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PL-11-1064Inspection Worksheet Miami Shores Village 10050 Ni. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 10- Inspection Number: I NSP- 160835 Scheduled Inspection Date: August 12, 2011 Inspector: Hernandez, Rafael Owner: DURU, CLEMENT Job Address: 139 NW 102 Street Miami Shores, FL 33150- Permit Number: PL -6 -11 -1064 Project: <NONE> Contractor: MIAMI DADE ENVIROMENTAL Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1131010220080 Phone: 786 -251 -4099 Building Department Comments INSTALL A NEW 1050 SEPTIC, AND 500 DRAINFIELD TRENCH CONFIGURATION Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS IN FILE August 11, 2011 For Inspections please call: (305)762 -4949 Page 8 of 18 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 vo JUN 0 9 2011 Permit No. Pi 11--- 1064 Master Permit No. i -5 -16 -Fill Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): de kt K17~ p u f) (J Phone#: Address: 13 g ►J a) ID?. c.,7 W(ii144(I RO. City: /%/ G.l A* 3140 (Le) State: rlo Zip: ' 3 Is 0 Tenant/Lessee Name: A )/ /� Phone #: Email: JOB ADDRESS: 1 I J(er IO2 S77' City: Miami Shores County: Miami Dade Zip: r31 Se7 Folio/Parcel #: /1^ 3/0 / .0 22 -on 80. Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: rr k3 V-f ( j)(/A D F' (.1(i10 /1) Phone #: 7c'6 , 2 5(^ L(0 99 Address: S? 90 2i'l.1i Q 0 n S, 3 City: WIC 4 GI State: r(G}., Zip: B 3( ' j Qualifier Name: `-v\ OS M `IA.(V (T1' Phone#: 7X-.9-5/^Y 0 9 g State Certification or Registration #: ..0q7/ % Certificate of Competency #: Contact Phone#: 786 I. c{(, cl Email Address: // ei D4 PeF UO(0 tilt / Pei/74 -s 1),11,1),11,-s Cq DESIGNER: Architect/Engineer: P(4 Phone #: Value of Work for this Pernlit: $ 6090 =- Square/Linear Footage of Work: Type of Work: °Address °Alteration *Jew °Repair/Replace °Demolition Description of Work: ( (0 l A-1) A MO ) 1050 gb4il0tt/y £ , �'n ( 'T'4 kl I l j) ®o aEi0g NIA1vl),elc,f ***+ x******+ x*************** *+ x*+ x********* Fees*** ****** *** ****** * * *** **** *:x*************** Submittal Fee $ Permit Fee $ 300 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 r fee will be charged. I Signature % Signature Owner or Agent The foregoing instrument was acknowledged before me this The f day of , 20 _, by , day of who is personally known to me or who has produced As identifi on and who did .4, It* N NOTARY PUBLIC: Sign: Print: My Commission Expires: Contractor instrument wal acknr t Jled ero , 20 I 14-10 O to e or who has produced ation and who did take an oath. N TARY PUBLIC: Sign: Print: �e SS My Commission Expires: t C\ jal �Q►c,1.0011"'C' 1 , N, k, k, k*** *x:, k, k, k, x, x, k, N, k, k, k*, k, k+ k********* **+ k, ksN, k, k*sk********** **, k, k*, k, k*, k*+ u*+k*+x+k*sk*****************fo*c.,j',k,i************** Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) 09 -08 -2010 ALEX SINK STATE Of FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXE 4IIPT 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: 10/26/2010 EXPIRATION DATE: 10/25/2012 PERSON: BOLANOS JOSE FEIN: 820553271 BUSINESS NAME AND ADDRESS: MIAMI DADE ENVIRONMENTAL SERVICE INC 8280 LAKE DR #334 MIAMI FL 33166 SCOPES OF BUSINESS OR TRADE: 1- SEPTIC TANKS 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 under this chapter. Pnrseant 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 the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certificates of election to be exempt shell be object 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 shell revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 QUESTIONS? (8501 413 -1809 06/20/2011 11:51 9545839802 JW INSURANCE PAGE 01/01 1.,____`4c),R"' CERTIFICATE OF LIABILITY INSURANCE , PRODUCER JVd Insurance Servicaa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 100 North State Road 7, # 106 • ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE " N Margate, FL 33063 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Phone Inrnll (954)583.7213 Fax (954)5$3.2045 ' - • A E llig_CoERAgE AFFOpEp BY THE POL CC I S B E1- W — - - — — — _ _, _ _ _ . _...._ ._ .. , INSURERS AFF ORDING COVERAGE DATE (MMfDD/YV) 08/20/11 RED Miami Dade Environmental Services, Inc. 8290 Lake Drive Ste #334 Miami, FL 33166 COVERAGES '- •__ .... INSURER_A• Atlantic C asuatty INSURER B — — — _ . —. _ . —...L _ • 1N55(URER ...— _ —.. — _— — -- — IN$URER INSURER E. — ..__. —...— _...— INSURER F: THE PA( IClFR nrium ie."`.«: -. e_ _ -- ANY RROUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OCUMENT WITH RESPECT TO1WH CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$, EXCLUSIONS AND CONDITIONS OP SUCH tt POLICIES, AGGREGATE LIMA'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. •J. R: !SI D _ GENERAL LutatLny . _ 'E OF INSURANCE POLICY NUMBER RATE m ap / _Arm Y EF_ E" — P" E PI—RA — IA j( COMMERCIAL GENERAL LIABILITY L0390018710 M _• CLAIMS MADE d OCCUR • GEN'L AGGREGATE LIMIT F APPLIES PER: Y_ POLICY __ PROJECT LOC AUTOMOBILE LIABIUTY ' • ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS _ NON OWNED AUTOS • GARAGE LIABILITY ._ _ _ • • ANY AUTO • EXCESS/UMSRELLA LIABJJ JY . OCCUR CLAIMS MADE DEDUCTIBLE I RETENTION $ WORI�L•'R9 coMPENSATION AND EMPLOYERS' LIABILITY ' ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? IWye% dGibe under • SPECIAL PR_ VISIONS below OTHER _ , .. EACHoccURaEnicE .9,000,6061 DOGE TO RrNTED 0722/10 07/22/11 .PaEmisgsigik cccurenceL _ MED EXP (MY one person) 5,0001 _ PERSONAL & AOV INJURY I —PRODUCTS.: GENERAL AGGREGATE —!— •• 1,000,000' 2,600,000j _COMP/OPAGO ! — 1,QOO,Ot10:1 File Damage Liability I 100,000, COMBINED SINGLE LIMIT - •, (Ea accident) ? I BODILY INJURY .�. , _ . _ .. »� (Per)_ .— BODILY INJURY (Peracdpent) PROPERTY DAMAGE . _..__ (Per acrl g _ __ AUTO-ONLY- EA ACCIDENT -�» OTHER THAN EA A,, : AUTO ONLY: O EACH CCURRENCE • AGGRRGATE -„m . -0 T Y E.L. EACH ACCIDENT • E.L DISEASE - EA EMPLO E,L ISEASEPOLICY LIMIT I » DESCRIPTION OF OPSRq'nONS / ;OCA r o / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT t $PECfAL PROV►$JONS * ** SEPTIC TANK CLEANING & INSTALLATION, SEWER & STORM DRAIN CLEANING *" CERTIFICATE HOLDER Miami Shores Village 10050 NE 2nd Avenue Miami Shores, FL 33138 ACOAD 26 (2001/08) QF 4* CANCELLATION .10••••••••••• 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 TI LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY • OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ® RD CORR©RgT25R -1988.— DO NOT FORWARD MIAMI DADE ENVIRONMENTAL SERVICE INC JOSE BOLANOS PRES 8290 LAKE DR 334 DORAL EL 33166 ltAI milm ilidiht ►lttttl”411tthtrltW{f e7nie4l4RI R,gistered Septic Tank Contractor_ SR0971276 Reglstratibn Expiration Date:. September 30, 2011 JOSE BOLANOS 8290 LAKE DRIVE SUITE 334 DORAL FL 3316.6- MIAMI DADE ENVIRONMENTAL SERVICE, INC. Business Authorization: SA0091617 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS New APPLICANT: Clement Duru PERMIT # : 13 -SC- 1283376 APPLICATION #: AP981 701 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR824874 PROPERTY ADDRESS: 139 NW 102 St Miami, FL 33150 LOT: 17 +18 BLOCK: 1 SUBDIVISION: PROPERTY ID #: 11- 3101 - 022 -0080 [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 [ 1,050 ] GALLONS /1 GPD Septic CAPACITY A [ ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS GREASE INTERCEPTOR•CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 500 ] SQUARE FEET Trench confiauration drainfi SYSTEM R [ ] SQUARE FEET N/A SYSTEM TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND CONFIGURATION: [X] TRENCH [ ] BED [ ] A I N I E L D 0 H E LOCATION OF BENCHMARK: F.F.E., 11.81' NGVD ELEVATION OF PROPOSED SYSTEM SITE BOTTOM OF DRAINFIELD TO BE FILL REQUIRED: [ 0.00 ] INCHES [ 10.90 ] [I INCHES / FT ] [ABOVE /J BELOW I BENCHMARK /REFERENCE POINT [ 40.90 ] [I INCHES I FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 72.00] INCHES *Invert elevation of drainfield to be no Tess than 8.90 ft. NGVD. *Bottom of drainfield elevation to be no less than 8.40 ft. NGVD. *Install 42" of slightly limited soil under the bottom of the drainfield. - Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption -The licensed contractor installing the system is responsible for installing the minimum cate sec. 64E- 6.013(3)(f). F.A.C. R SPECIFICATIONS BY: Carlos M Icaza APPROVED BY: Carlos 14 Icaza DATE ISSUED: 10/21/2010 TITLE: ain trenc e with TITLE: ATE: 04/21/2012 CHD DH 4016, 08/09 (Obsoletes all previous editions which may not be use Incorporated: 64E- 6.003, FAC v 3 1.4 AP981701 ( .Page 1 of 3 5E827850