PW-11-1800t
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 164992
Scheduled Inspection Date: November 18, 2011
Inspector: Hernandez, Rafael
Owner: SHORES VILLAGE, MIAMI
Job Address: 1502 NE 102 Street
Miami Shores, FL 33138 -0000
Project: <NONE>
Contractor: LASSETER PLUMBING CO INC
Permit Number: PW -9 -11 -1800
Permit Type: Public Works
Inspection Type: Final
Work Classification: Public Works
Phone Number 305/751 -1271
Parcel Number PUBLIC WORKS
Phone: (305)525 -5075
Building Department Comments
INSTALL 3/4" PRESSURE VACUME BREAKER ON
SPLINKLER SYSTEM
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
November 17, 2011
For Inspections please call: (305)762 -4949
Page 4 of 7
NCV 5 -2011 14:45 FROM:
ag V3
`_ hull
70:3058937852 P.3 +3
MIAMI -DADE WATER & SEWER DEPARTMENT
METER OPERTATIONS & MAINTENANCE
CROSS CONNECTION CONTROL UNIT
1001 N.W. 110 STREET; MIAMI, FL 3313•2219
Phone (305)54740 6 ? Fu (305) 54S-95U5
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
evHSEi6:
www.mlamtdade.govI e8dlback Iow.aap
I, kirro
.,, SONTACT.
GHM► hir e C t 1 .7 � ,
NM
j s‘,.
, ,. „. of i,a,4 A #
a. 1r
2
1) I 1 Jr/
. d JO .;
° 61”. .7e3.7 /
BM
3
TNT Kftame.
!hi 0 Ge ie�
`.3�
„3as =`!/
>E , .1/
..
•. ;�: :: +. ., :, ' ' • °c . ' '- * .
mAIID OT M
(4.184-71"5
.f w } 7 :,
60 11.1 c .r T'r
. <I 'L, "7gi ,siP
77 577
r;��} -
Jr,
LOTH -, OF ASSEMBLY:
s a-
PRC61.3URE STABLE. YES • NO
INITIAL TEST: ANNUAL TEST: L/""'
iiiiiEREMIIIIVii7WAIIIIIIII
SNWfAVALYE11;
NUM Vil a
CLOSED TIGHT:
CLOSED TIGHT: .it
_-
LEAKED:
LEAKED:
LINE PRESSURE C)
• ...r C�• '. - ^i % ;c V1 t
CHECK VALVE NO. 1
Iy. . • 4 t i't �. a ,..y- Y a-1;
CNNECX VALVE NO. 2
4-17�'.Y
OIFFERENTIAL RELIEF VALVE
s .h v,."s �,.c'',
CKECKVALVE
Closed Tight:
Closed Tight:
LEAI(ED
FAILED TO OPEN:
inaly
Leaked:
Leaked:
_.._,
(WISED - EDAT: PSI
(PERM AT:
3•
HELD AT:
p
PRESSURE OU+tFERENRlL ACROSS l31ECR
PSI
PRESSURE DIFFERENTI L ACROSR CHEN
PSI
fa, a n. ? c-,.. 3.`. "- `L.
,. .,;,'=7 j
REMARK$
REASON OR FAILURE (IF AP PARENT): z !
• •,t. _
y
k' ^ +,1.?.. . , c!IYP
r 'AHED: •
`t 2} l a .1" ,? ' '-i . m
CLEANED:
k4. r:1-' i
CLEANED:.
CLEANED:
REPLACED:
REPLACED:
REPLACED:
REPLACED:
..
• ' ..l? x% ':al. : 7r• k!� uox r. P -`;
— .. rz .. -��'+'"�G�?3kit`5�`�.SY,
CHECK VALVE NO. 1 CHECK VALVE NO. 2
t 7 . • 4 +1 4L ti, ,,-. fi -- 7�}tr�! ' tv .-.,. —
J !.:1 �;.t',�} SCI R- ZG' �:1[!'7 J.'- .�tch'�,f�'F�'�h�t �+1- "'�Y�m
OIFPEREPRIAL oEuEF vAtvE NR NET
C1IECKVALVE
y
Closed Tight: •
Closed Tight:
FAILED TO OPEN: Ramo cont
LEAKEHx --
Leaked: _ - -- —
Leaked:
OPENED AT: PSI
OPENED AT:
REID AT:
PSI
_
PKEssuRE DIFFERENTIAL ACROSS CHECK PRESSURE MENE *.ACROSSCIIE01
PSI CSI
:i• '
�1•, '.
1 ' ,,,, .f.1iK:r a t ,,;, t v� , r °' t ai ` ' : j ' v Z "7g�r6 ,
% Ai• I �' ` ��� ,y l� �'w � � iY { yY' i . �. .. p� tt' .#r. +q41. '.
f: ``% i l �` - pct • ..sr 1 . '1 ! it ..
_,'�1� �� � � Y A, iY...tL^.J:� m'Sn �` t 1- i�it'�3�� t �,� :•' y�r !'1a -. - r. _ �l • x..
F
,J�
: s ;_: � Y }
. •.-
F.,- . I %, O&Y:
DATE:
evHSEi6:
www.mlamtdade.govI e8dlback Iow.aap
Miami Shores Village �7l
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
Permit o. Pli° I
e tN
Master Permit No.
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: PLUMBING 1�p�
OWNER: Name (Fee Simple Titleholder): lVl ► r I �� Y ne #:
N1\
Address: / 113 IN/I
City: j,\ a
State:
Zip: )
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: (S ®OZ. 1\./ E ( O
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #:
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: LASS r i E `g '10 vvvb tt,' J Phone #: 305.
` 63(73 -1"1(€30
Address: 4 'S A) E _3.0 57-
City: ?es . 1 .4 t • pt it". ■ t , State: rc- • zip: 3
Qualifier Name: (.3 O t-x. Jai M. LA S S e°7- t------
Phone #: 3l9 b'...2.' i.�
State Certification or Registration #: 6 Fe. ef) 4 ( to 9 (r. Certificate of Competency #:
Contact Phone#: Email Address: LASS S e. -t-e Z •plvwlb 4 r%9 3 6 47 °-
DESIGNER: Architect/Engineer: - , } Phone #:
O
Value of Work for this Permit: $ g--5-c-' • a Y, Square/Linear tFootage of Work:
Type of Work: DAddress OAlteration ❑ w ORep'atir/Replace ODemolition
o1 Work 24) S r-4 t✓ (_ / '
4 ,a; k C5 ..r ® .mod.
4,
******** * * ************rx* **** ***** * * *** Fees***** ** * ** * ***** ** * '' *** *************** **
Subn4ttal Fee $ Permit Fee $ /690 CCF $ CO /CC $
Scans ng Fee $ Radon Fee $ DBPR $ Bond $
Not $ Training/Education Fee $
Dou a Fee $ Structural Review $
Technology Fee $
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, BOILERS, 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 of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Owner or Agent
The fo ... in; instrument was ackn . 1
fiday o _1_ ,2011 , by
who is personally known to me or who has produced
As identification and who did
NOTA ' Y ' UBLIC: • `
Sign: Sign:
Print: �o� v ��goJ Print:
• ° ° "' "• - State of Florida
My Commission Expires: My Comnuss ^ Notary
Signature
Contractor ,�
The f. - _oin� strument w s ackn 1^ ged befor n- thi
1 y� 4'
, day of L� , 20 , by
y-- r
o is pers`�nally„known to me gr who has produced `t' 1
ion and who did take an oath.
NO LA' Y ' BLIC:
41'
.
Public 23, 2018
r , TS • MY Comm. Expires Sep Comm
fi ' * i Commission # EE 128810
Comm
•••,,��'h�• � %; o�� °p`'� Bonded through National Notary Assn.
* ******** ***** *mix ***** ****** ** ** ****** ***** * *** ** **** ********** ****** ete #o ' Notary Ass ,
APPROVED BY Plans Examiner Zoning
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Clerk