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PL-12-4461 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 171099 Permit Number: PL- 3- 12-446 Scheduled Inspection Date: March 21, 2012 Inspector: Hernandez, Rafael Owner: PUYANIC, DAVID Job Address: 9259 N BAYSHORE Drive Miami Shores, FL Project: <NONE> Contractor: A.B.T. SEPTIC SERVICE, INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1132050270580 Phone: (305)218 -8883 Building Department Comments INSTALLATION OF 1200 GALLON SEPTIC TANK AND 500 DRAINFIELD IN BED CONFIGURATION Passed rxi Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS IN FILE March 20, 2012 For Inspections please call: (305)762 -4949 Page 16 of 23 9 2- 44(12 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 MAR 1 _2 : ;2 FBC 20 BUILDING Permit No. 2-- PERMIT APPLICATION Master Permit No. Permit Type: PLUMBING JOB ADDRESS: (1)56, �". Rc,7 '",0,,`-' ,P City: Miami Shores County: Miami Dade Zip: 3312: Folio/Parcel #: //- 32 C) 5-- C)7 - C7 5 s Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Or v ,c) /2y v' r. ' ( Phone #: 7 6 2-5---25” Address: 30 t''P` •(1''4 ; G1 -ie;. //r i ■ (1j Ile_ `l (11( ) City: A y 41�GC.r,r., State: / "L- Zip: - 3/32 Tenant/Lessee Name: ti/r7 Phone #: A//1 Email: , e- v 1 c) e (canA,,,,,e do cr! r5c. //y (car ^_ CONTRACTOR: Company Name: %/, 1. / 5' 7' ( �` , ,,� ° 2n(, '' S',5 .-Er 3 P Y yG Phone #: .� G � � / � �� Address: l ? 'i` «) 51,1 50 9) . City: /fn /1- ( S fer_I,i / [[ State: i/ e- Zip: 7 3 0 3 % Qualifier Name: :Ma /6e, / �ia�� ^��� Phone #: State Certification or Regi tration #: 5 /1^ 075 023 Ce ' icate of Competency #: Contact Phone #: (3C) ..2(f' u� S y k c �, Email Address: a • 5 e� l` . ye cw . Ce r DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ 9 /GlUO0 Square/Linear Footage of Work: Type of Work: Address DAlteration c ONew/� fRepair/Replace / UDemolition r (� 1 Description of Work: ,< �� � (�,l. l( '/, - fl /(fi _J, O f 00 Ca�Cn �,n�; r .�QO Jr! � /�it1 7r/ Submittal Fee $ Permit Fee $ 3C' c9' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ 0 - Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 779, , 40 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 ropy of the mice of commencement and construction lien law brochure will be delivered to the person whose property is subj t to attachment. / so, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspecti n w ch occurs,;' en (7) days after the building permit is issued. In the absepce of such posted notice, the inspection will no a a% proved and ' einspection fee will be charged. owleaed lsforea this who is personally known to me or who has produced 0 O 4 identification and who did take an oath. Signature The foreg day o who is pe NOTARY ' UBLIC: Sign: Print: Contractor ent was acknowle • ge • • efor: me thi , 20 123 by idit _ LiL4 orally known to me or who has produc- ixtification and who did take an oath. N i TARY PUBLIC: My Commission Expires: APPROVED BY CLAUDIA V. CUB o� "FYIPL rs Notaty PobHC i - State oi Sep 23 2015 hpy Comm, E P 128810 Commission # Ea Notaty Assn. s �? Nation Sign: Print: My Commi Plans Examiner Structural Review (Revised3 /12/2012XRevised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09) Tres SeP 23, ' My Comm. ExR Commission # EE 128810 Bonded Through NaliOital Notary Assn Zoning Clerk 06 -10 -2010 ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL 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: MIRANDA FEIN: 200996759 BUSINESS NAME AND ADDRESS: A B T SEPTIC SERVICE INC 15870 SW 250 STREET HOMESTEAD FL 33031 06/10/2010 EXPIRATION DATE: 06/09/2012 SCOPES OF BUSINESS OR TRADE: 1- SEPTIC TANKS ADALBERTO IMPORTANT: Pursuant to Chapter 440 . 05)14 F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation ender this chapter. Pursuant to Chapter 440.05!121, F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(131, 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 Ace. rtillcate, the person named on the notice or certificate no longer meets the requirements of Ibis section tar issuance of a certificate. The department shall rank s liticate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 VC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA )EPARTMENT OF FINANCIAL SERVICES )VISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY :ERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA MORKERS COMPENSATION LAW EFFECTIVE: 05 /10/2010 EXPIRATION DATE: 08/09/2012 'ERSON: ADALBERTO MIRANDA =EIN 200998759 3USINESS NAME AND ADDRESS: A B T SEPTIC SERVICE INC 15870 SW 250 STREET HOMESTEAD, FL 33031 MOPE 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. I I 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 an 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 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. C-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 .04E.„0/2/7::" CERTIFICATE OF LIABILITY INSURANCE DA04/1811 PRODUCER J.L. Hernandez & Associates, Inc. 18839 S.W. 117th Ave. Miami, FL 33177 Phone (305)238-7676 Fax (305)378 -9056 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED ABT SEPTIC SERVICE INC. /Adalberto Miranda 15870 SW 250th Street Miami, FL 33031 INSURER A: SCOTTSDALE INSURANCE COMPANY a15+ INSURER B: ASCENDANT COMMERCIAL INSURAN INSURER C: INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER CPS0984587 POLICY EFFECTIVE DATE (MMIDD/YY) 04/18/11 POLICY EXPIRATION DATE (MMIDDIYY) 04/18/12 LIMITS EACH OCCURRENCE 2,000,000 A V GENERAL V ❑ ❑ GEN'L n LIABILITY COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE V OCCUR PREMISES (Ea RENTED 50,000 MED EXP (Any one person) 5,000 PERSONAL & ADV INJURY 1,000,000 GENERAL AGGREGATE 1,000,000 PRODUCTS - COMP /OP AGG 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ❑ PROJECT ❑ LOC B ❑ AUTOMOBILE ❑ ❑ ❑ ❑ ❑ • LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG • EXCESS/UMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE • DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? Y If yes, describe under SPECIAL PROVISIONS below WC313570 06/10/10 06/10/11 V WC STATU- ❑ OTH- TORY LIMITS ER 100,000 E.L. EACH ACCIDENT 500,000 E.L. DISEASE - EA EMPLOYEE 100,000 E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS SEPTIC TANK INSTALLATION REPAIR, CERTIFICATE HOLDER CANCELLATION VILLAGE OF PINECREST 12645 PINECREST PARKWAY PINECREST FL 33156 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) CIF © ACORD CORPORATION 1988 y.?�*:{q.�±6t5'i: Ka". SV'2 uw'' �' 7u` 1J�,✓ ",J.Y3:^.Y13:859 ✓, °�Pi;S��ft.LiS The Florida Department of Health hereby certifies the business or entity named below has satisfied the requirements of Part III, Chapter 489, Florida Statutes, for septic tank contracting and has been duly authorized by the department to provide septic tank contracting services under the name of 1"1nn i zuiz WED 09:33 AM MIAMI -DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. . 1st FLOOR MIAMI, FL 33130 532631 -9 BUSINESS NAME / LOCATION ABT SEPTIC SERVICE INC 15870 SW 250 ST 33031 UNIN DADE COUNTY 2011 LOCAL BUSINESS TAX RECEIPT 2012 MIAMI -DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2012 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 THIS IS NOT A BILL — DO NOT PAY RENEWAL RECEIPT NO. 368622-8 STATE# SM0951223 OWNER ABT SEPTIC SERVICE INC Sec. Type of Business THIS ,S 1NL,0 Ag IALTY PLUMBING BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR UCENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUAUFICA- TIONS. PAYMENT RECEIVED MIAMI -DADE COUNTY TAX COLLECTOR: 09/29/2011 02210021001 000075.00 SEE OTHER SIDE CONTRACTOR FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 WORKER /S 1 DO NOT FORWARD ABT SEPTIC SERVICE INC 15870 SW 250 ST MIAMI 'FL 33031 Tli { ►TIlt�i {T, ► ►iil ►T ►lic,ililll, Iltiliil�lTi ►ITiti,TTi�i�i a STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: David Puyanic PERMIT #: 13-SC-1398259 APPLICATION # : AP 1065104 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR869598 PROPERTY ADDRESS: 9259 N Bayshore Dr Miami, FL 33175 LOT: 5 BLOCK: 4 SUBDIVISION: PROPERTY ID #: 11- 3205 -027 -0580 [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 [ A [ N [ K [ 1,200 ] GALLONS / GPD Septic 0 ] GALLONS / GPD 0 ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY D [ 500 ] SQUARE FEET R [ 0 ] SQUARE FEET A TYPE SYSTEM: [x] STANDARD I CONFIGURATION: [ ] TRENCH N CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS 8[ ]DOSES PER 24 HRS #Pumps [ ] SYSTEM SYSTEM [ ] FILLED [ ] MOUND [ ] Ix] BED [ ] F LOCATION OF BENCHMARK: C/L N. Bayshore DRive: 3.92' NGVD. I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: [ 0.00] INCHES 0 T H E R I 18.90 ] II INCHES f FT ] [) ABOVE f BELOW ] BENCHMARK /REFERENCE POINT [ 5.10 HI INCHES Y FT ] [ABOVE BELOW I BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 24.00] INCHES 1— Install 1200 gal. 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 500 sf of drainfield in bed configuration. 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 4.00' NGVD 6. Bottom of drainfield elevation to be no less than 3.50' NGVD.7. This permit includes the Abandonment of the existing septic tank. THIS PERMIT IS NOT FOR ADDITION(s). SPECIFICATIONS APPROVED B DATE ISSUED: DH 4016, 08/09 (Obso Incorporated: 64E -6k 4 vrftwri "PA v 1 .1.4 e contractor (or designee) is regoireti to perform a it born.+ afila e a -- ime of final inspection. Prior to Final Approval, the DOH InsiIIkF3Rhail witness the soil Coring and comrmp:arp ;-i,n sults to the =u, iginar site evaluation submitted. A reinspection fee will be asses . .f ,, -., • ctor is notade CHD a e arranged time. E3MIRATION DATE: 06/11/2012 A.Ona,Mbttbry not be used) AP1065104 SE865267 Page 1 of 3 STATE OF FLORIDA DEPARTMENT OF HEALTH — 1 3__L4 kLi APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION 'EfilIVIIT., Permit Application Number PART II- SITEPLAN wvol Scale: Each block re • resents 10 feet and 1 inch = 40 feet. 111M1111111111111111/111111.11g 111 •; r, r L.1 0.55 ii C 4 II 11111111111111111111N 1-1 411c. .te ...)., Notes: i 2_ oLdi ', . ,I( 0 ,, r ,,,, _ 4 4 7--,1 ., 44.. 11,KWEiva44A AL ca,,,,,is:.„ I-20 ..)- - , IOW • is.; td. ,T . .4 Z' CLSC \ 0 .1)/il lint i .t4t l'.., V.1.0At tif / f + 'Re , t U PP( 5% P IC4, c, I ( i s. I ( t.J41,4 I- ,.„ , c. t _.,.., / i i a, P, t1.4 SC lAns.w..100,e. I 51 ( 2S ."" 5 3* ' sirr* . I 11:s f i te ■ ),i : S Vo4t 114 A wAti, 0;1/ a , Site Plan submitted by: Plan Approved By Title Date V County Health Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015, 10/96 (Replaces HRS-H Form 4016 which may be used) (Stock Number 5744-002-4015-6) Page 2 of 4