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PLC-19-1162Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Nzn� flJl(lj�� Issue Date: 08/06/2019 Parcel Number Permit NO.: PLC-05-19-1162 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 02/03/2020 Project 9806 NE 2 AVE, Miami Shores, FL 1132060132241 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 IGE CONSTRUCTION INC Contractor ELIER GONZALEZ 6270 NW 114 ST, HIALEAH, FL 33012 Business: 7864880144 Description: SEPTIK TANK ABANDONMENT Valuation: $ 550.00 Inspection Requests: TotalSq Feet: 75.00 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 Check # 8629 12/20/2019 $110.00 Credit Card 08/06/2019 $60.30 Credit Card 05/21/2019 $50.00 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 AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws Ire ulWM!trzon1 Futhermore, I authorize the above named contractor to do the work stated. 1-dia0h Authorized 1g re: Owner / scant / Contractor / Agent Date December 20, 2019 Page 2 of 2 DIVISION ij9NAl9' OF Environmental Health Florida Health Miami -Dade County �D pQ� OSTDS/Well Division 11805 SW 26th Street - Miami, FL 33175 O •Inspector RAN Dtf 4S �fti Date / - �/- 1a c C.' fC Address_ ��e N-f �OSTDS # Comments: Signature L__ 'PLC, —1✓S - tcA -- I I lv Z BUILDING PERMIT APPLICATION Miami Shores Village 1VI Building Department o yC2019 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:� Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 Master Permit No. PLC-05-19-1162 Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS Q■ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9806 NE 2ND AVE 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): MIAMI SHORES CENTER LLC Phone#: (305) 864-8885 Address:210 71 ST STREET SUITE 309 City: MIAMI BEACH State: FL Zip: 33141 Tenant/Lessee Name: Miami Theater Center Phone#: (305) 751-9550 Email: orit@elyseeinc.com CONTRACTOR: Company Name: IGE Construction Inc ne#: (786) 488 0144 Address: jsj�'-u 1 kw `�- City: Hialeah State: FL Zip: 33018 Qualifier Name: Elier Gonzalez Phone#: .?7dSci % Z� 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: 75 Type of Work: ❑ Addition F01 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: SEPTIC TANK ABANDONMENT Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ _ Bond $ nn TOTAL FEE NOW DUE $ V oa (Revised02/24/2014) 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 Zi Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 C TRACTOR The foregoing instrument was acknowledged before me this The foregoin 7instrumentwasackn wI dged before me this 1,\ t day of QC� - 20 \ ` by day of1r 20 � by eh %�� who is p` ersonally k��+A ^ +� -= ip C1 C1n ho is personally known to �r who has produced as me or who has produced as identification and who did take an oath, identification and who did take an oath. gRU1Z NOTARY PUBLIC: NOTARY PUBL °P comm{siiwor 113978 * * Fucpires June,12, 2021 C OFf1•°0` gg4ed1:r811d0� Sign: Sign: � a Print: \ O Print: Seal: GRIT MIMOUN Seal: G 1 624N MY co MMISS{ON # G a: �. .; F; 1RES:Deoo ��¢Omrt �r#odf��e;: BOf1d0d T{IN �i APPROVED BY ! / Plans Examiner Zoning Structural Review 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`L Owner's Name (Fee Simple Title Holder): Miami Shores Center LLC Owner's Address: 210 71st Street Suite 309, City: Miami Beach State : Florida Phone #: (305) 864-8885 ZiD Code:33141 Job Address (Of where work is being done):9806 NE 2nd Ave 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 Qualifier's Name: Roberto Rodriguez State: Florida Architect/ Engineer of Record Name: Joseph Chan Address: 12000 SW 92nd Street City: Miami State: FL Describe Work: Septic Tank Abandonment for sewer hook up Zip Code:33031 Lic. Number: Phone #:.E- 786 - 488-1000 Zip Code: 33186 1 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 Shor s harmless of all leraNnv ment. n c . Signature v Signature Owner or Agenc ( ntraccor or Archi The foregoing instrument was aknowledged before me 1 The foregoi gin ent w s akn ledged before me this I day of 20 b _ Ni4AI 1 I this 3 day of i'l,)ti(w,1 v, 202-1by 12,h�+F��,DA Who is personally known to me or who has produced who is persona:ly known to me or who has produced as indentification. as indentificauon. Notary Public: _ ,!�`\ t Notary Public - Sign: `*L —C' Sign: Seal:-"°""i Seal: ORIT MI&MU6 i JANE1 V%LLECILLO ?.; My rOMMISS10N # GG 162466 fit`. ' Notary p - State of Florida EXPIRES: December 14, 2021 ? Commission • FF 991465 GrAdWThn7Notary Pu 11 UndetMfte _• 'e My comm. Expires May 11, 2020 tended tft* UWW Notary Assn. STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Centerllc) PROPERTY ADDRESS: 9806 NE 2 Ave Miami, FL 33138 LOT: BLOCK: 17 SUBDIVISION: PROPERTY ID #: 11-3206-013-2241 PERMIT #: 13-SC-1 981035 APPLICATION # : AP 1427655 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1248630 [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 [ ] GALLONS / GPD ] GALLONS / GPD ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY [ CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ D [ ] SQUARE FEET SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D F O T H E R [ ] BED [ ] ][ABOVE/BELOW] BENCHMARK/REFERENCE POINT ][ABOVE/BELOW] BENCHMARK/REFERENCE POINT 'ILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: L J tnUnzs 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 from retaining water, and(c) The tank shall be filled with clean sand or other suitable material, and completely covered with soilMMAIM RWOISA by the health department after it has been pumped, ruptured, and filled with sand anREdWgr"NK MUST BE PUMPED BY A STATE SEPTIC TANK CONTRACTOR ORS ATE LICENSED PLUMBER, BOTTOM OF TANK OPENED OR RUPTURED, AND TANK FILLED WITH CLEAN SAND OR OTHER SUITABLE MATERIAL. CONTRACTOR MUST CERTIFY COMPLETION OF ABOVE WORK AND MIAMI-DADE COUNTY HEAD H UCr/Am i Mr-Im SPECIFICATIONS BY: Yliaja Se a TITLE: Engineering Specialist II APPROVED BY: TITLE: Engineering Specialist II Dade CHD Jesus D gernandezAcosta DATE ISSUED: 11/12/2019 EXPIRATION DATE: 02/10/2020 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 v 1.1.4 AP1427655 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. Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 08/06/2019 Permit NO.: PLC-INS-19-1162 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 02/03/2020 Location Address Parcel Number Project 9806 NE 2 AVE, Miami Shores, FL 1132060132241 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: SEPTIK TANK ABANDONMENT Valuation: $ 550.00 Requests: Inspection f75-762-4949 Total Sq Feet: 75.00 11 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 08/06/2019 $60.30 Credit Card 05/21/2019 $50.00 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 contactor to do the work stated. E Authorized Signature: Owner / Applicant / Contractor / Agent Date August 06, 2019 Page 2 of 2 RECEIVED Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 MAY 21 2019 BY:- -1-1 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 PITT- ABC 20 BUILDING Master Permit No.lam- l I PERMIT APPLICATION Sub Permit No.2(-0--oL-;- ) Cf- i 6- ❑ BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL PLUMBING ❑ MECHANICAL it PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9806 NE 2nd Ave City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132060132241 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: Miami Theater Center Phone#:i(305) 751-955Q Email: orit@elyseeinc.com CONTRACTOR: Company Name: �J J�t�4� +/� S"C- Phone#: '-�> > q S-g1L 1W Address: 2l o S 1 SW al.5y 5� . City: )Aawo-5'k ""-� __ State: Zip: ' J a'71 Qualifier Name: R C' fl (C% C'u°�' Phone#: State Certification or Registration #: I 0?-I 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: $ b50 - GO 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 9-18-2374) Specify color of color thru tile: Submittal Fee $_ —C�0 ' Co Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $_ DBPR $ CO/CC $ Notary : Double Fee $ Bond $ TOTAL FEE NOW DUE $ ' 30 (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 (,� vvv Signature —O., R-L--, OWNER or AGEN C NTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument as acknowledge before me this _6 day of 20447 by day of 20 lC by j who is personally known to 6U�rvh p Y �4 �1y o is personally known to me or who has produced as me or who has produced TL��\i� �Ja� identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARYIPUMIC: Sign: nn ,,, Si*n:Print: 06.+ l iV1A10\A.J\ Pr Seal: ORITMIMOUN' Seal: .. �: MY COMMISSION # GG 162406 EXPIRES: December 14. 2021 APPROVED BY (213 Plans Examiner SINDIA ALVAREZ g = MY COMMISSION # GG 238273 =>P EXPIRES: September 3, 2022 Bonded firo Notary Public Undeiwrltars Zoning Structural Review (Revised02/24/2014) Clerk STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Center LLC) PROPERTY ADDRESS: 9806 NE 2 Ave Miami, FL 33138 LOT: NA BLOCK: 17 SUBDIVISION: I PERMIT #:13-SC-193W2 i APPLICATION # : AP 1 405779 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1210195 PROPERTY ID #: 11-3206-013-2241 [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 [ ] GALLONS / GPD CAPACITY A [ ] GALLONS J GPD CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ ] SQUARE FEET R [ ] SQUARE FEET A TYPE SYSTEM: ( ] STANDARD I CONFIGURATION: [ ] TRENCH N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D F 0 T H E R SYSTEM SYSTEM ] FILLED [ I MOUND [ I BED [ ] Ill ][ ABOVE/ BELOW] BENCHMARK/REFERENCE POINT ][ABOVE/ BELOW] BENCHMARK/REFERENCE POINT 11.L MKVV120.:U: t V.VU J INCHES EXCAVATION REQUIRED: [ I INCHES 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 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 filled with sand and covered. SPECIFICATIONS BY: TITLE: APPROVED BY: TITLE: Environmental Specialist II Erick Varara DATE ISSUED: 04/0312019 EXPIRATION DATE 07/02/2019 DR 4016, 08/09 tobeoletes all previous editions which may not be used) Incorporated: 64E-6.003, PAC V 1.1.4 AP1405779 SE-1 Dade CHD Page 1 of 3 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 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 a contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLrGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. 11 Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 16 day of [In , ?0 . By tFAi 4 Z,� &'�Z__ who is personally known to me or has produced as identification. Notary: SEAL: •. 011 MIMOUN MY t;OM &f1SS10N # G3162406 EXPIRES: December 14, 2021 Bonded TMu Notov wd�a, I IGE Construction INC Date: 12/ 19/2019 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: ige 1010@aol.com State of Florida County of Dade Before me this day personally appeared ` � V who, being duly sworn deposed and says: That he will be the only person working on the project located at 9806 NE 2"d AVE Miami Shores, FL 33138 / PLC-05-19-1162 Plu " ing C ac5OQure Swor to (or affirmed) and subscribed before me ` day of 20-0 By Personally Knovu� t,��e� YAo1RAGRUIZ ?o Or Produced Identification Commission # GG 1139?$ Expires June 12,2o2t Type of Identification Produced O Aeaa�an..d,a�nostirs«s ame of Notary