7, 20 (1 , by 2 l AI"' r2 -1u L J who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: as ********************************************************************************************************** APPROVED BY (Revised02/24/2014) Plans Examiner Zoning Structural Review Clerk Inspector 3:u Address //// 1t1 ° 9 DIVISION'` OF Environmental Health Florida Health Miami -Dade County OSTDS/Well Division 11805 SW 26th Street • Miami, FL 33175 Date 2•Z Y•/7 Comments: Signature OSTDS # 4I'f 27 11-0 . ?L_ fl — cacr 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -3-17-680 Permit Type: Plumbing - Residential Work Classification: Drainfield Permit Status: APPROVED Issue Date: 3/17/2017 Expiration: 09/13/2017 Parcel Number Applicant 141 NW 98 Street Miami Shores, FL 33150- 1131010240100 Block: Lot: JULIAN & ROSE BAPTISTE rner Information JULIAN & ROSE BAPTISTE Address 141 NW 98 Street MIAMI SHORES FL 33150-1738 Phone Cell Contractor(s) Phone A SUPER SEPTIC & DRAIN FIELD INC CeII Phone Valuation: $ 3,500.00 Total Sq Feet: 200 Type of Work: INSTALLING 200 SQFT BED DRAINFIELD Type of Piping: Additional Info: INSTALLING 200 SQFT BED DRAINFIELD Bond Return : Classification: Residential Scanning: 3 Fees Due Bond Type - Owners Bond CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $500.00 $2.40 $2.25 $2.25 $0.80 $5.00 $150.00 $9.00 $3.20 $674.90 Pay Date Pay Type Invoice # PL -3-17-63300 03/17/2017 Cash $ 624.90 $ 50.00 03/14/2017 Cash $ 50.00 $ 0.00 Bond #: 3347 Amt Paid Amt Due 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 constructiopWd3oning. • - more, I authorize the above -n ed contractor to do the work stated. uthorized ature: nt Contractor / Agent Building Department Copy March 17, 2017 Date March 17, 2017 1 Mar 18 17 11:18a a sup ACORN" CERTIFICATE OF LIABILITY INSURANCE l THIS CERTJFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 03/17117 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 1 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 policy(les) 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 hi lieu of such endorsement(s), p.1 DATE(MM/DD/YYYY) jl PRODUCER Blaize & Tyson Insurances 5955 SW 21st Street Hollywood, FL 33023 Phone (954) 989-9324 INSURED A SUPER SEPTIC 8 DRAIN FIELD, INC 7701 W 18 LANE HIALEAH, FL 33014 COVERAGES Fax (954) 989-5998 954 CONTACT NAME: PHONE /0. Plel ,E: (954) 989-9324 to c, No: (954) 989-5998 L ADDRESS: annyyhlszeandtyson.com INSURER(s) AFFORDING COVERAGE INSURER A: WILSHIRE INSURANCE CO INSURER B: GRANADA INSURANCE !Alen INSURER C : INSURER D : INSURER E INSURER F: THIS IS TO CERTIFY THAT REVISION INDICATED. CERTIFICATE EXCLUSIONS IN SR THE POUCIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH OF INSURANCE POLICIES. LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED E FOR THE POLJCY PERIOD TERM OR CONDITJON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, UMITS SHOWN MAY HAVE' BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE GENERAL ADDLSUBR INSR WVD POLICY NUM POLICY EFF (MM/DDYYY) POLICY EXPn' IM1IMIDD/YYYYI I A LIABILITY CL00182824 11/24/2016 11/24/2017 LIMITS EACH OCCURRENCE DAMAGE $ 1,000,000.00 n COMMERCIAL GENERAL LIABILITY • CLAIMS -MADE :] OCCUR ❑ 70 RENTED PREMISES (Ea occurrence) s 100,000.00 MED EXP (Any one person S 5,000.00 111 PERSONAL& ADV INJURY $ 1,000,000.00 GEN L AGGREGATE LIffi7APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00 POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG 1,000,000.00 B AUTOMIJ OBILE ABIUTY OFL00027082-0 S $ 01/19/2017 01/1912018 C MBINED SINGLE LIMIT (a accident$ III ANY AUTO ALL OWNED SCHEDULED ■ AUTOS AUTOS BODILY IWURY(Per person) 5 10,000.00 . ,---, N ON-O MI HIRED AUTOS AUTOSNON-OVVNED BOOILYIN:URY(Peraccident} 3 20,000.00 PROPERTY DAMAGE (Per accidenn $ 10,000.00 El)Iv PIP $ 10,000.00 UMBRELLA UAB ❑ OCCUR ❑ EXCESS LIAR ❑ CLAIMS -MADE EACH OCCURRENCE ❑ DEC, • RETENTIONS WORKERS COMPENSATIONS AGGREGATE $ $ AND EMPLOYERS' UABIIJTY 1N ANY PROPRIETOR/PARTNER/EXECUTIVE N 1A ❑ WC ST TTS ❑ M- $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL EACH ACCIDENT Funder IXeS describe ION OF OPERATIONS below E.L. DISEASE - EA EMPLOYE 5 EL DISEASE- POLICY DESCRIPTION LIMIT $ OF OPERATIONS / LOCATIONS1 VEHCLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) SEPTIC AND DRAINFIELD INSTALLATION, SERVICE AND REPAIR License Numbers are: SR0161772 and SA0161922 CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2nd Avenue Miami Shores Village fax 305-756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION, All rights reserved. The ACORD name and Togo are registered marks of ACORD REGISTERED SEPTIC TANK CONTRACTOR BRYAN K. ZERO 7701 WEST 18TH LANE HIALEAH, FL 33014- A SUPER SEPTIC & DRAIN FIELD INC SR0161772 Business Authorization: SA0161922 Registration Expires on September 30, 2017 a c0 Mar 1617 03:30p 002312 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 3820314 BUSINESS NAME/LOCATION A SUPER SEPTIC & DRAIN FIELD INC 7701 W 18 IA HIALEAH FL 33014 OWNER A SUPER SEPTIC & DRAIN FIELD INC C/O BRYAN ZERO PRES Worker(s) 1 RECEIPT NO. RENEWAL 3988772 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter EIA - Art 9&10 SEC. TYPE OF BUSINESS PAYMENT RECEIVED 196 SPECIALTY PLUMBING CONTRACTOR BY TAX COLLECTOR SEP0161772 $45.00 08/12/2016 CREDITCARD-16--047154 This Local Business Tax Receipt only confirms payment of the beat Business Tax. Tha Receipt is not a license, permit, ora certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must ba displayed on all commercial vehicles - Mieml-Dade Coda Sec as -276. For more information, visit www.mLemidado.aovrtaxcollector Mar 16 17 03:31p Mar 16 1703:30p a sup 1 ;1 1100% p.2 JEFF ATWATER CHIEF FINANCIAL OFFICER ig image STATE OF FLORIDA 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: 519/2016 EXPIRATION DATE: 519/2018 PERSON: ZERO BRYAN I( FEIN: 811781785 BUSINESS NAME AND ADDRESS: A SUPER SEPTIC & DRAIN FIELD INC. 7701 WEST 18 LANE HIALEAH FL 33014 SCOPES OF BUSINESS OR TRADE: IRRIGATION OR DRAINAGE SYSTEM Purewnrto ahaptet 4.0. D5(14), F. 6.. en oT0m o' a ccrporallor »t10 *Ieo% exemption hero this Weer by fling a certificate of election under /nlssecb0n may not recaer benefes or compensation under INo chapter. P o0 0..e to Choate, 440.(10(12. F5, Crriicales or election b be exempt apalc only Mthin the see. of Me business ar trade listed on the nake of eb:000n 10 be averem Pursuant 10 Cftapter440.05(17), F.S., Nob.. or eledioa to to wrtlpl and ocRlOcales d Napbon b Oe erslrp shall bo subject to re/walla] :f al any time atm Ore nog of the ..ice or the issuance of the cerlelaale. the person nerved on the nobpe or eeni8Ote no longer metre Ire requirements of the sect on ler Issuance of s omekale The department shall revoke a DPS-F2-DWC-252 CERTIFICATE OF ELECTON TO BE EXEMPT REVISED 08.13 QUESTIONS? (550;413.1600 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC PLUMBING Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 762-4949 E ROOFING ISL'(I T`' R„1 MAR 1 4 2017 11Y FBC20IU Master Permit No. P1 l—(DO0 Sub Permit No.4-p/? 7fJoe ❑ EXTENSION E RENEWAL ❑ MECHANICAL ElPUBLIC WORKS JOB ADDRESS: /9/ al.Ls! . 9 e _S Thee T City: Miami Shores County: ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Dade zip: .3.! C) Folio/Parcel#: H-3/0 — 0,g11- D 1 06 Is the Building Historically Designated: Yes NO Occupancy Type: Load: OWNER: Name (Fee Simple Titleholder): Address: /#// N.td. ?g sr City: /f'/%ami, a v Tenant/Lessee Name: Email: tr 4( T� CONTRACTOR: Company Name:, Construction Type: Flood Zone: BFE: FFE: 1 Phone#: - 7,Seo 14 - State: Zip: 33/3'U Address: 7ldi L✓• le A gpe. City: H ;A fe»4 Qualifier Name: Phone#: Rn d (i1�10t U P7til Phone#: � 01.61'.3 (oy' 01/ 3 �NC. State: State Certification or Regi tration #: DESIGNER: Architect/Engineer: Address: Zip: ,130/x/ Phone#:3Q3 = . 6h/- D // 3 0 i b / 7'%2 Certificate of Competency #:...914 0 r= b It 4 a7-4:2-- Value of Work for this Permit'$' g4100 Type of Work: ❑ Addition El Alteration ❑ Description of Work: Phone#: City: / State: /' Zip: Square/Linear Footage of.Work: 0206 Pr” New L_J Repair/Replace ❑ Demolition P i1 Specify color of color thru tile: Submittal Fee $ •CJP T 1 0 .Permit Fee $ Scanning Fee $ 4:1Radon Fee $ Technology Fee $ 3 •2. 0 Structural Reviews $ (Revised02/24/2014) 2 C..s Training/Education Fee $ CCF $ Z.(440 CO/CC $ DBPR $ 2 • Z 5 Notary $ 6 0 Double Fee $ Bond $ 500 o TOTAL FEE NOW DUE $ I Z( -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 permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signatur OWNER or AGENT The forreoing instrument was acknowledged before me this 1 ` day of tCA Vt►" \ , 20 -4 , by ?NOS -e- P,aPkisk-Q who is personally known to The foregoing instrument was acknowledged before me this 3 day of/i't#S'�" , 20 f ti , by \ v O'`-45 7.Crhpersonally known to me or who has produced 1 -9-Z04-1 �-1p2)-a�me or who has producedOr tdQ identification and who did take an oath. 9''KJ1 1, a .1 identification and who did take an oath. 6Yyl�llrl NOTARY PUBLIC: 1 NOTARY PUBLIC: Sign: Print: Seal: APPROVED BY (Revised02/24/2014) Sign: Print: Seal: 3q/f-f1 Plans Examiner V MY COMMISSION # GG 044602 v �t 4-; EXPIRES: Novombor 2, 2020 °odF.' " Bonded Thru Notary Public Underwriters LIAWARAUt rnti7n1 F7 s Zoning Structural Review Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption y. i����t�i,r� d rx 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. Signatur State of Florida County of Miami -Dade `` The foregoing was acknowledge before me this 1 day of `-la f ,20 By 19,0--e_ who is personally known to me or has produced —55J 1 t '" 12 (4 3 "R-Z-aRientification. Not .1 A SEAL: MAHARAI K. GONs ili.::4. 411. _ MY COMMISSION # •'•* EXPIRES: Novemr ;:20 �:$oTi 0" Bonded Thru Notary pe:' r.irwriters A SUPER SEPTIC & DRAIN FIELD INC. CC: SR0161772 7701 WEST 18 LANE HIALEAH, FLORIDA 33014 Licensed and Insured PHONE: 305-364-0113 E-MAIL: ASUPERSEPTIC@GMAILCOM FAX: 305-364-0349 WWW.ASUPERSEPTIC.COM MARCH 13, 2017 STATE OF FLORIDA COUNTY OF MIAMI-DADE BEFORE ME THIS DAY PERSONALLY APPEARED /JP tA.v 250-0 BEING DUL SWORN, DEPOSES AND SAYS: WHO I AM AUTHORIZING A SUPER SEPTIC AND DRAIN FIELD INC., TO MAKE THE NECESESSARY REPAIR TO MY SYSTEM AS SO STATED ON THE PERMIT FROM THE DEPARTMENT OF HEALTH. PERMIT NUMBER: AP1279505 THAT HE OR SHE WILL BE THEONLY PERSON WORKING ON THE PROJECT LOCATED AT: 141 N.W. 98 STREET MIAMI, FLORIDA 33150 SWORN TO (OR AFFIRMED) AND SUBSCRIBED TO ME THIS / 3 DAY OF Mcin ,20/7 ,BY: PERSONALLY KNOWN OR PRODUCED IDENTIFICATION .(.000 1-c `J - 2013 -O TYPE OF INFORMATION PRODUCED ©T 16Q I1Cr r 3 - PRINT, TYPE, OR STAMP NAME OF NOTARY MAHARAI K. GONZALEZ . MY COMMISSION # GG 044602 41 EXPIRES: November 2, 2020 %.`app• F ?. Bonded Thru Notary Public Underwriters STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION #: AP1279505 ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID: SYSTEM FEE PAID: CONSTRUCTION PERMIT RECEIPT #: DOCUMENT #: PR1053027 PERMIT #: 13 -SM -1745305 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: JULIAN BAPTISTE PROPERTY ADDRESS: 141 NW 98 St LOT: 22/23 Miami, FL 33150 BLOCK: 1 SUBDIVISION: Bonmar Park PROPERTY ID #: 11-3101-024-0100 [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 1 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] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS *Pumps [ ] D R A I N I E L D 0 T H E R [ 200 ] SQUARE FEET New Bed Conf. Drainf. SYSTEM [ 0 1 SQUARE FEET SYSTEM TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] CONFIGURATION: [ ] TRENCH [x] BED [ ] LOCATION OF BENCHMARK: FFE: 13.4' NGVD ELEVATION OF PROPOSED SYSTEM SITE [ 24.00 ] [I INCBES 1' FT ] [ ABOVE A BELOW BENCHMARK/REFERENCE POINT [ 60.00 1 [I INCHES Y FT ] [ ABOVE A BELOW b BENCHMARK/REFERENCE POINT BOTTOM OF DRAINFIELD TO BE FILL REQUIRED: [ 0.00 ] INCHES EXCAVATION REQUIRED: [ 48.00] INCHES EXISTING SEPTIC TANK TO REMAIN, REPLACE DRAINFIELD ONLY 1. -EXISTING 900 gal. septic tank with and approved filter TO REMAIN. 2.- Install 200 sf. of drainfield in BED configuration. 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. (Comments Continued on Page 2.) SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: Zero Andrew Yvenel Clermont 03/10/2017 TITLE: TITLE: ENGINEERING SPECIALIST I Dade EXPIRATION DATE: 06/08/2017 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC v 1.1.4 AP1279505 SE1026267 CHD Page 1 of 3 1 ti DOCUMENT #: PR1053027 5.- Invert elevation of drainfield to be no Tess than 8.90' NGVD 6.- Bottom of drainfield elevation to be no Tess than 8.40' 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)(f), FAC.