PL-11-1358Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 168520
Permit Number: PL -7 -11 -1358
Scheduled Inspection Date: January 27, 2012
Inspector: Hernandez, Rafael
Owner: ORTIZ, LAURA & JAVIER
Job Address: 474 NE 95 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: SOUTHERN SEPTIC CONTRACTORS INC
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060140440
Phone: (305)598 -8266
Building Department Comments
DRAINFIELD AND SEPTIC
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- 162553. missing hrs. as
January 26, 2012
For Inspections please call: (305)762 -4949
Page 6 of 17
<� DIVISION Of
Environmental 1
rida Depar atei t o
aanl -Dade County f ea t ►
OSTDS /Well Divis
11805 SW 26 St. Mimi Ft 31
17( 11-135
"Miami Shores Ville
Building Department
2 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
j r : h' Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PETIT A PLICATION
FBC 2004
JUL 2 7-RECD
Permit No. PLI 1 1 3SY
Master Permit No.
Permit Type: Plumbing
Owner's Name (Fee Si ple Titleholder) a%/ /k2 OM- Phone # 7g4- 22.3 - 87,7.4
Owner's Address
City M(J -41/ stile .PS State Zip 33/.3 0
Tenant/Lessee Name Phone #
E -MAIL: Ja,V/v here/.1%k . Aa
419 Ng 95- sT
Job Address (where th work is being done)
City Miami hores Village County Miami -Dade Zip 33 / `a
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company
Contractor's Address
City
Qualifier Name IZ.c
State Certificate or Reg
E -MAIL:
Name Se Sty/1' L Coi.keLuOf5 Phone# 3o1" J 4tT -$2i
iS11-"- S. D e N;esl.uttl
State F1-- Zip rY3I9
3 &11.70 -Q-ft: toff E L Phone # 3 o c. 5"1 • '2.-6 4
stration No. SR ocm1,472,1 Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ 3 00 0. ° O
Square / Linear Footage Of Work:
Type of Work: ❑ ddition ❑Alteration ❑New
Describe Work:
Repair /Replace ❑ Demolition
* * * * * * * **** ********* tY*********** *****Feesx4c*oY****oY********* * ***x *xxxx*****Yicxdcic*****
Submittal Fee $ Permit Fee $� CCF $ CO /CC
try[ ,r r
Training /Education Fee $ Technology Fee $
Notary $
Scanning $
Bond $
Structural Review. $
Radon $
DPBR $ Zoning $
Code Enforcement $ Double Fee $
Total Fee Now Due $3 (ao • go
See Reverse side -+
Bonding Company's Name (if applical
Bonding Company's Address. w�
City State Zip
Mortgage Lender's Name (if applicable) IS J a ,
Mortgage Lender's Address J
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me thhi .
day of , 201 L , by aVrier OI4j z , day of Jv , 20 by
The foregoing instrument was acknow
before me this 9-1
0
who is personally known to me or who has produced who is personally known to me or who has produced tO
as identification and who did take an oath.
NOTARY PUBLIC: \\\\\\`��„ ®i,a ®�y�`�' //
Jae j......,, /� ,.,
Sign: - ' "I Sign: j ' .o1� J/® ''
,: MY COMMISSION # OD 864974 /0,e, Print: ���J I � EE , Print: _ 1/ G : .
My Commission Expires: '"�" �. My Commission Expire. 7.: c./.' V21'
xxxxxxxx xxxx xx4exx xxxx* de 4:xxxaY 9e sYxxxxa: x4exdex4r d:xxic aY rd:xzxacxx4exxd : xx x9exxx xxx xxxxa:xx xxx xx xx/xST. icxg+$aexx r. �S,�.cxxxx xrx
s
/ / / // /,,del P 1 1�\\\\\\\
As identification and who did take an oath.
NOTARY PUBLIC:
3
Bonded Thru Notary Public Underwriters
APPLICATION APPROVED BY: 7-- 29- // Plans Examiner
Engineer
Zoning
(Revised 02/08/06)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT : Javier Ortiz
PROPERTY ADDRESS: 474 NE 95 St Miami, FL 33138
LOT: 2
PERMIT #:13 -SC- 1360957
APPLICATION #: API042422
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR850356
BLOCK: 52 SUBDIVISION: Miami Shores Sec 2
PROPERTY ID #: 11- 3206-016 -0440
[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 MAX 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 Septic CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 300 ] SQUARE FEET SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E.: 10.78' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D
0
T
H
E
FILL REQUIRED:
[ 0.00] INCHES
[ 20.60 ] [I INCHES r FT ] [ ABOVE /I BELOW b BENCHMARK /REFERENCE POINT
[ 50.60 1 [I INCHES I FT ] [ ABOVE /) BELOW (I BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ 48.00] INCHES
1— Install 900 gal. category-3 septic tank equipped with an approved filter. 2 -The licensed contractor installing the system
is responsible for installing the minimum category of tank in accordance with sec. 64E- 6.013(3)(f). 3- Install 300 sf of
drainfield in bed configuration. 3- Install 12" of slightly limited soil under the bottom of drainfield. 4- Perimeter of
excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. 5 -Invert elevation of drainfield
to be no less than 6.56' NGVD 6. Bottom of drainfield elevation to be no less than 6.06' NGVD.
THIS PERMIT IS NOT FOR ADD
SPECIFICA
The contra
sot T' g a
Xfal
I.
InS e7H,
esignee) is required to perform a
o ' e , rai 1e d excavation at the
DE COUNTY HEALTH PA0114. k!VNr
Insults to
x:.10
WI
e ;..,,Fr.-9n
DATE ISSUES = to -at ti¢/ eti time.
submitted.*
e co ractor is not
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1.1.4
AP1042422
EXPIRATION DATE:
SE843772
Dade CHD
10/23/2011
Page 1 of 3
1
07 -21 -2011
JEFF ATVVATER STATE OF FLORIDA
CHIEF RNANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE:
PERSON:
FEIN:
07/21/2011 EXPIRATION DATE: 07/20/2013
RODRIGUEZ ROBERTO
020803086
BUSINESS NAME AND ADDRESS:
SOUTHERN SEPTIC CONTRACTORS INC
30 SW 57 COURT
MANY FL 33144
SCOPES OF BUSINESS OR TRADE
1- SEPTIC TANKS
*
IMPORTANT: Pursuant to Chapter 441) . 05114), F.$., an officer of a corporation who elects exemption from this chapter by (fling o certificate of election under thls
section may eon recover benefits or compensation under this chapter. Pursuant to Chapter 440,05112), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of election 10 be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation if, at app time after the tiling of the notice or the issuance of the certificate. the person named on the notice or
certificate ea longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at Bay time for failure of the person
named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609
DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
PLEASE CUT OUT TILE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION To ifE EXEMPT FROM FLORIDA
WORKERS` COMPENSATION LAW
EFFECTIVE 07/21/2011 EXPIRATION DATE: 07/20/2013
PERSON ROBERTO ROORItJEZ
FEIN 020803086
BUSINESS NAME AND ADDRESS:
SOUTPIERN SEPTIC CONTRACTORS INC
30 SW 57 COURT
MAW FL 33144
SCOPE OF BUSINESS OR TRADE:
1- SEPTIC TANKS
IMPORTANT
OPursuant to Chapter 440.05(14), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
H
Pursuant to Chapter 440.05(12), F.S., Certificates of election to be
exempt.. apply only within the scope of the business or trade listed on
Rthe notice of election to be exempt
E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
QUESTIONS? (850) 413-1809
* Carry botto
CUT HERE
portion on the job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11