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PLC-18-1665PLc /8-f5 -12-2, Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. PLC-6-18-1665 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: APPROVED Issue Date: 8/23/2018 Expiration: 02/19/2019 Parcel Number Applicant 9600 NE 2 Avenue Miami Shores, FL 33138- 1132060132510 Block: Lot: PALAZZO LEONI LLC Owner Information Address Phone Cell PALAZZO LEONI LLC PO BOX 381703 MIAMI FL 33238- PO BOX 381703 MIAMI FL 33238- Contractor(s) Phone EDWARD ROJAS PLUMBING CORP (305)944-6788 Cell Phone Valuation: Total Sq Feet: $ 1,200.00 0 Type of Work: SEPTIC TANK ABANDONMENT Type of Piping: Additional Info: SEPTIC TANK ABANDONMENT Classification: Commercial Scanning: 1 Fees Due CCF Change of Contractor Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Amount $1.20 $110.00 $2.25 $2.00 $0.40 $150.00 $3.00 $1.60 Total: $270.45 Pay Date Pay Type Invoice # PLC-6-18-67963 08/23/2018 Credit Card 06/18/2018 Credit Card Amt Paid Amt Due $ 220.45 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: HRS Approval Final Review Plumbing 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 cer at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. F , ; -, aykhorize the above-narmed ontractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent August 23, 2018 Date Building Department Copy August 23, 2018 1 BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC 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 ❑ ROOFING LUMBING ❑ MECHANICAL ❑ PUBLIC WORKS JOB ADDRESS: too IY fi (yj City: Miami Shores Master Permit No. Sub Permit No. R 'CEIVED JUL 12 2018 0J) I/ CC h FBC 201-4 PIC iS —1& S ❑ REVISION ❑ EXTENSION RENEWAL CHANGE OF ❑ CANCELLATION SHOP CONTRACTOR DRAWINGS County: Miami Dade Zip: 33/3 Folio/Parcel#: I k -3 Z — b 13 - 25 / o Is the Building Historically Designated: Yes NO !( Occupancy Type: Load: Construction Type: Flood Zone: VC1-124N11-° OWNER: Name (Fee Simple Titleholder): L-4-40A1 �—(—G Phone#: B-ox Address: City: i�l i,,� State: BFE: FFE: 156 - 11�� EL Zip: 3323 Tenant/Lessee Name: Phone#: Email: jog &4 I Leona-Co.+kfano - oo @ CONTRACTOR: Company Name: 8dai a U Po /i., S pJu I !) /, I n' Address: G '1J c•C Ill ST City:.1 Sc Key L ' p 2& State: (- I • Qualifier Name: L1U((M cI:., p/,at State Certification or Registration #: ee.,C,CC;. n .l jar y.?/ Certificate of Competency #: N, ,,, DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Square/Linear Footage of Work: _caN► Phone16. #: . q$ 61 t. Zip: 3 3/6/ Value of Work for this Permit: $ Type of Work: ❑ Ad Description of Work: ition 17 Alteration ❑ New Phony#,.1•/:4. Yy3 S 4 ❑ Repair/Replace V Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ 6C - �� CCF $ ^^` CO/CC $ Scanning Fee $ Radon Fee $ 2 'CAD �1 DBPR $ ^ • o� 5 Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 2. 2 a • '7 5 4146E q: 0441(2e. e- 'Ito • OJ (Revised02/24/2014) Bonding Company's Name (if applicable) � a 4 Bonding Company's Address City 1 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. I e absence of such posted notice, the inspection will not be; approved and a reinspection fee will be charged. Signature',L buL' • OWNER or AGENT The foregoing instrument was acknowledged before me this I( day of -11209 GEtN! Signature ONTRACIOR The foregoing instrument was acknowledged before me this y 20 !O by f/ der of �,��� , 20 �1 , by , who is personally known to gb "J / 22 tr , who is personally nown_to me or who has produced as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ANDREW VOGEL MY COMMISSION # FF919683 EXPIRES: November 25, 2019 ***************** identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: �i�✓ I/ 0' ..e ANDREW VOGEL MY COMMISSION # FF919683 EXPIRES: November 25, 2019 ******************s******************************************** APPROVED BY - ) 1� .7/ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) • STATE Off` FLORIDA DEPART2 NT OF HEALTH ONSITE EWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR:n OSTDS Abandonment APPLICANT: (Palazzo Le i LLC) PERMIT # : 1 3-SC-1852011 APPLICATION #:AP1347808 DATE PAID: FEE PAID: RECEIPT #' DOCUMENT #: PR1119684 PROPERTY ADDRESS: 96Qd NE 2 Ave Miami, FL 33138 LOT:, 345 BLOCK: 19 SUBDIVISION: PROPERTY ID #: 11-3206»013-2510 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] 41 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 AASIS 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 PE MIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITT NG REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ ] GALLONS GPD CAPACITY ] GALLONS GPD CAPACITY ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ] GALLONS DING TANK CAPACITY ( ]GALLONS q[ ]DOSES PER 24 HRS #Pumps [ ] D [ ] SQUARE FE R [ ] SQUARE FE SYSTEM SYSTEM A TYPE SYSTEM: [ STANDARD ( ] FILLED [ ] MOUND [ ] I CONFIGURATION: ( TRENCH ( ] BED [ N F LOCATION OF BENC!DdAR11 I ELEVATION OF PROPOSEDSYSTEM SITE 11 E BOTTOM OF DRAINFIELDTO BE L D FILL REQUIRED: [ .00] INCHES EXCAVATION REQUIRED: ( ] INCHES Have the tank abandoned }n accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of o the tank shall be opened cYr ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The T tank shall be filled with clejn sand or other suitable material, and completely covered with soil.Have the system inspected by the health department sifter it has been pumped , ruptured and filled with sand and covered. E R ] (ABOVE / BE LON ]BENCHMARK/REFERENCE POINT ] [ ABOVE/ BELOW ]BENCHMARK/REFERENCE POINT SPECIFICATIONS BY: `TITLE: C'. ! APPROVED BY: /, TITLE: Engineering Specialist II Lti?aras X ponzalez DATE ISSUED: 00/04/2018 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.o 3, FAC Dade CHD EXPIRATION DATE: 09/02/2018 Page 1 of 3 s,W EDWARD ROJAS PLUMBING SERVICE 880 NE 111 TH ST BISCAYNE PARK, MIAMI FL 33161 SEWER AND DRAIN SPECIALISTS My phone 786-443-9846 305-944-6788 my office LICENSED -BONDED -INSURED CC-CFC 049431 Date: /' — Z 2 State of T167t Qla Country of Before me this day personally appeared6ELcI'ic/ who, being duly sworn, That he or she will be the only person working on the project located at: q(e Q 10 6. Z (We Contractor Signature Sworn to (or affirmed ) and subscribed before me this ay of v 3 I 2018 By Ebw 6 &Th,5 Personally Know OR Produced Identification Type of identification Produced Print Type or Stamp Name of Notary ANDP F7N VOGEL MYC ,..,a; ;ION#FF919683 E O I i 5. November 25, 2019 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 Exem tion ^tls' im Y . 4. J Ju'' 1 : F v :. MK` �� 'Wit, '' :3r . ' .4°, 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 By filed D L GoN I Notary: SEAL: 0 day of S J , 20 1?. who is persona4/41) known to me or has as identification. prod uced 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 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 19 day of 37)4 , 20 /1 By Tb DO LOA) I SEAL: AsIDRE'i / VOGEL .4*.MY COMASSION # FF919683 EXPIRES: November 25, 2019 who is personally known to me or has produced as identification.