PL-11-372Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 156699 Permit Number: PL -3 -11 -372
Scheduled Inspection Date: August 17, 2011
Inspector: Hernandez, Rafael
Owner: ZIBELLI, ANTHONY
Job Address: 400 NE 102 Street
Miami Shores, FL 33138 -2453
Project: <NONE>
Contractor: JOE LEWIS SPECIALTY SEPTIC
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060170620
Phone: (305)662 -7979
Building Department Comments
DRAIN FIELD ONLY
Passed
si
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
hrs in file
August 17, 2011
For Inspections please call: (305)762 -4949
Page 2 of 4
o,rs
STATE OF FLORIDA * PERMIT NO. /3ij
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID.. x
CONSTRUCTION INSPECTION AND FINAL APPROVAL RECEIPT #
APPLICANT:
AGENT:
PROPERTY ADDRESS: C?
et
LOT: " h ;" BLOCK:
�'`�
= — —
CHECKED [X] ITEMS 1 ARE NO'* IN COMPLIANCE' WITH 'STATUTE OR RULE AND MUST BE CORRECTED.
SUBDIVISION:
PROPERTY ID #:11- -7-2(7:: 7' - {% 62 0
- - == i = =_kk= =— _ _ __ _=_ ___ __`_
TANK1'1NSTALLATION
[01] TANK,�SIZE [1] ,
[02] TAN` K 1�IATERIAL
[03] OUTLET DEVICE
[04] MUL11I- CHAMBERED [Y 1
[05] ;, OUTLET FILTER 21
[06] LEGEND ,r1
[07 WATERTIGHT
__:171-_,
LEVEL
[09] DEPTH TO LID
D
- i
INFIIELD
INSTALLATION_ ,�
[1]/ T X/ (12] 2 lSQFT
- DISTlst18UZ1QN. BOX HEADER
NUMBER OF DR 1IIU S
DRAINLINE SEPARATION 3'(;
DRAINLINE SLOPE
DEPTH OF COVED
ELEVATION [ABO
SYSTEM LOCATI+
DOSING PUMPS ' e�
AGGREGATE SIZE J f...
AGGREGATE EXCESSIVE FINES
AGGREGATE DEPTH r/ /
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT ?"2 , .
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:.
[
[
SETBACKS
[ j [27] SURFACE WATER FT
[ ] [28) DITCHES FT
[ ] [29) PRIVATE WELLS FT
[ ] [30] PUBLIC WELLS :. FT
] [31] IRRIGATION WELLS ` FT
[ ] [321 POTABLE WATER LINES 3 C) FT
a ( [ ] [33] ' BUILDING FOUNDATION - FT
j [34] PROPERTY LINES • FT
.A. 1 [35] OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45]: ,' LOCATION CONFORMS WITH SITE PLAN
[46]::, FINAL SITE GRAC NG
[47]I1' CONTRACTOR
[48]i . OTHER'
ABANDONMENT'
[49]1; TANK PUMPED / /_.
[50] - TANK CRUSHED & FILLED
I
[ ]
[ l /
FINAL SYSTEI~P PROVE DISAPPROVED]•
DH 4016. (Page 2); •10/97 (Previous Editions May Be Used)
Stock Number. 5744 - 002 - 4018 -4
CONSTRUCTI PPROVDISAPPROVED]•
° CHD DATE.
CHD DATE .: r
PT 1: Applicant
PT 2: Installer/Contractor
PT 3: Building DepartMent-
1 PT 4: Health Department
Page 2 of 3
PERMIT NUMBER Permit' tracking number assigned by CHD.
APPLICANT: Property owners full name.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVIION Lot, Block and Subdivision for lot or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS pg ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (conCrete, fiberglass, etc)
OUTLET FILTER (mantifacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX HEADER (check box)
NUMBER OF DRAINLINESI(number installed)
SYSTEM ELEVATION in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contrIctor installing system)
ADDITIONAL INFORM
ABANDONMENT TAN
TANK CRUSHED AN
EXPLANATION OF VI
CONSTRUCTION AP
MN (as required)
PUMPED (date)
FILLED (date)
LATIONS:
AS BUILT INSTALLATION SKETCH
Record item number, explanation of violation, and required
ROVAL: Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final approval shall no be granted until the CHD has confirmed that building construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application.
ELEVATION WORKSHEET ELEVATION oP BENCHMARK OR REFERENCE POINT:
[+] SHOT
H.I.
ELEVATION
0
EXISTING GROUND TOP OF AGGREGATE
H.I. H.I. H.I.
[-] SHOT [-] SHOT [-] SHOT
e
•
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
BAR 032011
Permit No. l --'51 2_
Master Permit No.
Permit Type: PLUMBING //
OWNER: Name (Fee Simple Titleholder): �� ` Z eL L \ Phone #: 3 G`��co
Address: � � � ��� si
1
City: tM \oU� \S-N\ State: L zip: 3 i 3
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 140C) CO 2N Cc
City: Miami Shores
Folio/Parcel #:
Is the Building Historically Designated: Yes
County:
Miami Dade
zip: (iS t c J a
Flood Zone: 6 `F e7
CONTRACTOR: Company P.—Cc'a(s S J ���` try'
y
Address: 3 U 75 ' %O 6 / v z
City: /7✓ its r ",� 1
Qualifier Name: �� C L ,/ C4a. S ✓(.
State:
Phone #: 2X4- 2 L 3-1723
Zip: 3,302i
Phone #:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ L_ �Z.G C/ Square/Linear Foo ge of Work: 2 ;7_5 5/
Type of Work: Address DAlteration New iclRepair/Replace ODemolition
Description of Work: Vii-A-14 flirt C»..$1_
/-f
Submittal Fee $
Scanning Fee $
Notary $
Double Fee $
* * * ** **** x** * * **** **********x:m**** Fees***** ****+ x*** **** * * *.x******* ** * *** * *** **** *
CAD
P Permit Fee $ /$Z) CCF $ CO /CC $
Radon Fee $ DBPR $ Bond $
Training/Education Fee $ Technology Fee $
Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City 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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOB F.RS, HEATERS, TANKS and 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 such posted notice, the
inspection will not be approved and a reinspec ion fee will be charged.
SignaturelLV_ ;‘
0 e r •r Agent Contractor
' r
The foreg . k ins o ed b fo m s t ,i ,� The foregoing instrument was acknowledged before me this
day o - 1 V ° i W'4 - - day of , 20 _, by
Signature
w
ment was ac
11, by
Tally k no
ed
o me or who has pr
identification and who did take an oath.
NOTA
Sign:
Print:
PUBLIC:
My Commission Expires:
APPROVED BY
who is personally known to me or who has produced
as identification and who did take an oath.
-et\ 't‘ftrirs NOTARY PUBLIC:
•
Sign:
Print:
My Commission Expires:
`1 /Plans Examiner Zoning
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
Clerk
.SAC
PRODUCER Admiral Insurance, Inc.
17340 NW 27th Ave.
Miami Gardens, FL 33056
Phone (305)621 -2939
CERTIFICATE OF LIABILITY INSURANCE
Fax (305)621 -1370
INSURED JOE LEWIS SPECIALITY SE TIC LLC
3075 SW 61 AVE
Miramar,FL 33023
COVERAGES
DATE (MMIDDIYY)
09 24'11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURER A. AMERICAN VEHICLE
INSURER B:
..._......_ .....
INSURER C:
INSURER D:
INSURER E:
INSURER F:
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
x LTR NERD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POOATEE E%IDDIYYI LIMITS
LTR INSRD . S drr1 ' iNl11/�/YY)
GENERAL UABIUTY EACH OCCURRENCE RENTED
J COMMERCIAL GENERAL UABILI Y 08-12551 09 241 0 09 24 11 PREMLSES TO occurenceL
MED EXP (Any one person)
CLAIMS MADE V OCCUR
A PERSONAL 8 ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER / MEMBER EXCLUDED?
If yes. describe under
SPECIAL PROVISIONS below
OTHER
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
(Per accident)
AUTO ONLY - EA ACCIDENT
OTHER THAN E ACC
AUTO ONLY: AGG
EACH OCCURRENCE
AGGREGATE
WC�STATU- OTH-
TOR_. LIMITS . ER__
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE'
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
10050 N.E. 2nd Avenue
Miami Shores, fl. 33138
ACORD 25 (2001 /08) QF
100,000
10,000
100,000
100,000
100,000
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE TO DO SO SHALL IMP • A • N OR LIABILITY
OF ANY KIND UPON THE INSURER, [MASERU OR REPRE' • ATIVES.
AUTHORIZED REPRESENTATIVE
ANGELO R. LAVEZGCHIA
ORD CORPORATION T988
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Anthony & Heather Zibelli
PROPERTY ADDRESS: 400 NE 102 St Miami, FL 33138
LOT: 12
PERMIT #: 13 -SC- 1303391
APPLICATION # : AP995447
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR836391
BLOCK: 91 SUBDIVISION: Miami Shores
PROPERTY ID #: 11- 3206 - 017 -0620
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MOST 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 [ 900 ] GALLONS / GPD CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS m[ ]DOSES PER 24 HRS #Pumps [
D
R
A
I
N
F
I
E
L
D
O
T
E
E
[ 225 ] SQUARE FEET SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [X] TRENCH [ ] BED [ ]
LOCATION OF BENCHMARK: F.F.E.: 11.97' NGVD.
ELEVATION OF PROPOSED SYSTEM SITE [ 22.60 (1 INCHES I/ FT ][ABOVE4 BELOWIIBENCHMARK /REFERENCE POINT
[ 58.60 3 [1 INCHES i FT ] [ ABOVE /I BELOW h BENCHMARK /REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED:
[ 0.00] INCHES
EXCAVATION REQUIRED: [ 36.00] INCHES
1— Existing 900 gal. septic tank certified by " Statewide Septic Connections Inc," on 02/21/2011 to remain. 2- Install 225 sf
of drainfield in trench configuration. or the maximum available space for the trench system. 3- Perimeter of excavation area
shall be at least 2 ft wider and longer than the proposed absorption trench. 4- Invert elevation of drainfield to be no less than
7.58' NGVD. 5. Bottom of drainfield elevation to be no less than 7.08' NGVD.
THIS PERMIT IS NOT FOR ADDI
R
SPECIFICATIO
APPRO
DATE ISSUED:
Pedro N Ospina
02/28/2011
TITLE: CHD
1'
EXPIRATION DATE: 05/29/2011
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1 ,1.4 AP995447 $E837314
Page 1 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION P
Permit Application Number
PARrIl - SITEPLAN
Scale: Each block represents 10 feet and 1 inch = 40 feet.
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Notes:
bel - 400 PI E O2 31
g
ci O�- ---r-10 %n-Reid 220
v; l
Site Plan submitted by :'
Plan Approved
By
Signature
'2-3 i Co -4c.. ,
Title
Date
County Health Department
-=Ii• roved
ALL CHANGES MUST BE APPROVED BY THE.COUNTY HEALTH DEPARTMENT
pH 4015,10/96 (Replaces HRS -H Form 4016 which may be used)
(Stock Number. 5744002- 4015 =6),
Page 2 of 4