PL-12-20-2972, 173 NW 108th StMiami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Permit NO.: PL-12-20-2972
Permit Type: Plumbing - Residential
Work Classification: Drainfield
Permit Status: Approved
Issue Date:01/11/2021 Expiration: 06/28/2021
Location Address Parcel Number
173 NW 108TH ST, Miami Shores, FL 33168 1121360100260
Contacts
IRMIDE VALCIN Owner AFFORDABLE SEPTIC SOLUTIONS LLC Contractor
173 NW 108 ST, MIAMI SHORES, FL 331684312 DURA BRYANT
irmidevalcin@comcast.net 14261 NW 24 AVE, OPA LOCKA, FL 33054
Business: 3057298022 dbryant1416@gmail.com
Mobile: 7865806729
Description: drainfield repair and trench connfiguration
kk
i Valuation:
$ 3,500.00
�
Ins ection Requests:
REPLACED 17-223
305-762-4949
Total Sq Feet:
0.00
Fees
Amount
Payments
Date Paid
Amt Paid
100% Permit Renewal Fee
$150.00
Total Fees
$150.00
Check # 216
01/11/2021
$150.00
Total:
$150.00
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
regulating construction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent Date
January 11, 2021 Page 2 of 2
,n
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Miami Shores Village�c���r��
Building Department DEC 28 2020
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 l `�
BUILDING Master Permit No. �� IZ 20- 2-9-1 Z
PERMIT APPLICATION Sub Permit No.
❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I N 10 8 it
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): I rfrnt k \/"x f t C J1 Phone#: J 0 -3 5 Q 3) S S
Address: ) i NUJ f O $
City: )I 6:mkU ..i S kz'y) State: Zip: 3 3 1 6
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:Af-k-r&t-�L'
j1
, I -C �'� t u']1 C C Phone#: (qO(: "l O -- 6 t7 2- 1
Address: I q U I t\l \fJ
City: 0 yhi - Lv r k a
State:
� � Zip:, 7 o
Qualifier Name: 1 J (! C (�
(�
' 6 �- -q 01
Phone#:
State Certification or Registration
#: r�1 C
LL��`T
_ 1 f
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State: Zip:
Value of Work for this Permit: $,�fl
C7 a
Square/Linear Footage of Work:
Type of Work: ❑ Addition
❑ Alteration
❑ New ❑ Repair/Replacer ❑ Demolition
Description of Work: �Fi �'0.`t
'\1 Ce
f 9-p0.c
f GAj -TD- Ch C0 n H dl �o l t CM
J
o
V
Specify color of color thru tile:
Submittal Fee $
Permit Fee $
CCF $ CO/CC $
Scanning Fee $
Radon Fee $
DBPR $ Notary $
Technology Fee $
Training/Education Fee $ Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ 00
(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 reinspection fee will be charged.
Signature C�', &
OWNER or AGENT
The foregoing instrument was acknowledged before me this
�h
day of .JCC'_L�2.���'-.. , 20 06 , by
f rY1't P �) ci1 C who is personally known to
me or who has produced i�L "Cl �PZ- C./ L as
identification and who did take an oath.
NOTARY PUBLIC:
r--
Print
MY COMMISSION # GG 116653
Seal: EXPIRES: June 20, 2021
,,F °`�� Bonded Thru Notary Public Underwriters
Signature % --�(:
CONTRACTOR/
The foregoing instrument was acknowledged before me this
day ofh1liL. -Z_ . 20 `' by
who i personally known to
(:�me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Pri
Seal: My MY COMMISSION# GG 116653
L�;xgEXPIRES: June 20, 2021
:���� BondedThrnNot
ary PubliC Underwriters
************************************************************************************************************
APPROVED BY t//Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
BUILDING
PERMIT APPLICATION
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
l JAN 2 12017
I
FBC 20ILI
Master Permit No. P ( [ q - ? 23
Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: � 0 Lk ) 1 C) � }}
City: Miami Shores County:
Miami Dade Zip:
Folio/Parcel#: 2 C�lo ���� (>� �Z Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): _1LC_ Y \� 6C \I rk I �� n Phone#:
Address: til\.Q k �<��i
City: (Y\ IGfy-\'j `7� i�Pcj State: VA Zip:�2:>) -2:�) a
Tenant/Lessee Name:
Email
hone#:
CONTRACTOR: Company Name:�L^�
Address: t `1
City: (_:�) State:
Qualifier Name: � >rca l �r-���-i- Phone
State Certification or Registration #:�\�\�1 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
City:
ne#:
State: Zip:
Value of Work for this Permit: $C��� �U Square/Linear Footage of Work:
Type of Work: ❑ Addition_ ❑ Alteration ❑ New
� ` Repair/Replace ❑ Demolition
Description of Work: 1 t44 C^_�i r � C C1 E1
Specify color of color thru tile:
Submittal Fee $ 50 P+Ilb ' Permit Fee $ j �y
Scanning Fee $ Radon Fee $ 2 • Z=
Lb
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ Z CO/CC $ .
DBPR $ Z 2 `S Notary $
• g Double Fee $
Bond $ 5010 _0
TOTAL FEE NOW DUE $ I 1 0/
(019, 90
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature 0 r-Jk- - —
OWNER or AGENT
The foregoing instrument1 was acknowledged before me this
1—b dayof� XN , 20 1 - by
/
cf-10C' O( CI(\ who is personally known to
me or who has produced -f-t—n —r— i�, as
identification and who did take an oath.
NC)TARY PURLIC-
Si
S1
oti�av"�ef�., JERRICA L. ARMSTRONG
Notary Public - State of Florida
iN1 .O`, �I�111(IIIfOIUli rr 1.7/JOJ
My Comm. Expires Feb 9, 2019
Signature
CON JRCTOR
The foregoing instrument was acknowledged before me this
13 day of JGf> 20 by
�L 621 who is personally known to
me or who has produced
identification and who did take an oath.
as
NOTARY PUBLIC:
Sign: &,.k,�
Print: ',2121 �1 a
Seal: v
•`itill ►+'Y of ^JERRICA L. ARMSTRONG
Notary Public - State of Florida
******************** ,�nn• ' **�$th�Fifdfbfidfi*#'PF*lV589** ***********
My Comm. Expires Feb 9, 2019
Plans Examiner Zoning
(Revised02/24/2014)
Structural Review
Clerk
Miami Shores Village
Building Department
10050 NE 2 Ave, Miami Shores, FI 33138
Tel: (305)795-2204 • Fax: (305)756-8972
01 /02/2019
To: Current Owner
173 NW 108 ST
Miami Shores, FL 331684312
Permit: PL-1-17-223
Address: 173 NW 108 ST Miami Shores, FL 331684312
Dear Owner,
Our records indicate that the above referenced permit application has expired without obtaining the proper
permit approval. In order to serve you better, we need to keep our files up to date.
As per section 105.3.2 of the Florida Building Code, `An application for a permit for any proposed work shall be
deemed to have been abandoned 180 days after the date of filling, unless such application has been pursued in
good faith or a permit has been issued. "
Please be advised that open permits will hinder your ability to refinance or sell this property.
Please contact the Building Department, within 15 days of receipt of this letter in order to take care of
this matter.
Sincerely,
Ismael Naranjo (CBO)
Building Director
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR
APPLICANT: Irmide Valcin
OSTDS Repair
AND DISPOSAL SYSTEM
PROPERTY ADDRESS: 173 NW 108 St Miami, FL 33168
LOT: 10
PROPERTY ID #
BLOCK: 2
30-2136-010-0260
PERMIT #:13-SC-1725645
APPLICATION #:AP1266686
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1044772
SUBDIVISION: Dunnings Miami Shores
[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 [ 1,050 ] GALLONS / GPD Existinq Septic Tank to Remain CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY 2.
N [ 0 j GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS.1,W)e,11',at `?
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24LHRSta�y},#]?ramps ,'[°S�J]
D [ 225 ] SQUARE FEET New Trench Conf. Drainfie SYSTEMu-
\L'
R [ 0 ] SQUARE FEET SYSTEM cpt� ri1121 to �t :: t tis Gi="�`U
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [x] TRENCH BED };sar - p^,ta. }sr.; i,.4vn
N tv ':,'' ,•s'yi'0
F LOCATION OF BENCHMARK: FFE: 12.7' NGVD d�tni1"
I ELEVATION OF PROPOSED SYSTEM SITE [ 24.00][ INCHES FT j[ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 79.001[ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D E
0
T
H
E
R
11'L tCC; 2uj uu): L U.UU J 1NUHN:5 EXURVATIUN eu:wU
EXISTING SEPTIC TANK TO REMAIN, REPLACE DRAINFIELD ONLY
1-EXISTING 1050 gal. septic tank with and approved filter TO REMAIN.
2.- Install 225 sf. of drainfield in TRENCH configuration.
3.- Install 12" of slightly limited soil at the bottom of the drainfield.
(Comments Continued on Page 2.)
55.UU J 1NC riY S /�
lee V.
r�
SPECIFICATIONS BY: Yv lermont TITLE: ENGINEERING SPECIALIST I
APPROVED BY: TITLE: Engineer Supervisor III
DATE ISSUED:
trid V Edwards
01/10/2017
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
I*ii4 7-V*1r* W§"- "
Dade CHD
04/10/2017
Page 1 of 3
v 1.1.4 AP1266686 SE1018895
STATE OF FLORIDA APPLICATION # AP1266686
DEPARTMENT OF HEALTH PERMIT # 13-SC-1725645
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE1018895
SITE EVALUATION AND SYSTEM SPECIFICATION
APPLICANT: Irmide Valcin
CONTRACTOR / AGENT: Affordable Septic
LOT: 10 BLOCK: 2
SUBDIVISION: Dunnings Miami Shores ID#: 30-2136-010-0260
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.20 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY ( RESIDENCES -TABLET / OTHER -TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 500.00 GALLONS PER DAY [ 1500 GPD/ACRE OR r 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 338.00 SQFT UNOBSTRUCTED AREA REQUIRED: 338.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: FFE: 12.7' NGVD
ELEVATION OF PROPOSED SYSTEM SITE 24.00 [ INCHES / FT ] [ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: N/A FT DITCHES/SWALES: N/A FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON -POTABLE: N/A FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 40 FT
SITE SUBJECT TO FREQUENT FLOODING?
10 YEAR FLOOD ELEVATION FOR SITE:
Qn TT. AROFTT.F. TNFORMATION SITE 1
[ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO]
FT [ MSL / FTVq
] SITE ELEVATION: 10.70 FT [ MSL / NGVD
SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES:
Munsell #/Color
Urban land
Texture
Depth
10YR 5/1
Sand
0 To 11
10YR 6/2
Sand
11 To 72
USDA SOIL SERIES: Urban land
Munsell #/Color Texture Depth
10YR 5/1 Sand 0 To 14
10YR 6/2 Sand 14 To 72
OBSERVED WATER TABLE: 72.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE:
ESTIMATED WET SEASON WATER TABLE ELEVATION: 80 INCHES [ ABOVE / BEE]
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [X ] TRENCH [
r- REMARKS/ADDITIONAL CRITERIA
[ PERCHED / APPARENT ]
EXISTING GRADE
DEPTH: INCHES
Replacement 4-FS/0.80 DEPTH OF EXCAVATION: 55 INCHES
] BED [ ] OTHER (SPECIFY)
Replacing the existing 300 sgft bed configuration drainfield with new 225 sgft trench-pqp�pq iQ Or draonfieeld in the is required area to perform d
Existing 1050 gal septic tank to remain.
boring adjacent to the drainfield excavation
� athe time off),'
insoertinn prig;, t- 3 ai
SITE EVALUATED BY:
Affordable Sept, (Title: )
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
witness the soil boring and comparED jes I Tob7iMV1
uun suDrTiitt@d, A reinspection fee will be a Ys� a
iblW,S(et9 a �e�,°d4
pora`t�ea. ta`i�-P6?6di)1ISAat the jobgito A th4 arr @� time.
AP1266686 EID1725645
v 1.0.2
DOCUMENT #: PR1044772
- Invert elevation of drainfield to be no less than 6.62' NGVD
- Bottom of drainfield elevation to be no less than 6.12' NGVD
S PERMIT IS NOT FOR ANY ADDITIONS.
The system is sized for 3 bedrooms with a maximum occupancy of 6 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)(0, FAC.
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.
:• •
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 13 day of - .......... ___ , 20 ) .
By nC\�'I C t 1 who is personally known to me or has produced
I , (\ as identification. _
Notary:
SEAL:
JERRICA L. ARMSTRONG
c 6
'' Notary Public - State of Florid&
.:. ? Commission # FF 197589
0 My Comm. Expires Feb 9, 2019
Fl`��
AFFORDABLE SEPTIC SOLUTIONS LLC
14261 N.W. 24T" AVENUE
MIAMI FL 33054
(786)580-6729
DATE:'-�%1----
State of —
County of`l'�L-- Z _--_----
Before me this day personally appeared _7v CJ+- who,
being duly sworn, deposes and says:
That he or she will be the only person working on the project located at
S orn to (or affirmed) and subscribed before me this 2�_ day of
Tk-" _.2011 , by
JERRICA L. ARMSTRONG
Notary public . State Of Florida
Commission it FF 197589
My Comm. Expires Feb 9, 2019
Personally Known_ ✓
r Produced Identification
vile Identification Produced__--_