PL-12-94Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 172920 Permit Number: PL- 1 -12 -94
Scheduled Inspection Date: May 11, 2012
Inspector: Hernandez, Rafael
Owner: , DUSA ACQUISITION LLC
Job Address: 455 NE 91 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: G&L PLUMBING SERVICE
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number (305)496 -7442
Parcel Number 1132060140140
Phone: 305 - 551 -5090
Building Department Comments
REPLACE EXISTING SEPTIC TANK WITH NEW 900 GAL
TANK. TO BE PLACED IN FRONT YARD AND OLD TANK
TO BE ABANDONED.
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 -172
REINSPECTION FOR INSP- 168968. missing s
9. CREA
d need hrs.
D AS
May 10, 2012
For Inspections please call: (305)762 -4949
Page 5 of 11
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
PERMIT NO ?
DATE PAID.
FEE PAID:
RECEIPT #•
APPLICANT:
AGENT:
r
PROPERTY ADDRESS.
LOT: - BLOCK: SUBDIVISION: - ` ==' PROPERTY ID #:
CHECKED [X] IT&A ARE - NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK
[01]
[0 *]
[04]
[04
TANK SIZE [1] E' e- - [2]
TANK MATERIAL C-'- - ,>
OUTLET DEVICE ._`z -- -�
MULTI - CHAMBERED +t1 / N ]
[05]t' OUTLET FILTER vx =
� 06]�'t LEGEND e4';.:21.:".- -a°''E -r, 7; , °,`,
[07] WATERTIGHT
'[p8] LEVEL
[09] / DEPTH TO LID
D AINFIELD INSTALLATION - t
[ ] [1 0] AREA [1] -" •'. [2] SQFT
[ ' )-, 11; " DISTRIBUTION BOX I F HEADER
[ ):., [12] ;NUMBE=FI.OF DBAINUpNES 1;- .
[ ] [13]?°•} RAINLI,NE-SEPARATION'
[ ] [14] DRAINLINE - SLLOPE
[ 1 [15] `°"DE- P- T+4=- OF=COVER t:
[ 1 [16] ELEVATION-[ABO1 E/BELOV11]i BM
[ ] [17] SYSTEM LOCATION
[ 1 [18] DOSING-P.UMPS
[ ] (19] ___AGGREGATE-AGGRE-GATE --SIZ
[ -- ]. -[20] AGGREGATE EXCESSIVE FINF$�'
[ 1 [21] AGGREGATE DEPTH -2;k-,
[
[
[
]
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT / •
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
[
[ -1
[ -- ]
[
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
[30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES C FT
[33] BUILDING - FOUNDATION 1 FT
[34] PROPERTY LINES'° FT
[35] OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADINGy,
[47] CONTRACTOR
[48] OTHER
ABANDONMENT
[ ;! [49] TANK PUMPED /1 '
[� [50]
TANK CRUSHED & FILLED
-,
CONSTRUCTION [APPROVEDIDiSAPPROVED]
CHD DATE- ! -
FINAL SYSTEM" APPRO EDYDISAPPROVED]: "-- " Fwf�.. ` s� 'f F = CHD DATE. '' a
DH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number. 5744-002 - 4016 -4
PT 1: Applicant
PT 2: Installer/Contractor
PT 3: Building Department
PT 4: Health Department
PERMIT NUMBER: Permit tracking number assigned by CHD.
APPLICANT: Property owner's full name. - -
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. Box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX ! HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS: Record
item number, explanation of violation, and required
CONSTRUCTION APPROVAL Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted until the CHD has confirmed that building construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
( +) SHOT H.I. H.I. H.I.
H.I. ' [ -] SHOT [ -J SHOT [`] SHOT
ELEVATION
n.
Dalyo
-10 1L11
J Pilr.r(60 11C);CM
fitrY171-111,=-1-D'Olb 164 -EV
i»znue
61,
Miami Shores Village
Building Department
6 J a/ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
�� /S( INSPECTION'S PHONE NUMBER: (305) 762.4949
f ��'�' Permit No.
Master Permit No./C-1/4° Z
BUILDING
PERMIT APPLICATION
FBC 20
RECEIVED
JAN 2 d 2012,
Permit Type: BUILDING ROOFING ,�� , /� ''JJ,'
OWNER: Name (Fee Simple Titleholder):Z t ' let/ /vim_ a t, Phone #: ga(— '' 7`7s
Address: -(:. 6) Step / » a. 7//'
City: / State: F� Zip: 331. 3
Tenant/Lesse9 Name: Phone #: 363--- `I% —77-1112.-
Email: /CYYI5, /f& ( fYi)L 1 /1 C .
JOB ADDRESS: Liss- Ale 1' 54
City: Miami Shores County: Miami Dade
Folio/Parcel #: / / -370C 6/L/_ ,JqO
Is the Building Historically Designated: Yes NO
Zip: 33)3g
X
Flood Zone:
CONTRACTOR: Company Name: e t L P►-%nb 9 r)1_ Phone #: 3f Lo—cies5-- D
Address. 1 \ �� 01 -L'�
City: )._&. State: Zip: S5 I3----.
Qualifier Name: tc:"'\ ff' i C_ Phone #: °
State Certification or Registration #: Certificate of Competency #:
Contact Phone# c,- g i'6 Email Address:
DESIGNER: Architect/Engineer: Phone#:
i
Value of Work for this Permit: $ 14 VD 0 Square/Linear Footage of Work: 32
Type of Work: ❑Addition
Description pf Work:
lc h
shefia
❑Alteration
3—//in
❑New
RRepair/Replace ❑Demolition
e C� CA C- ,ifILEA) 0 f
1�-
** * *************** *************+x***x *** Fees ***** **+ *** ** * *** ***** *****+x********* * *** ***
Submittal Fee $ ii 4-) Permit Fee $ /CC CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 2 J, 0 . OD
b, 2
"] Q.0)
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. 1 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 ins.: _ tion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection wi, not e approved and a reinspecttion fee will be charged.
.v,8P 14. ( lo-r.
Signatur 6e,ry 1 j 1/ Signatur
Owner or Agent
The foregoing instrument was acknowledged before me a this J
day of .14404 / , 20 It a , by &cc' t l� Sch a 11
who is personally known to me or who has produced
Contractor
The foregoing instrument was acknowledged before me this
day of '% %77/ , 20 , by ®G 4e.' €/ ("/
who is personally known to me or ' ho s produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY UBLIC:
Sign: •
Print:
My Commission Expires:
L
c��tMRY P�B�,c
4
* * * * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY
JOSEPH R. COLLETTl
* MY COMMISSION # DD 988187
EXPIRES: September 4, 2014
e Bonded Thru Budget Notary Services
—2.0— )7--
ans Examiner
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
/
Structural Review
NOTARY PUBLIC:
Zoning
Clerk
01- 17 -'12 14 :57 FROM-ROYAL CARIBBEAN INS. 3056421087 T -281 P0001/0001 F -641
ACC) O®
_V
CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDD/VYYY)
01/17/2012
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 POLICIES
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 policy(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 ondorsemont(s).
PRODUCER
ROYAL CARIBBEAN INS. AGENCY
1772 W FLAGLER STREET
MIAMI, FL 33135
Parr LAYDA TUNON
Q ca
/CC Nn PwL 35. 44 FAX Nob 305-642-1087
a oRE9R:LTUNONROYALIl BELLSOUTH.NET
INSURER(S) AFFORDING COVERAGE
NAIL p
INSURED
G & L PLUMBING SERVICE, INC.
7411 SW 67 AVE
SOUTH MIAMI, FL 33143
COVERAGES
INSUReRA:ASCENDANT INS. CO.
INSURER a :ASSOCIATED INDUSTRIES INS. CO.
INSURER C
INSURER 0 r
INSURER E •
INSURER P :
THIS
INDICATED.
CERTIFICATE
EXCLUSIONS
INSR
RV IJ, JI\ .,...00R:
IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS.
LYR
TYPE OF INSURANCE
ADDL
MISR
SUER
MD
POLICY NUMBER
POLICY EPF
(MMIDD/YWY)
POLICY EXP
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL !ABILITY
XX
GL- 37161 -0
04/22/2011
„IMM/DD/YYWI
04/22/2012
EACH OCCURRENCE
5 1,000.000.00
M 3-PS a wrr
PPRE occurrence)
$ 100,000.00
CLAIMS.MADE X OCCUR
MED EXP (My one person)
$ 5,000.00
PERSONAL &ADV INJURY
DERMAL AGGREGATE
$ 1.000,000.00
s 2.000.000.00
S INCLUDED
GEN1 AGGREGATE LIMIT APPLIES PER:
—1 POLICY n PRO- n LOC
PRODUCTS - COMP /OP AGO
5
AUTOMOBILE
—
LIABILITY
COMBINED SNGLE LIMIT
accident)
$
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
—""
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident
$
PROPERTY DAMAGE
/Par accident}
$
$
UMBRELLA LIAe
EXCESS LIAR
_
OCCUR
CLAIMS -MACE
04/21 /20117..ARY
EACH OCCURRENCE
5
AGGREGATE
DED J RETENT ON S
LIMITS OAR
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY y / N
ANY OFFICER/MEM:MRPEXCCLUDEa9ECUTIVE a
(Mandatory In NN)
a yea, describe under
DESCRIPTION OF OPERATIONS below
N / A
AWC 1007126
04/21/2011
E.L. EACH ACCIDENT
S 1,000,000.00
E.L. DISEASE - EA EMPLOYEES
1,000,000.00
s 1,000,000.00
E.L. DISEASE - POLICY LIMIY
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remark!! SohedWO if more epaee la mired)
PLUMBING CONTRACTOR.
ry=DTIGIC ArC un' nro - - -- -
CANCELLATION
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
10050 N.E. 2ND AVENUE
MIAMI SHORES, FLORIDA 33138
SHOULD ANY OF TH BOVE DESCRIBED POLICIES BS CANCELLED BEFORE
THE EXPIRATJD THEREOF, NOTICE WILL BE DELIVERED IN
ACC WITH j' POLICY PROVISIONS.
C® 19 ACORD CORPORATION. All rights re erVed.
ACORD 28 (2010/05) The ACORD name and to • • are registered marks of AC • RD
19. 2012 I:52D DE•l aa" t
STATE OP PLOR:'DA
DEPARTMENT OP HEALTH
ONSI'1'E SEA TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION .,'E1704CT
=INSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT:
(Dusa Acquisition LLC'
NO C8 P.
PERMIT H: 13-SG-13876M
APPLICAX1ON 0: AP1'058522
DATE PATO:
FEE PAID:
RECEIPTS:
Dom' N i PR884147
PROPERTY Masan 1 455 NE 91 St Miami, FL 33138
LOT: 20
BLOCK: 49 SVN►IVISTON: Merril Shores Sec 2
PROPERTY ID 0: 11- 3208 - 014 -0140
(sECTIOR, TOWNSHIP, RANGE, PARCEL NUMBER)
[OR TAx ZO MOW
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OP SECTION
361.006E, F.S., AND CHAPTER i4E -6, F.A.C. DEPARTMENT APPROVAL or SYSTEM DOSS NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR P.SY SPECIFIC PERIOD OF TIME. ANY CRAM IN Id74TERIAL FACTS,
WXZCH SERVED A8 A BASIS FOR ISSUAN::E OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT TN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMTTTTNG REQUIRED FOR DEVELOPMENT OF TETE PROPERTY.
SYSTEM BESTG'N AND SPECIFICA'PYONS
T [
A [
• [
K [
900 1 GALLONS / 0PD
0 1 GALLONS /
0 1 GALLONS GREASE YNTERCSPTOR CAPACITY
1 GALLONS DOSING. TANK CAW=
Sect;
D [ 300 3 SQUARE BEET
R [ 0 3 sQ 5L VEST
A TYPE SYSTEM: (xi' STANDARD
I CONFIGURATION: [ 1 TRENCH
CAPACITY
CAPACITY
[MAXIMUM CAPACITY SINGLE TANK :1250 GALLONS]
1GALLONS 21 (DOSES PER 24 RAS ape [ 1
SYSTEM
SYSTEM
( I FILLED [ ] MOND [
(x3 BED [ l
N
F LOCATION of BENCHMARK: F.F.E.: 11.28' NOVD.
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILI. REQUIRED:
t 0.001 u1CHIes
[ 30.40 1 [l INCHES I FT 11 ABOVE 4 DELON tIBENCENARK /REFERVISC5 POINT
1 48,401 FT 31 ABGVE SELOW BENCHMARK /REFERENCE POINT
INCHES
EXCAVATION REQUIRED: [ 16.001 INC5E5
1-- Install 800 gal category-3 septic tank equipped with an approved filter. 2 -The licensed contractor installing the system
0 is responsible for installing the minimum category of tank in accordance with see. 64E- 8.013(3)(f). 3- Install 300 of of
• drainfield in bed configuratior. 4- lnstaii 12" of slightly limited soil under the bottom of dranfield. 5- Perimeter of
excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. 6- Invert elevation of drainfield
to be no less than 7.76 NGVD. 7. Bottom of drainfield elevation to be no less than 7.22' NGVD. 8. This permit includes
E the Abandonment of the existing septic tank.
THIS PERMIT IS NOT FOR ADDITION(s).
R
SPECIFICATIONS EY;
Biro N 0594ala
DATE ISSUED: 01/16/2012
DR 4010, 09 /09 (Obaoletee all prOViOUS edi
Incorporated: 14E- 0.003, FAO
,, 1.3,4
REPAIR
T �ofi ,r '�" )►s required to
iRs ✓a8CPi0A. G ''�:,�It7 ?Q'.ift, al a
results shalt tes tee Ot z0 rai Rep r` $ latch DATE:
esurfs o the 0 t r sort bori I' are CON
the jostle ew 088 annOhrrilt are
Ar30®88 2 po0 i!!A@, is not
Dade CED
04118/2012
Page 1of3