PL-11-2030Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 166147 Permit Number: PL -11 -11 -2030
Scheduled Inspection Date: December 14, 2011
Inspector: Hernandez, Rafael
Owner:
Job Address: 9899 NE 2 Avenue
Miami Shores, FL
Project: <NONE>
Contractor: HANLON PLUMBING CO
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060134360
Phone: (305)824 -5575
Building Department Comments
INSTALL NEW BACK FLOW PREVENTER
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
December 13, 2011
For Inspections please call: (305)762 -4949
Page 17 of 53
MIAMI •DADE
COUNTY
MIAMI -DADE WATER & SEWER DEPARTMENT
METER OPERATIONS & MAINTENANCE
CROSS- CONNECTION CONTROL UNIT
1001 N.W. 11TH STREET, MIAMI, FL 33136 -2209
Phone (305) 547 -3046 • Fax (786) 268 -5485
PREVENTION ASSEMBLY TEST REPORT FORM
BUSINESS ADDRESS:
EXPIRATION DATE:
0
4
LOCATION OF ASSEMBI:
DATE LAST CAL.
/t1 QLe_)
ZIP CODE:
SITE TUBE:
YES / NO-
INITIAL TEST: xe
ANNUAL TEST: `
SHUT OFF VALVE #1:
CLOSED TIGHT: )`
LEAKED:
SHUT OFF VALVE #2:
CLOSED TIGHT: '.(
LEAKED:
Closed Tight:
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI.
METER READING:
PRESSURE STABLE
NO
Closed Tight:
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI.
FAILED TO OPEN
OPENED AT: PSI.
AIR INLET
FAILED
TO OPEN
OPENED AT:
CHECK VALVE
LEAKED:
HELD AT:
{•2 PSI
THIS
REMARKS / REASON FOR FAILURE (IF APPARENT):
co
cc
a
W
cc
CLEANED:
REPLACED:
CLEANED:
REPLACED:
CHECK VALVE NO. 1
Closed Tight:
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI.
SIGNATURE OF CERTIFIED TESTER:
CLEANED:
REPLACED:
CHECK VALVE N0.2
Closed Tight:
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI.
CLEANED:
REPLACED:
DIFFERENTIAL RELIEF VALVE
FAILED TO OPEN
OPENED AT: PSI.
AIR INLET
FAILED
TO OPEN
OPENED AT:
PSI.
CHECK VALVE
LEAKED:
HELD AT:
PSI
NOTE: TEST FORM MUST BE C • MPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL BE RETURNED.
110_01 -158 8 /09 www.miamidade.gov /wasd /cross- connection.asp
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
RECEIVED
NOV 01`2011
d ai
BUILDING Permit No. t LI I — 203D
PERMIT APPLICATION Master Permit No.
FBC 20
• Permit Type: PLUMBING
z Avv�ew��e 1
OWNER: Name (Fee Simple Titleholder): 5 0 LIT KT RI .57 3��cK� Ad 5 ° 5-2-4 X575
Address: F_ ® ,Bb ,BN 2440 M5 41 I SITE_ 1435110
City: 5 POK 4NE State: V)A Zip: 992.10 - /'440
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 98 -1-1 14 E. 2ND AVEM LLE.
City: Miami Shores County:
Miami Dade
zip: 33138
'Folio/Parcel #:
Is the Building Historically Designated: Yes NO Flood Zone:
1Qt- J t 7 - 2 3(cG
CONTRACTOR: Company Name: 1-1ANLot4 PLtthA61N& s , Phone #: 3o - [324 -5575
Address: M WA/ 1544, STREET # 563
M
City: )AMM. i LfKE5 State: FL Zip: 33 014
Qualifier Name: EiztC J , J 1* .5ON Phone #: 305 - 9.5i q — rG i o
State Certification or Registration #: i:' t'.—C.f.. ! q 2.8 19 3 Certificate of Competency #:
Email Address: at}1V LQN9L.0 a N + �r}TT, NET Contact Phone #:
DESIGNER: Architect/Engineer: Phone #:
e° 1<'iVi;A i'tS ` $ a DD'. °?= Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
tiWti13'b ` . Xpi.5/ /r ofp. 764'% - F a,r-' 7- --
7,-o r"
***********+ a** ************ **** * ******** Fees* *****w **+ x* ********+ x+ x*********,x****** *******
Submittal Fee $ Permit Fee $ .4)0 CCF $ _ '° CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ � /�
TOTAL FEE NOW DUE $ (O. O
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage, 'tender's Address
s
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 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 ° t be approved and a reinspection fee will be charged.
Signat
Signature
Owne or Agent / Contractor
The foregoing instrument was acknowledged before me this 5® The foregoing instrument was acknowledged before me this 3'
day of 4a , 20 IL, by 14. OA ,L9 , day of MAY , 20 LL, by ERIC—D o c T ®Hi4 s®,4 ,
who personally known'. me or who has produced who •
As identification and who did take an oath.
NOTARY PUBLIC:
nt:
My Commission Expires:
APPROVED BY
* MYMISSION DD NOM
EXPIRES: AptII 12, 2014
Bonded TM Budd Natal SeMoes
me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
/(Z " Plans Examiner
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
-Sign:
Prin
My Commission Ex
IN COMM NI KA A9I"
Q EXPIRES: dctober 23,-2014
'
d.
7 r F y P B edDiu Bildgd May Swims
Zoning
Structural Review Clerk
AWRI
CERTIFICATE OF LIABILITY INSURANCE
OP ID: TR
DATE BIONODANYY)
10112111
THIS CERTIFICATE IS ISSUED 'AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTRICJITE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISS1MIG INSURERS), AUTHOREED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the centre -holder Is an ADDITIONAL INSURED, the poitrylies) must be endorsed. if SUBROGATION RA WAIVED, wubyrct to
the terms and condHHons of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certittcate holder to lieu of such endorsementfsl.
PRODUCER 954- 616 -1800
Roebuck Associates insurance g.616 -1
Exchange LLC
5599 5 University Drive, 0 301
Davie, FL 33328
Roebuck Associates
CONiAl,r
I'Flt)NE
fAfG, Ne, Eae:
I FAX
,Na):
ADDRESS:
PRODUCER ,i HANLO -1
INSURERS) AFFORDING COVERAGE
NAIL E
INSURED
Hanlon Plumbing Company
8004 NW 154th Street, # 563
Miami Lakes, FL 33016
INSURERA: Accident Insurance COMpany
INSURER B : Technology Insurance Co
INSURER C : Nautilus Insurance Company
INSURER D :
INSURER E :
IN$I MFR F
.T1 1 Ri_:.__ _t1_
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 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 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
A
GENERAL LIABIIJ IY
X COMMERCIAL GENERAL LIABILITY
1 CLAIMS -MADE fl OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
7 POLICY fl . 1 1 LOC
AUTOMOBILE LIABILITY
ANY AUTO
_ ALL OWNED AUTOS
SCHEDULED AUTOS
^_ HIRED AUTOS
NON -OWNED AUTOS
M ids _,� - i_i;;l 9i IrifJ2ell eel
91713
06/26/11
R
LINTS
06/26112
EACH OCCURRENCE
$ 1,00
nJI
DAMAGt TO REMED
PREMISES (Ea occurrence)
MED EXP (My one person)
PERSONAL & ADV INJURY
GEb ERAL AGGREGATE
PRODUCTS - COMP/OP AGG
100,
5,
UI
$
_$
nor
III
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person) $
BODILY INJURY (Per eoc dent) $
PROPERTY DAMAGE $
(Per accident)
J UMBRELLA LIAB u occuR
X EXCESS LIAB �II�11 CLAIMS-MADE
DEDUCTIBLE
B
ON
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y N
ANY PROPRIETORiPARTNERiEXE(JTIVE
OFRCERIMEMBEROCCLUDED?
(Mandatory In NH)
It yes, describe under
!.�.'-.. WA: • •;J4L 1 •.L_ !�
NIA
150
EACH OCCURRENCE
02118111 02/18 112 AGGREGATE
C3290319
M 2033
10/16111 10/161.12
10/1 6110 10/16/11
X
TORY L
ITS
X
EL EACH ACCIDENT
1,000,
11..:1..
EL DID- EA EMPLOYEE
,000l 11
EL DID - POLICY LIMIT
1 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Ariech ACORD 101. Additional Reinerke Schedule, Nf more plate Is re4u Ired)
1171., 1 .. a
Miami Shores Vie
Building Dept
10050 NE 2nd Ave.
Miami Shores, FL 33138
ce.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
AccORDANCE 1RtITHTHE POLICY PROVIS$ONS.
AUn{ORDIYTAT1VE
ACORD 25 (2009109)
X71818 -2009 ACORD CORPORATION. Ail rights reserved.
The ACORD name and logo are registered marks of ACORD
WL F-._I
•
- C0UNTY`
March 24, 2011
SOUTHTRUST BANK NA
CIO ADVANTAGE I ! y S �p
PO BOX 2440 MS 411 5144,
SPOKANE, WA 99210 -2440
Re: Required Backflow Prevention Asserbly installation.
Account No: 0944315200
Service Address: 9899 NE 2ND AVE
MIAMI SHORES, FL
SPRINKLER COMMERCIAL
Type Required: Pressure Vacuum Breaker
Date Required: January 1, 2012
Water and Sewer Depart/Mt
Cross-ConneclionControl
1001 NW 11 th Street
Miami, Florida 33136
T 305-547-3046 F 786-268-5485
Dear Customer.
has brought to the i of the Miami -Dade Water
An inspection of the above referenced property prevention assembly at meter service
and Sewer Department, the need to install a backfow pr rohat contamination service
of
connection. A Backflow Prevention Assembly is a mechanical device p
the public water supply system.
This letter is a way of providing you, our customer, notification that under Section 32-154 of the Miami -
Dade County Code, a backflow prevention assembly of the type fisted above is required to be installed,
by the above-mentioned date. Failure to comply
could result in a fine of $100 per day. A copy of this
rule may be found on on -line at www.miamidade.00v rvasdlcross- connectlan.aso.
the assembly must be tested to ensure proper operation and the
Upon completion of the installation, 85,
backflow prevention assembly test form must be sent to the above address, or faxed to (766)
If you should require any further assistance, or if you have any questkms, please feel free to contact
this office at: telephone (305)
547-3046 or by e-mail at °'°C1m�m
Your prompt attention to this matter is greatly appreciated.
Sincerely,
Cross - Connection Control Program
cc: File
PRINTED MTN
ENENIONMENTALLY
FRIENDLY GREEN DNS
,sota
FSC
Med Sources
City of Hialeah
Business Tax Receipt
Mayor Julio Robaina
2010 -11
•
-FIRST. 4
'U.L'PDSTAGE
=.w _.
DO NOT FORWARD
HANLON PLUMBING CO
WILLIAM D JOHNSON PRES
8004 NW 154 ST *563
MIAMI LAKES FL 33016
PHONE 305-824-5575
••
FAX 305-824-3397
PLUMBING Co.
PLUMBING, HEATING & REPAIRS
TWARV35
140V 0 1 20U V.)
t
6 Ps4 .......
Lji 7_,636.
;
3
JUJFCT TO COMPLIANCE WITH ALL FEDERAL,
sl ANn COUNTY RULES AND REGULATIONS
QUAL! F 1FR NAMF
ER 1 CJ OHNSON
CFC 11+28193
JOB ADDRESS
9899 NE znd AVE
MIAMI SHORES, FL.
TEST COCK
METER
VAULT
PLAN VIEW
1
H
{1 i
ii
CONC. SUB wnH#4Al2'EN
ELEVATION VIEW
a oEra 11154.5 xx o 0
CROSS ITEM SPEC.
Rff.
APPROVED 11Y
11/01/2006
V.EF.
STANDARD DETAIL WS
PRESSURE VACUUM BREAKER 4,19
IRRIGATION SYSTEM ONLY sr 1 OF