PL-11-1803Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
k 1S'R
Inspection Number: INSP- 165018 Permit Number: PL -10 -11 -1803
Scheduled Inspection Date: October 11, 2011
Inspector: Hernandez, Rafael
Owner:
Job Address: 180 NW 103 Street
Miami Shores, FL 33150-
Project: <NONE>
Contractor: MIAMI DADE ENVIROMENTAL
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)825 -7080
Parcel Number 1131010230020
Phone: 786- 251 -4099
Building Department Comments
INSTALL 500 SQFT OF DRAINFIELD
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
October 07, 2011
For Inspections please call: (305)762 -4949
Page 13 of 22
a.rt Ede
i
APPLICANT: -
AGENT:
PROPERTY ADDRE
LOT: °/- BLt
CHECKED [X] ITE
TANK INSTALLATION _,7
[01] TANK SIZE [1]../---((/ [2]
[02] TANK MATERIAL!-
[03] OUTLET DEVICE �a
[04] MULTI - CHAMBERED [Y hN ]
[05] OUTLET FILTEF1717 �,- %:''�=
[06] LEGEND "Viq
[07] WATERTIGHT ff
[08] LEVEL
[09] DEPTH TO LID
DRAINFIELD INSTALLATION
[10] AREA [1yc [2]• SQFT
[11] DISTRIBUTION BOX HEADER "'f
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER,/,
[16] ELEVATION [ABOV' BELOW)7BM
[17] SYSTEM LOCATION ESe_
[18] DOSING PUMPS
[19] AGGREGATE SIZE A/ 7r-‘9.-
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH /k/1/Li.-4
f
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT %%
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
SETBACKS
] [27] SURFACE WATER FT
] [28] DITCHES FT
1 [29] PRIVATE WELLS FT
PUBLIC WELLS FT
] [31] IRRIGATION WELLS FT
r [32] POTABLE WATER LINES ,40( FT
(] [33] BUILDING FOUNDATION 6 FT
[ [34] PROPERTY LINES / 3 FT
[ ] [35] OTHER FT
1 [30]
FILLED'/ MOUND $YSTEM
[36] DRAINFIELD COVER
[37] I SHOULDER'S
[38] SLOPES
[39] STABILIZATION -
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
4] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING, %1 s i
[47] CONTRACTOR22e° ,.-,(��
[48] OTHER
ABANDONMENT
[49] TANK PUMPED
[50] TANK CRUSHED & FILLED___._ /
[
1 s)L 1
[
[ )
[
CONSTRUCTIOIAPPROVED/ ISAPPROVED]:
"a. CHD DATE] T) //
CHD DATF/' -- 7- / ! /
Page 2 of 3
DISAPPROVED]:-"-fr)_1
OH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number: 5744- 002 - 4016 -4
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
Regded LS Pup,
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Parcel Number
Applicant
180 NW 103 Street
Miami Shores, FL 33150-
1131010230020
Block: Lot:
ALION PROPERTIES LLC c/o JA
Owner Information
Address
Phone
Cell
ALION PROPERTIES LLC c/o JAVIER VA 6500 COWPEN Road
MIAMI LAKES FL 33014-
(305)825 -7080
6500 COWPEN Road
MIAMI LAKES FL 33014-
Contractor(s)
MIAMI DADE ENVIROMENTAL
Phone
786- 251 -4099
CeII Phone
Type of Work: DRAINFIELD
Type of Piping:
Additional Info:
Bond Retum :
Classification: Residential
Scanning: 1
Fees Due
Bond Type - Contractors Bond
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$500.00
$3.00
$2.25
$2.25
$1.00
$150.00
$3.00
$4.00
$665.50
Pay Date
Invoice #
10/03/2011
10/04/2011
Pay Type
PL -10 -11 -42171
Credit Card
Credit Card
Bond #: 2074
Amt Paid Amt Due
$ 50.00 $ 615.50
$ 615.50 $ 0.00
Available Inspections:
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in comp;
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the prof
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes
required for ELECTRICAL PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL wor
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in com
construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated.
ince with all ordinances and regulations
ar authorities of Miami Shores Village. In
I understand that separate permits are
c.
?liance with all applicable laws regulating
Octo er 04, 2011
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
October 04, 2011
"Date
1
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
Permit No. Ski rar7
Master Permit No.
Permit Type: PLUMBING 9 (� n
OWNER: Name (Fee Simple Titleholder): f to ate f°hi+� 1 —p
t e5 Phone #: 30S° a 241-7 �sA
Addres s Go c Ce Ak..p A tin 7 .- P t Ak i 1141,24 P/ 4 ?� O
City: Mink( / tt e State: ieL e(
Zip: 3611
Tenant/Lessee Name: �i f Phone #:
Email: 9�
JOB ADDRESS: / go Amy • (b �r
City: Miami Shores
Folio/Parcel #: f/ IC(—. :' 2 .0021)
Is the Building Historically Designated: Yes
County: Miami Dade
Zip: , 3 / SD
NO � Flood Zone:
CONTRACTOR: Company Name: {!'((10 { 1 IS N ELM two) M e I to i, Phone #: 7 &G 23 I - LI C3 ?9
Address: R290 L (Q R P l� s ( 33 (1
City: /I Ka 1 State: �`!i� Zip: 3 (Gc,
Qualifier Name: &S R l Iii kM 3 Phone #: 786. 2_ 51- 14099
State Certification or Registration #:s(k .O9-1 .11 Certificate of Competency #:
Contact Phone #: 7& . � I - (f ® C/9 Email A dress: /t 4 (la/Q (� a II FICe%(¢( 0� Stil -.( %'1
DESIGNER: Architect/Engineer:
N g-
Phone #:
Value of Work for this Permit: $ j S00 Square/Linear Footage of Work: SOO
Type of Work: ❑Address UAlteration UNew air/Replace UDemolition
Description of Work: / ILIS°T(& V1 A-500 Ste.(f ®r on . l ri 1(e�
* * * * * * * * * * ** *. *******+x***** **** * **/ *� *** Fees�x�x�x+ x�:* �x: ��u�x�x* �xx��x* �x�x�x�x�x *** * *** **** **�x�x+x**** ***
e kto Submittal Fee $ ��` ° Permit Fee $ `�� CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ (61SM
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, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AN'N'IDAVIT: 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 fi inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspecti a -a proved and a reinspection fee will be charged.
Signa
The fore
day of
Owner or Agent
oing instrument was acknowledged before me this
,201 ,by�lJtt A-2q0ey
ts)
who is p rsonally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Pri
y Commission Expires:
APPROVED BY
JOSE R. BOLANOS
N e oe Flodda
-5
Signature
Contractor
The egoing instrument was acknowledged before me this -3
y of t, 20 if , by �ZSo �1r 'ii�� // ` ,��� O.
who is personally known to me or who%ocucll g
as identification 1d whdc{iVdt le 1 oath.
3I180d ANY1011
j 1L0/190I €0
sev, Plans Examiner
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Structural Review
NOTARY PUBLIC:
Sign: �� ;'� / S
Print:
My ommission Expires:
Zoning
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: (Alon Properties)
PERMIT #: 13-SC-1368778
APPLICATION #: API 046979
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR855300
PROPERTY ADDRESS: 180 NW 103 St Miami, FL 33150
LOT: 4-6
BLOCK: 1 SUBDIVISION: Bonmar Park
1
PROPERTY ID #: 11 -3101- 023 -0020
[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 [ 750 ] GALLONS / GPD Septic existinq CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ 1
D
R
A
I
N
F
I
L
D
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
[ 500 ] SQUARE FEET SYSTEM
[ ] SQUARE FEET N/A SYSTEM
TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [x] BED [ ]
LOCATION OF BENCHMARK: C/L NW 103 St: 10.67' NGVD
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED:
[ 2.04 111 INCHES I FT ] [ ABOVE /I BELOW I1 BENCHMARK /REFERENCE POINT
[ 32.04 ] [ INCHES I FT ] [ ABOVE /I BELOW ]1 BENCHMARK /REFERENCE POINT
0.00] INCHES EXCAVATION REQUIRED: [ 72.00] INCHES
- Install 500 sq ft drainfield.
- Install 42" of slightly limited soil under bottom of drainfield.
- Elevation of bottom of drainfield to be no less than 8.0' NGVD.
- Existing 750 g septic tank, to remain.
Joseph R Piverger
R Piv ='. ger
7/20
TITLE: Engineer Specialist II
ngineer Specialist II
DH 4016, 08/09 (Ob, 1, =tes all previous editions which may not be used)
Incorporated: 64 003, FAC
v 1.1.4
Dade CHD
EXPIRATION DATE: 03/27/2013
AP1046979 SE852907
Page 1 of 3
10/06/2008 23:59 9545800576 JW DESK PAGE 01101
°'°r_ _ CERTIFICATE OF LIABILITY INSURANCE OATE(MMUDDIYY)
_ 10/03/11
PRODUCER JW Insurance Services I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
100 North State Road 7, # 108 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Margate, FL 33063 ALTER THE COVERAGE AFFORDED 13Y TTHE POLICIES BELOW,
Phone (954)683.7213 Fax (954)583 -2045 1 INSURERS AFFORDING COVERAGE
• NAIC #
INSURER A., Atlantic Casueli�i
INSURED Miami Dade Environmental Services, Inc.
8290 Lake Drive Ste #334
Miami, FL 33166
COVERAGES _ ' INSURER F:
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAM- E- D 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 Au. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR Aim . —
LTre,! DD L TYPE OF INSIiRANGE POLICY NUMBER, �(P�_O_Li Y EFFec IvE ; POUOY EXPIRATION
DA E (MWDONN) • DATE (MMIDD LIMITS
GENERAL LIABILITY --
EACH OCCURRENCE 1,000,000
l% COMMERCIAL GENERAL LABlLnY DAMAG 'TO REN 1'ED
L039002057 : 07/22/11
07/22/12 s PREMISES �a occursnce)
MED EXP (Any one person)
A
INSURER B:, — —
INSURER C:
INSURER D:
INSURER E:
=LJ CLAIMS MADE OCCUR
PERSONAL & ADV INJURY ':
— _ i GENERAL AGGREGATE
' GENT. AGGREGATE LIMIT APPLIES PER:.
:]Ci POLICY ;_ PROJECT I LOC
AUTOMOBILE LIAssiTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR L • CLAIMS MADE
DEDUCTIBLE
rl RETENTION $
WORKERS CO i4PENSA`nON AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR / PARTNER 1 EXECUTIVE
OFFICER / MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
OTHER
•
i PRODUCTS - COMP /OP AGG
Fire Damage. Liability
• COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per peen)
BODILY INJURY
{Per accident)
PROPERTY DAMAGE
(Per accident)
I AUTO ONLY - EA ACCIDENT
OTHER THAN EIAACC •
AUTO ONLY: AGG
EACH OCCURRENCE
AGGREGATE"
5,000'
1,000,000
2,000,0001
1,000,0001
100,000.1
•
•
=- o�p = f RYU _
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE;
E.L. DISEASE - POLICY LIMIT —
DESCRIPTI IN OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED Y ENDOR5EMENT/ SPECIAL PROVISIONS
* * SEPTIC TANK CLEANING & INSTALLATION, SEWER & STORM DRAIN CLEANING'`*
CERTIFICATE HOLDER
Village Of Miami Shores Building Dept.
10050 NE 2nd Ave,
Maim' Shores, EL 33138
Fax 305 756 -8972
ACORD'25 (2001108) CIF
CANCELLATION
•SHOULD ANY OF THE ABOVE DESC,BIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, T - SUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN N • r TO THE CERTIFICATE HOLDER NAMED TO
; THE LEFT, BUT FAILURE *• SHALL IMPOSE NO OBLIGATION OR LIABILITY
. OF ANY KIND UPON ITS AGENTS OR REPRESENTATIVES.
0 ACt RD CORPORATION 1988 ..
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
' CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE: 10/26/2010
PERSON: JOSE BOLANOS
FEIN: 820553271
BUSINESS NAME AND ADDRESS:
MIAMI DADE ENVIRONMENTAL SERVICE INC
8290 LAKE DR 8334
MIAMI, FL 33166
SCOPE OF BUSINESS OR TRADE:
1- SEPTIC TANKS
EXPIRATION DATE: 10/25/2012
Registered Septic' Tank Contractor
SR0971276
JOSE BOLANOS
8290 LAKE DRIVE SUITE 334
RAL FL 33166-
MIAMI DADE ENVIRONMENTAL
SERVICE, INC.
Business Authorization: SA0091617
Registration Expires on September 30. 2012
retxto
FT-EST0 R
W. -
-0.''I'Afil°0-R LER St
L 3313Q
2011 LOcAIBL., 201
AVE!) AT PLACE 0;1-
PURSUANT TO
, UNTY COOF '`HAPILP
ZONI
0014
COES
..c,.
DO NOT FORWARD
MIAMI DADE ENVIRONMENTAL SERVICE
INC
JOSE BOLANOS PRES
8290 LAKE DR 334
DORAL FL 33166
11,11„,ii„„ndiumini„sin„imitia„1,,..)011.1