PL-13-555Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 187705
Permit Number: PL -3 -13 -555
Scheduled Inspection Date: April 10, 2013
Inspector: Hernandez, Rafael
Owner: DAVITAN, GEORGE
Job Address: 85 NW 102 Street
Miami Shores, FL 33150 -1229
Project: <NONE>
Contractor: A AMERICAN SEPTIC & PLUMBING
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1131010180080
Phone: (305)866 -5600
Building Department Comments
DRAINFIELD REPAIR
Infractio Passed Comments
INSPECTOR COMMENTS
False
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
HRS APPROVAL IN FILE
April 10, 2013
For Inspections please call: (305)762 -4949
Page 14 of 28
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
64.0ft9 'TO 1.(23
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
L` N\/) t0-2, c"r
JOB ADDRESS:
MAR 19 2013
FBC2010
Permit No.
Master Permit No. F (- 1 `3 -55s
City: Miami Shores p County: Miami Dade Zip: 3 3 I c 0
Folio/Parcel#: 11 "' 3 I 0 t - 0 J" 00 5 0
Is the Building Historically Designated: Yes NO Flood Zone: / Fi
OWNER: Name (Fee Simple Titleholder):
Cy or n Phone#:
Ads: W j02 Ss
City: 1�''ii (Air - t S State: Zip: 3 3 vx 0
Tenant/Lessee Name: NIA Phone#: 31 W - r 8 t
Email:
CONTRACTOR: Company Name: � f�-�i C. a--(N. �� " t P � UYPh
na#L 30-S !wow 5bao
Address: L BC� C..ta, \( - B(A) d ' 9.Dro - mi-D--'fl^ 1 c L 3 3 LE (
City: State:`` Zip:
Qualifier Name: t i GLY Vi 0- 0 d Ca. ril Phone#:
State Certification or Registration #: S T" 00013 ii a Certificate of Competency #: SO . 9-
Contact Phone#: 3 1 VAS BOO Email Address: , mar K P 0.01/4rf tr i c r\ e 1 i..t.mi31 r-j Lt 2 C..at,•.
DESIGNER: Architect/Engineer: Ni i Pt Phone#:'
Value of Work for this Permit: $ 74 • " Square/Linear Footage of Work: Ko 13
Type of Work: OAddress CDAlteration ONew Repair/Replace L (Demolition
Description of Work:
t) ru4� -fie �� �;r SO
P *8a 8Si«* *** *****8***Cs********* ****RM*k ees******** *3+ ID******** **************dd**** **+ ***
Submittal Fee 0 0 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 $ 1112:
Bonding Company's Name (if applicable) I
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
dJ I �i
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 ins ection which occurs seven (7) days after the building permit is issued the absence of s posted notice he
inspection w not be appred and a reinspection fee will be charged.
Signature '' L � - Signa
Owner or Agent
The foregoing instrument was acknowledged before me this Z_
day of Ka, 20 3 by ,
who is personally known to me or who has produced �-
P Y4l As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print
NOT
C- STATE OFFLORIDA
.ruz
ion # EE030407
ire s: SEP. 28, 2014
n,,.i The.
BONDED
My Commission Expires:
* * * * * * * * *** * * ** * * * **
APPROVED BY
Contractor
'Me lo - going instrument was acknowledged before me this
day of ti.rZ\ , 20 , 11, by 'V.4114 i17, ms's
who is rsonall kn to me or who has produced
as identification and who did take an oath.
NOTARY P
Sign: •, ,,, ` Aires, am L8, GUi`t
Print: B ? THRU AnA� nc soN ING CQ,MC.
My Commission Expires: I 2-4 11--(
LIC:
ARY PLBLIC:SThTE OF FLORIDA
`F.
3. Cruz
si
EE030407
**** ******* **w***** ** * ****** * **** *** *** *** * *** *axe .ara * ******* * **sws * *+ *****
Plans Examiner
Structural Review
(Revised3 /1212012)(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: George Davitian
PERMIT #: 13-SC-1460867
APPLICATION #: AP 1100692
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR900269
PROPERTY ADDRESS: 85 NW 102 St Miami, FL 33150
LOT: 17
BLOCK: 1 SUBDIVISION:
PROPERTY m #: 11- 3101- 018 -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 DOE$ NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIIIE. 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 [ 900 ] GALLONS / GPD Septic existing CAPACITY
A [ 0 3 GS / GPD CAPACITY
N C 0 ] GALLONS GREASE INTERCEPTOR CAPACITY CIOXIM M CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS 8( ]DOSES PER 24 HRS #Pumps [ ]
D [ 150 ] SQUARE FELT in trench configuration SYSTEM
R [ 0 ] SWAM FEET SYSTEM
A TYPE SYSTEM: [ml STANDARD [ ] FILLED [ ] NCOND
I CONFIGURATION: [x] TECH [ 3 BED [ 3
N
P LOCATION OF BENCHMARK: FFE: 12.5'ngvd
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINF'IELD TO BE
L
D FILL REQUIRED:
0
T
H
E
R
SPECIFICATIONS BY: William Woodard
APPROVED BY:
[ 0.00 INCHES
1 25.20 ] [ INCHES FT 1 [ ABOVE A BENCHMARK /REFERENCE POINT
[ 57.20 ] [I INCHES f FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: 1 32.00] INCHES
- Install 150 so ft drainfield in trench configuration.
- Elevation of bottom of drainfield to be no less than 7.73' NGVD.
- Existing 900 g septic tank, to remain.
- The system is sized for 2 bedrooms with a maximum occupancy of 4 persons,
for a total estimated sewage flow of 200 g /d.
- Not for additions
Joseph R Piverger
DATE ISSUED: 03/16/2013
TITLE:
TITLE: Engineer Specialist II
Dade CHD
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
incorporated: 64E- 6.003, FAC
v 1.1.4
AP1100692
EXPIRATION DATE: 06/13/2013
3E892917
Page 1. of 3
AAMER -1
OP ID: BG
m
`- - CERTIFICATE OF LIABILITY INSURANCE
DATE (Nwmamrq
04/01/2013
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 poacy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain polices may require an endorsement- A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
Insurance Market Place Phone: 352237 2700
�aSW College Rd, Suite 3 Fax: 352-237-5884
House Account
CONTACT
t EA: I SAVC. Nou
ADDRESS:
INSURERS) AFFORDING COVERAGE
NAIC #
INSURER A :Ascendant Commercial Insurance
LIABILITY
CO CIAL of em'. LLABIL rt
INSURED A American Septic & Plumbing
Inc
12555 Biscayne Blvd Ste 970
North Miami, FL 33181
INSURER B : Southern Insurance Company
$ 1,000,000
INSURER C
$ 100 000
INSURER D:
ENSURER E:
X
INSURER F :
MED EXP (Any one )
COVERAGES
CER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDHTIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
value
POLICY NUMBER
GL371261
04/21/2012
)tIYYYY{
Laws
A
GENERAL
X
LIABILITY
CO CIAL of em'. LLABIL rt
04/21/2013
EACH OCCURRENCE
$ 1,000,000
° � TO RENTED
PREM�ES ma oxearence)
$ 100 000
CLAIAAS -MADE
X
OCCUR
MED EXP (Any one )
$ 5,000
PERSONAL & AOV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIM T APPLIES PER:
1l I POLI n CY IFRT 1— LOC
PRODUCTS - COMP/OP AGG
$ 1,000,000
$
AUTOMOBILE
—
LIABILITY
ANY AUTO
A OOg NED
HIRED AUTOS
�
NON-OWNED
COMBINED SINGLE UMrr
(Ea acckiect)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per strident)
$
PROPERTY DAMAGE
$
EXCESS LI4B
OCCUR
CLAIMS-MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED 1 1 RETENT ON $
$
B
AND KERB COMPENSATION
EP NS Y
ANY PROPRIETORIP0.RTNERf[ THE YIN
N /A
PWC�048 -13
02/03/2013
02103/20/4
�yC g
x 1 TORY `, MITTS
EAR
EL EACH ACCIDENT
$ 100,000
OFFICER/MEMBER EXCLUDED' n
(Mandatory In NH)
t/ m describe DESCRIPTION OF OPERATIONS below
L E DISEASE -EA EMPLOYEE
$ 100,000
E.L DISEASE - POLICY LIAR
$ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks mule, If mere apace Is required)
Plumbing & Septic pump contractor
CERTIFICATE HOLDER
CANCELLATION
MIAMISH
Miami Shores Village
Building Department
10050 NE 2nd Ave
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORS REPRESENTATIVE
ACORD 28 (2010105)
®1$88.2010 ACORD CORPORATION. Ail rights reserved.
The ACORD name and logo are registered marks of ACORD
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: