PL-11-893Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 167127 Permit Number: PL -5 -11 -893
Scheduled Inspection Date: December 09, 2011
Inspector: Hernandez, Rafael
Owner: KIM, PHILIP
Job Address: 173 NE 105 Street
Miami Shores, FL
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1121360050150
Phone: (954)963 -0082
Building Department Comments
REPLACE DRAINFIELD ON SOUTHEAST CORNER OF
PROPERTY
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP- 159866. HRS IN FILE missing
sod
December 08, 2011
For Inspections please call: (305)762 -4949
Page 11 of 14
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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 No. P 5- i t- If 9.3
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): P k j I; F4 Phone #:
Address: n5 N E loS
City: t.-A Silo red State: Zip: 39
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 1`1 h 10 5 St
City: Miami Shores
Folio/Parcel #: t (° 2i '6G-00 S--01 �o
Is the Building Historically Designated: Yes
County:
Miami Dade Zip: 3 3 3 8
NO Flood Zone:
CONTRACTOR: Company Name: S'tc++A\ ckC1 c e-P i C- Crt ■/'"► C Phone#:
Address: `25G 0 & 1-0 26
City: Mtr'e∎'n`1at— State: rt. Zip: 23o 23
Qualifier Name: ` edre,Sc Si:::(o ret Ors Phone #:
State Certification or Registration #: SM0 ct 1 t 26 2. Certificate of Competency #:
Contact Phone #: Email Address: 1
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ 2.2.E Square/Linear Footage of Work: 22S tP
Type of Work: Address DAlteration New epair/Replace ODemolition
Description of Work: Rep( of csL re rot c r' -e 1 d 'Ov
CS4944-Hneci-i- t.CD v n e.r. °Or e le-0 freekj)
* * * * * *** ** **** x***+ x ************+x******* Fees**** ******x: ** **+ x****** ******w*****+x*********
Submittal Fee $ Permit Fee $ / S. CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double 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, 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.
XSignature
Owner or Agent
Signature � `\\'�° '"°"'�a V
Contractor
The forego g instrument was acknowledged before me this 1 1 The fo-goi '; instrument was acknowledged before
day of k, , 20 1 L , by Phi (I? K m , day of
who is personally known to me or who has produced FL ID who is personally own to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign: ..isi .L _d Sign:
Print: (3 Print: t* C" 1'14
' 'l' JESSICA LOPEZ �R �. 1 1
My Commission Expires: :' MY COMMISSION # DD787443 My Commission Expires: �,N9' . 9.4 1'1 c.
EXPIRES AprII 22, 2012 i►`�� �as�
own 39e-Ots3 FtorideNoteryBervrcscan d 100 ,1,t1,
, x*, x,x**** *****x,*a: **x:*****+ * ** *,u :, ***************************************************4; _ •. * *40 ** * ** * ******
APPROVED BY 1 Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Philip Klm
PROPERTY ADDRESS: 173 NE 105 St Miami, FL 33138
PERMIT #:13 -3C- 1350339
APPLICATION #: APB 035994
DATE PAID:
FEE PAID:
RECEIPT #:_.
DOCUMENT #: PRUU44923
LOT: 15 BLOCK: 201 SUBDIVISION:
PROPERTY ID #: 11- 2136 -005 -0150
[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 MAt'ERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT T:t 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 O8.'HER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T
A [
N [
K [
D
R
A
I
N
F
I
E
L
D
0
T
H
R
750 l GALLONS / GPD
1 GALLONS / GPD
] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
SEPTIC TANK
[ 225 1 SQUARE FEET
[ ] SQUARE FEET
TYPE SYSTEM: [x] STANDARD
CONFIGURATION: [x] TRENCH
CAPACITY
CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONE1
]GALLONS @[ ]DOSES PER 24 HRS Pumps (
DRAINFIELD SYSTEM
SYSTEM
[ ] FILLED 1]
[ ] BED [ ]
LOCATION OF BENCHMARK: F.F.E.: 12.20' NGVD.
MOUND [ ]
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
[ 24.00 l [I INCHES FT [ ABOVE /I BELOW II BENCHMARK /REFEI:STCE
[ 54.00 l [I INCHES I' FT 1 ( ABOVE 4 BELOW b BENCHMARK /REFEL:NNCE
FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 30.001 INCHES
THIS PERMIT IS FOR THE NORTHEAST SYSTEM OF THE PROPERTY ONLY. 1— Existing 750 gal. septic tank
cxertified by " Statewide Septic Connections Inc." on 05/08/2011 to remain. 2- Install a 225 sf of drainfield in trench
configuration. 3- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption trenc
4 -Invert elevation of drainfield to be no less than 8.20' NGVD. 5. Bottom of drainfield elevation to be no less than 7.70
NGVD.
THIS PERMIT IS NOT FO
SPECIFICAT
APPROVED B
DATE IS
IONS v" :in': a s147 . r - : � � n .
time of fin
Inspe
res
TITLE:
41/4414i4
I MI Oiluti Uio 1 Iii ' �,,t it
i �s MIXWiRTIOla ,P" 4 ®„
Ali �M�y Iwo +�c,� ^�.Ir,TT11c; '.' moan) file CHD
1 1tlrignitil >ite 4valuelor st omitted. A EXPIRATION DATE:
ton rer� wti. bee assessed i1 the :: :o,itractor Is not 08/14/2011
IffaiiteNerimpdaditions which may not be used)
.001, FAC
POINT
POINT
DH 4016, 08 + (Obs'
Incorporated: 64E-
v 1 -1.4
API03S994
SE844224
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STATE OF FLOFilDA
DEPARTMENT OF HEALTH A '
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PENA/111
-LLI
trv,
Permit Application Number
PART II - SI FEPLAN
Scale: Each block re resents 10 feet and 1 inch = 40 feet.
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Notes:
Site Plan submitted b
Plan Appr• = •
Byt.
gnature
CI) tet4C+00-
Title
Date
County H safth Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
H4015; 10/96 (Replaces HRS-H Form 4016 which may be used)'
ocl% Number: • 5744-002-4015-6)