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PL-12-501Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 171417 Scheduled Inspection Date: April 16, 2012 Inspector: Hernandez, Rafael Owner: FREDRICKS, THOMAS Job Address: 433 NE 91 Street Miami Shores, FL Project: <NONE> Contractor: A AMERICAN SEPTIC & PLUMBING Permit Number: PL -3 -12 -501 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Drainfield Phone Number Parcel Number 1132060140120 Phone: (305)866 -5600 Building Department Comments DRAINFIELD REPAIR Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS IN FILE April 13, 2012 For Inspections please call: (305)762 -4949 Page 21 of 36 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 APPLICATION FBC 20 Permit No. RECEIVED MAR 2 2 2012 Master Permit No. Permit Type: PLUMBING p� /,��, OWNER: Name (Fee Simple Titleholder): Timms ('' [ h-d Phone#: 'ES -4 Address: ^��,,� C C s ' City: m,�,M Sli C ( State: - zip: 331313 Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 4'33 (JE ct City: Miami Shores County: Miami Dade Zip: 33 138 Folio/Parcel#: l t — 3 210 - 014 012.0 Is the Building Historically Designated: Yes NO I Flood Zone: CONTRACTOR: Company Name: T e'rrtar 1?-1-17 + Pluty‘ P h irb#: 31 9 0(0 .V000 Address: ) S'SC 12113 CAN! Ae taltrzA -k� P City: N. WM-111:1 State: -Pau Zip: 3319 Qualifier Name: ' flho m (l IN D 0 Q,t� Phone#: 305 1$ ∎24 i`54o00 State Certification or Registration #: SET'DCOCt4-1" Certificate of Competency #: S -too 04 a. Contact Phone#: qiCe Z4.0 SS e -Ck Email Address: ' CLainericaln DESIGNER: Architect/Engineer: W I IV Phone#: v �,�,n c11 Value of Work for this Permit: $ v V J Square/Linear Footage of Work: Type of Work: ❑Address DAlteration ❑New Repair/Replace Description of Work: ❑Demolition Submittal Fee $ L� ' Permit Fee $ / ° CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 1 1 ' 3c Bonding Company's Name (if applicable) I Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) (0- 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' lvon, Owner or Agent The foregoing instrument was acknowledged before me this day o , 20 by 1fl ` who is personally known to me or who has produced i i-- DrN S Liz- As identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC-STATE OF FLORIDA Sign: Jazzmin Cruz Commission # EE030407 -,,,, ,,,.•" Expires: SEP. 28, 2014 BONDED THRD ATLANTIC BONDING CO., INC. Print 1-61Z4 Gtr U2 My Commission Expires: Z/ 1 ZblL * * * * * * ** * * * * * * * * * * * * * * * ** * * ** APPROVED BY Signature Contractor The foregoing instrument was acknowledged before me this Q`` day of prOt-t1 , 20 LZ, by M"LIT3-44` , who i rsonally known or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PLBLICSTATE OF FLORID! Sign: Print: \ Jazzmin Cruz Commission # EE03040i Expires: SEP. 28, 2014 Mutual) Ltin ATLANTIC BONDLNG CO., INC My Commission Expires: see 2 t ** * * * * *** ** ***MGM **** ******* * **** *****#**** **** ** * *+ ***** *kip * *** * *******+U+Rds+B*** 3-7-3 -° . Plans Examiner Structural Review (Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk • STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Thomas Fredricks PROPERTY ADDRESS: 433 NE 91 Ter Miami, FL 33138 LOT: 18 PERMIT #:13 -SC- 1398222 APPLICATION #: AP 1065078 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR869671 BLOCK: 49 SUBDIVISION: PROPERTY ID #: 11- 3206- 014 -0120 [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 SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DOES NOT GUARANTEE MATERIAL FACTS, TO MODIFY THE NULL AND VOID. OTHER FEDERAL, SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ 900 ] GALLONS / GPD Septic 0 ] GALLONS / GPD 0 ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY D [ 225 ] SQUARE FEET R [ 0 ] SQUARE FEET A TYPE SYSTEM: I CONFIGURATION: N F LOCATION OF BENCHMARK: CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] in trench configuration SYSTEM SYSTEM [ ] FILLED [ ] MOUND [ ] [ ] BED [ ] [x] STANDARD [x] TRENCH FFE : 11.2' NGVD I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: 1 0.00 ] INCHES 0 T H E R SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: 1 30.00 ] I) INCHES I FT ] [ABOVE/) BELOW b BENCHMARK /REFERENCE POINT 1 62.00 ] II INCHES I FT ] [ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: 1 32.00] INCHES - Install 900 g (minimum) septic tank. - Install 225 (minimum) sq ft drainfield in trench configuration. - Elevation of bottom of drainfield to be no less than 6.03' NGVD. - Not for additions The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s. 64E- 6.013(3)(f), FAC. The contractor (or designee) is required to perform a soil boring adjacent to the draintield excavation at the time of final inspection. Prior to Final Approval, the DO inspector shall witness the soil boring and compare the results to the original site evaluation submitted. A reinspection fee will be assessed It the contractor is not at the jobsite at the arranged time. William Wo Jos 0 t 3/20 TITLE: ITLE: Engineer Specialist II DH 4016, 08/09 (Obso es all previous editions Incorporated: 64E - •.003, FAC v 1.1.4 which may not be used) AP1065078 Dade CHD EXPIRATION DATE: 06/11/2012 5E865345 Page 1 of 3 ACCPRO CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the poiicy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). IDATE(MWDDIYYYII) PRODUCER 954- 318 -2469 954 - 318-2474 INFINITY INSURANCE SOLUTIONS 6412 N UNIVERSITY DRIVE SUITE 132 TAMARAC. FL 33321 INSURED 305 -866 -5600 305- 891 -6905 A AMERICAN SEPTIC & PLUMBING, INC 12555 BISCAYNE BLVD SUITE 970 NORTH MIAMI. FL 33181 NCQA INFINITY INSURANCE SOLUTIONS No 954-318-2474 PHONE AfAICf . No. Eatk 954-318 -2469 mom: BERNADETTEK@IISFLCOM INSURERS) AFFORDING COVERAGE INSURER A: ASCENDANT INS. CO. INSURER s: SOUTHERN INS. CO. INSURER C: INSURER D : INSURER E: INSURER F : NAIC S REVISION NUMBER: LAJVCKAte= $...=Irt i 1r no" I c rvvmocr . 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Matt LTR TYPE OP INSURANCE AD= a MAR POLICY NUMBER IIRINODD/1fYYY1 tAANUO tYYYYI LIMITS A GENERAL ✓ LIABILITY coMMERCULL GENERAL Lu►slllry GL- 37126 -0 04118111 04/18112 EACH OCCURRENCE $ 1.000.000 s 100 000 S I MED EXP (Any one person) $ 5.000 CLAIMS -MADE ✓ OCCUR PERSONAL & ADV INJURY $ 1.000.00 $ 2.000,000 GENERAL AGGREGATE PRODUCTS- COMPIOPAGO $ INCLUDED G� AGGREGATE LIMIT APPLIES TER: 71 POLICY n PA- n LOC $ AUTOMOBILE — — LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ _ SCHEDULED AUTOS AUT�D COMBINED accident) SINGLE UNIT BODILY INJURY (Plrp peen) $ BODILY INJURY (Per accident) S qD�� $ UMBRELLA LIAR EXCESS MB OCCUR I CLAIMS-MADE EACH OCCURRENCE S AGGREGATE $ $ DED I RETENTIONS B WORKERS COMPENSATION AND EMPLOYERS' LIAELJTY Y / N ANY �CEERR/MEMBE�REXCLLUUD [] ! D "sC RI+ OPERATIONS below N/A PWC002043 -12 02(0312012 02/03/2013 ✓ I TORY LIMITS I I ER EL EACH ACCIDENT $ 100.000 EL DISEASE -EA EMPLOYEE $ 100.000 E.L. DISEASE - POLICY u s 500.000 DESCRIPTION OF OPERATIONSI LOCATIONS /VEHICLES (Attach ACORD 101, AddiUOnal Remarks Schedule, 4 mote space Is resulted) 98482 PLUMBING COMMERCIAL & INDUSTRIAL 98483 PLUMBING RESIDENTIAL & DOMESTIC 98805 SEPTIC TANK SYSTEMS CLEANING (WC) 5183 AIR CONDITIONING SYSTMERS NON PORTABLE PLUMBING & DRIVERS CERTIFICATE HOLDER MIAMI SHORES VILLAGE 10050 N.E.2ND AVENUE, MIAMI SHORES, FLORIDA 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1818 -2010 ACORD CORPORATION. All rights ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD