PL-7-16-2016 Canceled�<'V Miami Shores Village
RECEIVED
o. Building DepartmentaR
20�7
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2011s 1
BUILDING OCELLED Master Permit No.CAN k
— �—
PERMIT APPLICATION Sub Permit No. f L— I� _7
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL [::]PUBLICWORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
!�
��
z D
JOB ADDRESS:
City:
Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#:
rs I -,�() 3 6 •-COS - C)U) b
Is the Building Historically Designated: Yes NO
Occupancy Type:
Load:
Construction Type:
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
/'
iK FO(Acrp.�
I
71 YL
CS) LD'\
Phone#: -
Address: .16Q-
d9E JL76-4
� (�'Ya_
City: !(G"( sk"ed State:
2-
Tenant/Lessee Name: �— Phone#:-"
Email: 13 fC,�CYOrs .S (� T� �d� • C""v✓►.
CONTRACTOR: Company Name:
Address: / ygG/ '�'ti
City: V 6 t o e
Qualifier Name: (,
State Certification or Rt-gistration �#:
Phone#: 7ed r 3/ $ - 4,-7S6
Zip: 3/c'
hone#:
Certificate of Competency #:
DESIGNER: Architect/Engineer: 1-C-h 4rc-k;�aj .Tle ) v«,. At C,"P Phone#: 3pf_ 2$S. ` V51113
Address: 1361 L0141f 1,14, JLf` e 0'077 City: ! 14-Att, State: Zip:-33/c/1
Value of Work for this Permit: $ ) e0o Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration' �t ❑ N��ew���� ❑ Repair/Replace ❑ Demolition
Description of Work: _ �LW lJf� 1rC `&C„C4 b1
'P L (� ?�► to PL -1 2- -Zm - 2-97 I 1
Specify color of color thiu tile:
Submittal Fee $ Permit Fee $ 5y CCF $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
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. 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 rei ection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The
foregoing instrument was acknowledged before me this
1 day of MArfi�i 120 ? by
�r_" � ho is personally known to
me or who has produced 4&& /�C�� � as
identification and who did take an oath.
The foregoing instrument was acknowledged before/me this
C day of 20 ` 7 by
n who is personally known to
me or who has produced Y ILrkas
identification and who did take an oath.
NOTARY PUBLIC: 1111111111/// NOTARY PUBLIC:
SILVF/��
•oNF�•.,.
Sign: a 9c� �• k ign:_&,,,,, Q2
Print: •� e'er : o rint: 1
P.
Seal: Zoe, #F a �.;�'�(Z'eal:
PNubwkll
�•F v
�8++ �AR" JERRICA L. ARMSTRONG
_ Notary Public - State of Florida
My Excr,'; Feb 9, 2019
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
' DIVISION OF
°i Environmental Health
�o Florida Health
pQ�0� Miami -Dade County
OSTDS/Well Division
11805 SW 26th Street • Miami, FL 33175 O
Ins Spector //� / i�y7 cy !]
p J`ff �j('r' Date
L
K Address �� �!(S T OSTDS #
Comments:
Signature
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
�y CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT: Brandon Simon
AGENT: Statewide Septic Connections, Inc.
PROPERTY ADDRESS: 162 NE 106 St Miami, FL 33138
LOT: 3 BLOCK: 201
APPLICATION #:AP1245695
PERMIT #:13-SC-1691387
DOCUMENT #: F11069044
DATE PAID:06/24/2016
FEE PAID :200.00
RECEIPT #:13-PID-2991402
SUBDIVISION: Dunnings Miami SHores Ext No 1 ID#: 11-2136-005-0030
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION
[01] TANK SIZE [11 900.00 [21
[021 TANK MATERIAL Polyethylene
(031 OUTLET DEVICE
[041 MULTI -CHAMBERED [ L-IJ N ]
(05] OUTLET FILTER Tuf-rite EF-4
[06] LEGEND 1. 70-156-90D-C3 2.
[071 WATERTIGHT
[081 LEVEL
[09] DEPTH TO LID
DRAINFIELD INSTALLATION
[101 AREA [1] 240 [21 SQFT
[111 DISTRIBUTION BOX HEADER X
[121 NUMBER OF DRAINLINES 1. 4.00 2.
[131 DRAINLINE SEPARATION
(141 DRAINLINE SLOPE
[15] DEPTH OF COVER
[161 ELEVATION [ ABOVE / BELOW ]BM 37.20
SETBACKS
[ ] [27] SURFACE WATER
FT
[ ] [28] DITCHES
FT
[ ] [291 PRIVATE WELLS
FT
[ ] [301 PUBLIC WELLS
FT
[ ] [311 IRRIGATION WELLS
FT
[ ] [321 POTABLE WATER 2(40 pyC)
FT
[ ] [33] BUILDING FOUNDATIONS 15
FT
[ ] [341 PROPERTY LINES 8
FT
[ ] [351 OTHER
FT
FILLED / MOUND SYSTEM
[ ] [361 DRAINFIELD COVER
[ ] [371 SHOULDERS
[ ] (38] SLOPES
[ ] [391 STABILIZATION
[171 SYSTEM LOCATION L J
[18] DOSING PUMPS [ ]
[191 AGGREGATE SIZE [ ]
[201 AGGREGATE EXCESSIVE FINES [ ]
[211 AGGREGATE DEPTH [ ]
[ ]
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[411 STORMWATER RUNOFF
[42] ALARMS
[431 MAINTENANCE AGREEMENT
[441 BUILDING AREA
(45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
FILL / EXCAVATION MATERIAL
[ ] L47I
CONTRACTOR
Affordable Sept (Affordable S
[ ] [22] FILL AMOUNT
[ ] [48]
OTHER
ADS ARC 24
( ] [231 FILL TEXTURE
[ ] (241 EXCAVATION DEPTH
ABANDONMENT
[ ] (251 AREA REPLACED
[ ] [49]
TANK PUMPED
08/05/2016
[ ] (26] REPLACEMENT MATERIAL
[ ] [501
TANK CRUSHED
& FILLED 08/05/2016
Comments: Comments are on page 2.
/
Dade CHD DATE:
08/05/2016
CONSTRUCTION
[ APPROVED
DISAPPROVED
) ' Environmental Specialist II Heber Montero (Department of Health in Da
FINAL SYSTEM
[ APPROVED / DISAPPROVED
]: Dade :
08/10/2016
Environmental Specialist II Heber Montero (Department of Healt t
(Explanation of Violations on following page)
Florida Health Miami -Dade
County
DH 4016, 08/09
(Obsoletes all previous
editions which may not be used) -i D, ,cat 'ellP
m
Incorporated:
64E-6.003, FAC
P
e 2 of 3
EH Database v 1.0.1
AP1245695 EI01691387
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Violation Number Comment
APPLICATION #:AP1245695
PERMIT #:13-SC-1691387
DOCUMENT #:F11069044
DATE PAID:06/24/2016
FEE PAID :200.00
RECEIPT #:13-PID-2991402
iVLllllCll t-�
The system is sized for 2 bedrooms with a maximum occupancy of 4 persons (2 per bedroom), for a total estimated flow of 200
gpd.
-16 chambers, 4 drainlines (4 chambers each)
-bed configuration, all sand
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Page 2 of 3
Incorporated: 64E-6.003, FAC
EH Database v 1.0.1 AP1245695 EID1691387