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PLC-19-1161Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 180 NE 99 ST, Miami Shores, FL Contacts 7 -, T -11 ftl Issue Date: 08/06/2019 Parcel Number 1132060132230 Permit NO.: PLC-05-19-1161 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 02/03/2020 Project NE 2 AVE SEWER CONNECTION MIAMI SHORES CENTER LLC Owner MIAMI SHORES CENTER LLC Applicant 20171 ST 309, MIAMI BEACH, FL 33141 20171 ST 309, MIAMI BEACH, FL 33141 Mobile:7862368569 ORIT@ELYSEEINC.COM Mobile:7862368569 ORIT@ELYSEEINC.COM Other:3058648885 Other:3058648885 IGE CONSTRUCTION INC Contractor ELIER GONZALEZ 6270 NW 114 ST, HIALEAH, FL 33012 Business: 7864880144 Description: SEPTIC TANK ABANDONMENT Valuation: $ 550.00 quests: Ins ectiIi -762on on Requests: TotalSq Feet: 79.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 Change of Contractor $110.00 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $220.30 Payments Date Paid Amt Paid Total Fees $220.30 Credit Card 05/21/2019 $50.00 Credit Card 08/06/2019 $60.30 Check # 8629 12/20/2019 $110.00 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS A FIDAVIT. I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws re ula ing n ucf a d z ing. Futhermore, I authorize the above named contractor to do the work stated. gal ao1�� Authorized Sign e: ne / pplicant / Contractor ! Agent Date December 20, 2019 Page 2 of 2 BUILDING PERMIT APPLICATION Miami Shores Village C Building Department o c s 19 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 Master Permit No. PLC-05-19-1161 Sub Permit No BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL 70PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS 0 CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 180 NE 99TH STREET City: Miami Shores County: Miami Dade zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): M IAM I SHORES CENTER LLC Phone#: (305) 864-8885 Address:210 71 ST STREET SUITE 309 city: MIAMI BEACH State: FL Zip: 33141 Tenant/Lessee Name: DR THROWERS SKIN CARE Phone#: (305) 757-9267 Email: orit@elyseeinc.com CONTRACTOR: Company Name: IGE Construction Inc Phone#: (786) 488 0144 Address: city. Hialeah state: FL Zip: 3301$, Qualifier Name: Elier Gonzalez Phone#:. State Certification or Registration #: CFC 1429669 Certificate of Competency #: DESIGNER: Architect/Engineer: JOSEPH CHAN Phone#: (786) 488-1000 Address:21051 SW 234 STREET city. HOMESTEAD State: FL, Zip: 33031 Value of Work for this Permit: $ 550.00 Square/Linear Footage of Work: 79 Type of Work: ❑ Addition X Alteration ❑ New ❑ /Re lace Re air p p ❑Demolition Description of Work: SEPTIC TANK ABANDONMENT Specify color of color thru the: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ toTOTAL FEE NOW DUE $__. 110 . (Revised02/24/2014) 1 Bonding Company's Name (if applicable) NA Bonding Company's Address City State Mortgage Lender's Name (if applicable) NA Mortgage Lender's Address City State Zip 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. 1 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 AGE T The foregoing instrument was acknowledged before me this — 1� , day of V 20 ki by �t LL,yo, Y��e e . who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as ------------ Signature C RACTOR The foregoing instrument was acknowledged before me this ��-day of Q3t!r.3V10-eC , 20 1 C by. o is persQ40ARM2 to me or who has produced Commis0on9GG113.R8 identification and who did take : Exp{tesJune 12,2021 f Itro pudget Notwy Services NOl Sign: �"�' Sign Print: O ht Pria Seal:., `•' o ; : Seal ORITMIMOUN If( COMMISSION # GG 162406 . ` ` cem EXP'IRES: Deber 14, 2021 bonded 71iry NeMn, w ��,�:.. � ...----• APPROVED BY ****ssssssss*ssssss*sssssssssss**s*******sss******sss****s***ss Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. PLC-05-19-116,1, Owner's Name (Fee Simple Title Holder): Miami Shores Center LLC Owner's Address: 210 71st Street Suite 309, City: Miami Beach State : Florida Job Address (Of where work is being done):180 NE 99th Street Phone #: (305) 864-8885 Zip Code:33141 City: Miami Shores State:_Florida Zip Code:33138 Contractor's Company Name: SOUTHERN SEPTIC AND LIFT STATION C Phone #: (305)598-8266 Address: 21051 SW 234 Street City: Homestead State: Florida Zip Code:33031 Qualifier's Name : Roberto Rodriguez I_ic. Number: Architect/ Engineer of Record Name: Joseph Chan Phone #:786 - 488-1000 Address: 12000 SW 92nd Street City: Miami State: FL Zip Code: 33186 Describe Work: Septic Tank Abandonment for sewer hook up I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all IeV 7ment. Signature I K,�t' 6 Signature Ownero Agenc ancra_tor jakn ett The foregoing instrument was ``aknowledged before me r The foregoing instrument wwledged before me this I day of _, __,20t1,by {Giw• �G�t this j 3 day ofNoe e . 4,v 202•3by Who is personattY lmo, wnn to me or who has produced who is personally known to me or who has produced as indendfication. as indentification. Notary Public: rf Notary Public: Sign,: %iYP • �' Sign: Seal: 001rop.0zrhi6tf0UN .� Seal: MISSbn r"."��.,, JANET VALLECILLO Q naQy RES, osoem c" rFpt06 ?ape �: = Notary PUb:IC - State of Florida �ru P��O� d e2; j. _• Commission # FF 991465 My Comm. Expires May 11, 2020 Bonded through National Notary Assn STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Centedic) PROPERTY ADDRESS: 180 NE 99 St Miami, FL 33138 PERMIT #: 13-SC-1981034 APPLICATION #: AP1427654 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT # : PR1248631 LOT: 1 BLOCK: 17 SUBDIVISION: [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 11-3206-013-2230 [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 [ GALLONS / GPD GALLONS / GPD GALLONS GREASE INTERCEPTOR CAPACITY GALLONS DOSING TANK CAPACITY [ D [ l SQUARE FEET R [ ] SQUARE FEET A TYPE SYSTEM: [ ] I CONFIGURATION: [ ] N CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps SYSTEM SYSTEM STANDARD [ ] FILLED [ ] MOUND [ ] TRENCH I I BED [ ] F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D E 0 T H E R ][ABOVE/BELOW] BENCHMARK/REFERENCE POINT ][ABOVE/ BELOW] BENCHMARK/REFERENCE POINT 'ILL REQUIRED: [ 0.00 ] INCHES EXCAVATION REQUIRED: [ J iNCkMb Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank FF&R @MA *ffi&N d9(b; The tank shall be filled with clean sand or other suitable material, and completely cove ffi T SEP I TA y fSTATE RA�C1OR OR STATE by the health department after it has been pumped, ruptured and filled with sand 001110 $'B►Q0,1MBER, BOTTOM OF TANK OPENED OR RUPTURED, AND TANK FILLED WITH CLEAN SAND OR OTHER SUITABLE MATERIAL. CONTRACTOR MUST CERTIFY COMPLETION OF ABOVE WORK AND SCHEDULE INSPECTION WITH THE MIAMI-DADE COUNTY HEALTH DEPARTMENT SPECIFICATIONS BY: Yliana rra TITLE: Engineering Specialist II APPROVED BY: E: Engineering Specialist II Dade CHD VJesus-'b HerAanpezAcosta EXPIRATION DATE: 02/10/2020 DATE ISSUED: 11/12/2019 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Page 1 of 3 Incorporated: 64E-6.003, FAC v 1.1.4 AP1427654 SE-1 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. i Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address iMR Issue Date: Parcel Number Permit NO.: PLC-05-19-1161 Permit Type: Plumbing - Commercial Work Classification: Septic Permit status: Approved Expiration: 02/03/2020 Project 180 NE 99 ST, Miami Shores, FL 1132060132230 NE 2 AVE SEWER CONNECTION Contacts MIAMI SHORES CENTER LLC Owner MIAMI SHORES CENTER LLC Applicant 20171 ST 309, MIAMI BEACH, FL 33141 20171 ST 309, MIAMI BEACH, FL 33141 Mobile:7862368569 ORIT@ELYSEEINC.COM Mobile:7862368569. ORIT@ELYSEEINC.COM Other:3058648885 Other:3058648885 SOUTHERN SEPTIC AND LIFT STATION Contractor CORP ROBERTO RODRIGUEZ 12040 SW 118 ST, MIAMI, FL 33186 Business: 3055988266 Description: SEPTIC TANK ABANDONMENT Valuation: $ 550.00 Inspection Requests: 762-4949 TotalSq Feet: 79.00 305- Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $110.30 Credit Card 05/21/2019 $50.00 Credit Card 08/06/2019 $60.30 Amount Due: $0.00 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 zoning. Futhermore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent o Date August 06, 2019 Page 2 of 2 e I. 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 RECEIVED MA 21 2019 BY: 6 FBC 20 BUILDING Master Permit NoTL �-� �� y - 3-ib PERMIT APPLICATION Sub Permit No. PLC -G S T7 - 116 F—IBUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION RENEWAL PLUMBING ❑ MECHANICAL *UBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 180 NE 99 street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132060132230 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Miami Shores Center LLC Phone#.305-864-8885 Address:210 Seventy First Street city: Miami Beach State: FL Zip: 33141 Tenant/Lessee Name: Dr Thrower's Skin Care Phone#:F(305) 757-97971 Email: orit@elyseeinc.com CONTRACTOR: Company Name: S ' Phone#:'J0� Address: 21 0 S t SW 'Z"?q `7 City: AA 0d"\P-- C41� State: E L- Zip: N 3 Qualifier Name: Zo?�,tfL-N O O(L, b Lk L Phone#: State Certification or Registration M S R'O a 2 I`i2 Certificate of Competency #: DESIGNER: Architect/Engineer: Joseph Chan Phone#: 786-488-1000 Address:12000 SW 92 street city: Miami State: FL Zip: 33186 Value of Work for this Permit: $ S�E30 _ U7 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Septic Tank Abandonment, Property connecting to sewer (PLC 9-18-2376) Specify color of color thru tile: Submittal Fee $ 150 ` Q Permit Fee $ Scanning Fee $ _ Technology Fee $ Structural Reviews $ Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 0. to (Revised02/24/2014) Bonding Company's Name (if applicable) na Bonding Company's Address City State Mortgage Lender's Name (if applicable) _ Mortgage Lender's Address na City State Zip 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 AGEN The foregoing instrument was acknowledged before me this The foregoing instrument was acknowld before me this �_ day of GC 20 by �l day of 1 �' I/A 20 1 by I M / ho is personally known to �h( [3 &b 6U who is personally known to me or who has produced as me or who has produced DQI WE (.0 ENS-G as identification and who did take an oath. NOTARY PUBLIC: identification a d w did take an oath. NOTARY PUBLI : Sign: r-,��c Sign: Print: nrr, 1 ►'yyt o -AY—) Print: LV p� S ORITMIMOUN Seal: ::�."•'°°d MY COMMISSION # G3162406 ,'e= EXPIRES: December14,2021 ********************************************* APPROVED BY Gi / 3 / '9 Plans Examiner SINDIA ALVAREZ MY COMMISSION 4 GG 238273 EXPIRES: September 3, 2022 Bonded Thru Notary Public Underwrltors Zoning Structural Review (Revised02/24/2014) Clerk r,' fN STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Center LLC) PROPERTY ADDRESS: 190 NE 99 St Miami. FL 33138 LOT: 1 BLOCK: 17 SUBDIVISION: PROPERTY ID #: 11-3206-013-2230 PERMIT # :13SC-1936639 APPLICATION #: AP1405856 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1210203 (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 [ j GALLONS / GPD j GALLONS / GPD J GALLONS GREASE INTERCEPTOR CAPACITY j GALLONS DOSING TANK CAPACITY [ D [ ] SQUARE FEET R ( ] SQUARE FEET A TYPE SYSTEM: [ ] STANDARD I CONFIGURATION: [ l TRENCH N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D E 0 T H E R CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps SYSTEM SYSTEM [ I FILLED [ ] MOUND ( ] BED [ ] Is ][ABOVE/ BELOW] BENCHMARK/REFERENCE POINT ][ABOVE/ BELOW] BENCHMARK/REFERENCE POINT ILL REQUIRED: ( U.UU j INCHES EXCAVA IU1V kU,(jU LrtAJ : L j LNk nr a Have the tank abandoned in accordance with the fo::owing procedures:(a) The tank shall be pumped out.(b) The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The tank shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system Inspected by the health department after it has been pumped and ruptured but before it is Cled with sand and covered. SPECIFICATIONS BY: TITLE: APPROVED BY: TITLE: Environmental Specialist II Eridk Peter& Dade COD DATE ISSUED: 04103/2019 EXPIRATION DATE: 07/02/2019 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) IncoLporated: 64E-6.003, FAC rage i of 3 v 1.1.4 AP1405856 SE-1 U f` Notice to Owner — Workers' Com Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 on 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: I . 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 a contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLF �i THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. j Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 1� day of D�n , ,7011. By U M V FRE ZK t`L. — who is personally known to me or has produced as identification. Notary: SEAL: ORIT MIMOUN MY COMMISSION # GG 162406 EXPIRES: December 14, 2021 xx,W T1xu Notary P„N� i .If IGE Construction INC CGC 111522734 Certified General Contractor & CFC 1429669 Certified Plumbing Contractor 6270 NW 114 ST Hialeah FL 33012 PH: 305-967-2117 PH: 954-825-7274 Email: ige1010@aol.com Date: 12/19/2019 State of Florida County of Dade Before me this day personally appeared t('JJ0Xwho, being duly sworn deposed and says: That he will be the only person working on the project located at 180 NE 99`h ST Miami Shores, FL 33138 / PLC-05-19-1161 m g Co tractor signature Swore to (or affirmed) and subscribed before me By C Personally Known t-�� Or Produced Identification Type of Identification Produced `1 day of P.Q&, 0�. Print, � r a YADIRAB RUIZ s° .••' Commissioo#GWIW8 * Eei June 12.2D21 �~�'OFF�� 8atq�0TNr9udp�N°d"1' Name of Notary lLer*# % o .�� DIVISION OF Environmental Health Florida Health �O Miami -Dade County _QQ OSTDS/Well Division ll805 SW 26th Street - Miami, FL 33175 Inspectorrot4I� L/ 1 Date Address / O v lv ( l d iQ!�T_ Comments: Signature DS# /IP-142��4� FLt--("�-Ii -I►(l