PL-12-1470•
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 177273 Permit Number: PL -8 -12 -1470
Scheduled Inspection Date: December 05, 2012
Inspector: Hernandez, Rafael
Owner: POLITI, VICKI
Job Address: 286 NE 107 Street
Miami Shores, FL
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Drainfield
Phone Number
Parcel Number 1122310130450
Phone: (954)963 -0082
Building Department Comments
REPLACE DRAINFIELD ONLY
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- 176819. HRS IN FILE broken
side walk
December 04, 2012
For Inspections please call: (305)762 -4949
Page 7 of 37
L8- IZ_ 1LFT0
inspector .�.
Address
DIVISION OF
Envi'fonfiontal Health
Florldif bipartment of Healtb
Miotni -Dade County
Health Deportment
DST DS/We11 Div s oD
11804 SW 26 St. , MI *m►, FL 33115
Date }--- --"�4- :..� --
ALTOS # ,,
Comments:
attire
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
mr -emE Z
Arc; Q LU 1L I!J
Permit No. P ( a— l 4') O
Master Permit No.
Permit Type: PLUMBING r
OWNER: Name (Fee Simple Titleholder): �� � �1 f �4 Phone#: 78 5Z S 4-7 99
Address: 26G t4'6 lo-1 Street
City: I" 1 S (PP rrS State: ,44Z Zip: 33 161
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: c NE (0-7 street
t
City: Miami Shores County:
Folio/Parcel #: (t - 2-2-3 (- O (2— O 4,S O
Is the Building Historically Designated: Yes NO ✓
Miami Dade
Zip: 33161
Flood Zone:
CONTRACTOR: Company Name: �c.c) I d € ' O Phone b o 1- 6.6 3 S i"I
Address: Coro 2,2_ ,S...0 23 .51
City: r- ■ IG rrrt r' State: 1Z Zip: 33023
Qualifier Name: TP_,/CSG Se
0 r'r1-0 n Phone #:
State Certification or Registration #: ,SM ®q -7( le v Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ ,t 2-300
Type of Work: ❑Address
Description of Work:
Square/Linear Footage of Work: 1 50
❑Alteration New Repair/Replace
,oZt ,plGck), D Ql'ri id 0��j.
❑Demolition
*** * * ****x ******** **+x****x:***x:** ***rr*** Fees****+ x**= H*** *****+ x ** ** * *********** ******** ***
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ 1 ("3•3()
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
� P
Application is hereby made to obtain a permit to do the work and installations as indicated. [ 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
Signature
The foregoing instrument was acknowledged before me this -2- The for going
day of F4AJ3 , 2012- , by VICI 4 PO 1.1 "f1` , day of
who is personally known to me or who has produced r' tV bee -64
As identification and who did take an oath.
NOTARY PUBLIC:
dV
Sign: ` °`4
111 TER ESA QJ SOLOMON
Print: S te' ` W MY COMMISSION # EET3 -935
My Commission Expires: `''a„ aws• EXPIRES November 08, 2015
(407) 398 -0153 FlaidallotaryService.com
Contractor
trument wm ackn wledged befo
20) , by
e "nally known t
e or who has produced
as identification and who did take an oath.
NOT _ iY ' UBLIC:
Sign:
Print:
My Commis
Notary
MY MY Comm. Expires fires Sep 23,20
oa commies +on # EE 128810
'.. % °f ;o .
, Bonded
Natimlat N
****> x= x*>k>x *>k=k>k*>tia:*** *>k ****. x*+ x> k**** ***** *> x> k> k***> k* *= K*****+ x*>x>k *>k*>k**>"+x *>k****., .: , a.,,> k****= p *** *>k**+t< ***>k*>k *>k******
APPROVED BY
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: Martin Politi
PROPERTY ADDRESS: 286 NE 107 St Miami, FL 33161
LOT: 9
PERMIT #: 13-SC-1423040
APPLICATION #: API079130
DATE PAID:
FEE PAID:
RECEIPT #•
DOCUMENT #: PR881726
BLOCK: 13 SUBDIVISION:
PROPERTY ID #: 11 -2231- 013 -0450
[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 [ 750 ] GALLONS / GPD CAPACITY
A ( ) GALLONS / GPD CAPACITY
N [ ) GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [
D ( 150 ) SQUARE FEET SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED ( 3 MOUND
I CONFIGURATION: [x] TRENCH ( ] BED [ 1
N
F LOCATION OF BENCHMARK: F.F.E.: 14.8' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED: [ 0.00] INCHES
0
T
H
[ 34.80 ] 11 INCHES I/ FT ] [ ABOVE 4 BELOW Ii BENCHMARK /REFERENCE POINT
( 64.80 ] [I INCHES I/ FT ] [ ABOVE /I BELOW ] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: ( 30.00] INCHES
1- Existing 750 gal. septic tank certified by "Statewide Septic Connections In." on 07/20/2012 to remai. 2- Install 150 sf of
drainfield in trench configuration.3- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed
absorption trench. 4 -Invert elevation of drainfield to be no Tess than 9.90' NGVD. 5. Bottom of drainfield elevation to be
no Tess than 9.40' NGVD.
THIS PERMIT IS NOT FOR ADDITION(s).
At
a'^ 'am) pa6ueJJe aUl le allsgol a4l le
)ou s] JoloeJ1 03. ay; ji passasse a
of plena ails leul6uo aql of sposaJ
Woo P #ekuuoq Ilos. ayl ssaulIM pegs Joloadsui
aU1 avnn l�db Ir1urj of .s„d uuuaaasupi, aeull 10 W e CHD
a41 le, uo1leneoxa p]allweJp all of lua�sl a 6uuor �
P O1o�'ad o1 pennba, (Bauoisap Jo) J010eJ1u03 a
EXPIRATION DATE: TU /31/2012
SPECIFICATIONS
Pedro N Ospina
DATE ISSUED: 08/02/2012
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1.1.4
AP1079.30
SE875905
Page 1 of 3
717trATE CYP PLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
I
Permit Application Number'
1 .
! PART II • SITE PLAN-
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Notes:
Site Plan submitted by:
Plan Approved
By
-7
Signature
--Net-ApproVid
;---// 2 7,
County Health Department
Title
Date
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
OH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
Page 2 of 3