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PL-13-521Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 187536 Permit Number: PL -3 -13 -521 Scheduled Inspection Date: May 06, 2013 Inspector: Hernandez, Rafael Owner: MCLAUGHLIN, BRENT HURSEY AND irwo�M Job Address: 125 NW 107 Street Miami Shores, FL Project: <NONE> Contractor: A SUPER SEPTIC TANK, INC. Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Drainfield Phone Number 305/759 -0429 Parcel Number 1121360100140 Phone: (05)364 -0113 Building Department Comments INSTALLATION OF 900GAL SEPTIC TANK AND 200 SQ FT OF DRAINFIELD IN TRENCH CONFIGURATION 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 itiRj •IC May 06, 2013 For Inspections please call: (305)762 -4949 Page 16 of 48 STATE OF FLORI A DEPARTMENT OF L13 -5? 1 ONSITE SEWAGE RREATNENT AND DIPO Are SXSTEM CONSTRUCTION LCTION AND- -FINAL APPROVAL, � / Z.� DATE PAID; PERMIT NO. FEE PAID: RECEIPT #: APPLICANT; AGENT: . PROPERTY ADDRESS s �' . '- /V/ Crt/: /® 7 J BLOCK; SDBDIyISIQNs PROPERTY 70 #/ /— Z13 [ Cf /tj/ • CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE•OR RUI,E AND MUST•BE.CORRECTED. TANK INSTALLATION 1' [01] TANK SIZE [1] [ ' [021 TOK MATERIAL F f —a' [031 OUTLET DEVICE*�.t [ /T C [041 MULTI - RAMERED [ / N 1 [ (051 OUTLET FILTER ,y [ ] [061 LEGEND "1)1-42 U 3i 107] WATERTIGHT ( .' [08] . LEVEL [ 4 [091 DEPTH TO LID 00.[21 DRAINFIELD INSTALLATION [ 4 [10] AREA (11/42X..2 r [2]30VOSQFT [ ...1^ [11] DISTRIBUTION BOX HEADER.,/ •[ /]' [121 NUMBER OF DRAINLINES y ait. ", [--f [13] DRAINLINE SEPARATION v, [� [14] DRAINLINE SLOPE �b [ [151 DEPTH OF COVER/4 [ 1 1161 ELEVATION (ABOVEZIMEN BM [ 1^ [17] SYSTEM LOCATION _ —' [ [18] DOSING PUMPS ^/ J!d [19] AGGREGATE SIZE 6 ®,Q [.Q [20] AGGREGATE EXCESSIVE FINES ' Q [ [21] AGGREGATE DEPTfl,i /, FILL / EXCAVATION MATERIAL [✓F [22] FILL AMOUNT ..- [ �,/ 123 ] FILL TlsXMS [ ✓J [24] EXCAVATION DEPTH- 1 [25] AREA. REPLACED '1 1 [26] REPLACEMENT MATER, EXPLANATION OF VIOLATIONS / REMARKS: [ [ 1 [ [] 1 1 1 1 i 1 [ SETBACKS _ [27] SDRFACE Wl'TER FT [28] DITCHES - [29] PRIVATE WELLS FT [30] PUBLIC WELLS FT [311 IRRIGATION WELLS FT [32] POTABLE WATER IjINEB FT [33] BUIIIDING FOUNDATION _ FT [34] PROPERTY LINES � �� FT [351 OTHER FT FILLED / MODND SYSTEM (36] DRAINFIELD COVER [371 SHOULDERS [38] SLOPES [39] STABILIZATION ADDITIONAL INFORM/TON' 140] UNOBSTRUCTED AREA [41] STORMWATER RUN '* 142] ALARMS [43] . MAINTENANCE AGREEMENT [44] BUILDING AREA [45] LOCATION CONFORMS WITH SITE PLAN [46] FINAL SITE [47] CONTRACTOR [481 OTHER ABANDONMENT' [� ]' [49] TANK PUMPED [ ] (50] TANK CRUSHED && FILLED rate CONSTRUCTIO 'INAL SYS DISAPPROVED] s o.-. -- CHO. DATE: 3 /DISAPPROVEDI: Zqy,. �Q ® DATE: fJ `16, 08/09 (Obsolete: all previous editions which may not be used) rated.: 64E- 6.003, VAC• Page 2 of 3 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 Permit Type: PLUMBING JOB ADDRESS: i FBC 20�D 3 -52-4 Permit No. Master Permit No. City: Miami Shores County: Miami Dade Folio/Parcel #: 1 t -^ ® Cr.) 1 t-(Q Is the Building Historically Designated: Yes NO A Zip:�t� Flood Zone: OWNER: Name (Fee Simple TitleholdezWV"-g -- I %1 ` Is !r11', Phone#:3Q Q.' 1 Cs-Part Address: e —? 1-� k - -) t City: 1-'1 0 7n I t ∎, State: �'I ■3 v- t Zip: '?'' 1 c.=, R, Tenant/Lessee Name: - Phone#: `—'° Email: CONTRACTOR: Company Name: J 77a1 w' /e La ifre (Q /e- h Address: City: -fcU Phone #: -3 State: /® I If' zip: f�0' / « Qualifier Name: Phone#: 3.' $ 34 4o /13 State Certification or Registration #: S' 01 08-7 Certificate of Competency #: J // ,.,G�. Contact Phone#: 3' 5 369 �' i/ 3 Email Address: 4 sir T T 4/ Bel .i �k t4 0. /I/ 1 DESIGNER: Architect /Engineer: Phone #: Value of Work for this Permit: $ e� Type of Work: OAddress Description of Work: Olt .5 aU, n103 ****** * * * * * * * ** **** ** **** ****** **** ** Submittal Fee $ Permit Fee $ * ***x xs'w *** ********* * *********** CCF $ v CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ �L 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 reinspection fee will be charged. The foregoing instrument was ackn ledged before me this 1 The foregoing instrument was ackno ledged before me this day ovitarti, 20 15 by 1 OLSVia— 1 day of 44.1 , 201 , by al' -" 2 , who is personally known to me a who is personally known to me or who has produced10 As identification and who did take an oath. NOTARY PUBLIC: Sig Print: My Commission Expires: as identification and who did take an oath. NOTARY PUBLIC: i Ov NI G 1210 7 %' %,,% Sign: 0 41, :, s, .'— Print: _ c° ; !a 'db 0 6'42 /gyp / ,i.. My Commission Expires: ** **** ********** ** ******* *** ,. ************************************************ ** * * * * * * ** * ** * ** * * * *** * * * ** * * *o APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised3 /12 /2012)(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) MIAMI COUNTY HEALTH DEPARTMENT STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Brent McLaughlin PERMIT #:13 -SC- 1458641 APPLICATION #: AP 1099326 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR898988 PROPERTY ADDRESS: 125 NW 107 St Miami, FL 33168 LOT: 14 BLOCK:. 212 SUBDIVISION: Dunnings Miami Shores PROPERTY ID #: 11- 2136 -010 -0140 [ SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX 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 [ A [ N [ K [ 900 1 GALLONS / GPD ] GALLONS / GPD ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY [ septic tank D [ 200 ] SQUARE FEET R [ ] SQUARE FEET A I N F I E L D O T H E R TYPE SYSTEM: CONFIGURATION: CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] bed configuration SYSTEM SYSTEM [ ] FILLED [ ] MOUND Ix] BED [ [x] STANDARD [ ]:TRENCH LOCATION OF BENCHMARK: FFE 12.6' NGVD ELEVATION OF PROPOSED SYSTEM SITE BOTTOM OF DRAINFIELD TO BE [ 22.80 ] [I INCHES f FT ] [ ABOVE 4 BELOW G BENCHMARK /REFERENCE POINT [ 42.80 ] [I INCHES I FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 32.00] INCHES 1.- Existing 900 gal. septic tank, certified by Drain Masters on 2/20/2013 to remain. 2.- Install 200 sf of drainfield in bed configuration. 3.- Install 12" of slightly limited soil at the bottom of the drainfield. 4.- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. 5. -Invert elevation of drainfield to be no less than 9.53' NGVD. 6. -Bottom of drainfield elevation to be no less than 9.03' NGVD. (Comments Continued on Page 2.) SPECIFICATIONS BY: APPROVED BY DAVID A PRENDERGAST DATE ISSUED: 03/04/2013 TITLE: TITLE: Dade CHD EXPIRATION DATE: 06/02/2013 DH 4016, 08/09 (Obsoletes all previous editions which may not bRiettt t otor (Or deSignve) is regilirett t0 Del r'?"{ a Incorporated: 64E- 6.003, FAC soil boring ai:ja:;fmt to the drainfield exc:fiii',.get it,of 3 v 1.1.4 nP1099926 time of finaliospwaaon. Prior to f i;imi r. ai, tof, l)OH inspector shall witness the scii b: ?'i:44 3?;J Cor'ip )=;re t to results to the original sits :: :' ; (,r; :: ;:?lriit'<:i A reinspscoion lee the r:oiittx;ojr is not at the joLsite at he of rangeu ii;ue Z•d Registered Septic Tank Contractor SR0890722- . .Registration Expires -on Sep .ember.30, 2013 ANDREW M ZERO 7701 WEST 18•LAN • • HtALEAH FL • 33014 A SUPER SEPTIC . ANK. INC. Business Authoriz; Lion: SA0960829 617£0179£90£ )ue} of }des Jedns C:01:#9 "1 /1.1; OCILL.1:114 34" SI. • WWII!. FL. :43 Z012 LOCAL BUSINESS FAX RECEIPT • 2013 . • . RRBT.CLASS • M DAD IAMI-E COUNTY ... STATE . E OF FLORIDA • • . ; U.S. POSTAGE • EXPIRES SEPT. 30,2013 • . • PAID 11/11181* BE DISPLAYED AT PLACE OF BUSINESS .. • • .: WHAM!, PL puRstmur TO COUNTYDODE CIIAPTEPSA ... ART. 0 & 10 • • *; PERMIT NO. 231 . . . • • • . • . .: , THIS IS NOT A BILL - DO NOT PAY RENEWAL RUMNESS W3M / LOCATION RECEIPT NO. 398877 -2 A SUPER SEPTIC TANK INC CC 0 SEP890722 7701 W 18 LA 33014 HIALEAH owwH A SUPER SEPTIC TANK INC :-.tet; gii3lishicao 1 ECIALTY PLUMB/NO CONTRACTOR r.lo H oALY A LOCAL INC.I.:CSS 'I' RECEIPT. DOFF tiffi FETVAIT 'OLDER 10 VtOLATF EAS111:0 f:EOCLATOST ZOOUPT LAWS OF VW SOUOTY (} CITIES. MN DUG r jturr The 110LOCIT FflflL ANY PI:WIT 02 LICENSE COT A COOVICAOTAI 1oLOFTF5 OCALIFICF- OOXS. We/MOT OECEIVED i.liall•LIACE mum, -,hr. mum:Milt 10/10/2012 09010046001 000049.50 ..3EE OTIIER SIDE WORKER'S 1 DO NOT FORWARD A SUPER SEPTIC TANK INC AMIWFW ?rim Pacq 7701 W 18 LA HIALEAH FL 33014 >fuel of }des iedns e 6ti£01P9£90£ l i 03/20/2013 10:34 9549895998 Ark BLAIZE AND TYSON CERTIFICATE QF LIABILITY INSURANCE PAGE 01/01 FDATE (MM,DDIYYYY) HIS CERTIFICATE IS !MED AS A MATTER OF INFORMATI N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE0R3, HIS 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 CIR PRODUCER, AND THE CERTIFICATE HOLDER. IMPO TTANT; If the certificate holder Is an ADDITIONAL INSURED, the policyrges) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and cot ditlor s of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the _ certiaate holder In lieu of such endorsement(s). PRODUCER - Blake 8 Tyson Insurances 5955 SW 21st Strom Hollywood, FL 33023 Phone (954) ESE -93241 Fax (954) 989-5998 INSURED A SUPER SEPTIC TANK„ INC 7701 W 18 LANE HIALEAH, FL 33014 ACT 1v,Extk (954) 989.9324 LOCERg-s: annMb1n eandtysgn.com FAX (A/C, M4)080-5998 1 INSURER(5) AFFORDING COVERAGE INSURE A ; ACCIDENT INSURANCE COMPANY „INSURER a; INSURER C INSURER 0 : 954 , INSURER n _. COVERAGES CERTIFICATE NUMBER; INSURER F; THIS IS TO CERTIFY TH/ T 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 CERTIFICATE MAY BE IS^>UED OR MAY PERTAN THE INSURANCE AFFORDED BY THE POLICIES DESCRIB DESCRIBED N IS SUBJECT UBJECTRTO ALL THE TERMS, �G EXCLUSIONS AND CONGTIONS OF SUCH POLICIES, LIMIT$ SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LR NI` TYPE OF INS MANGE AOLILSUB �y GENERAL LIADILITY --leg .1AL1(D POLICY NURSER I (tilIN1pDiYY T POLICpYPryYTi LIMITS 21 COMMERCIAL GIN$ RAL LIABILITYi —�i- Q❑ c1.14iMS.MApE ® OCCUR CC� a T- NAIL S i GEM AGGREGATE LIMIT APPLIES PIER: ®PBLICY ❑ Ma. ❑ LOO AUTOMOBILE LIABILITY © ANY AUTO ALL ❑ AUTO$ ❑ HIR6D AUTOS CI rHEDuLED CI pAioNzwNED ❑' UMBRELLA LAS 0 ocouk ❑ EXCEDD UAD ❑ cLAIM_MADE WORKERS COMPENSATOR $ AND EMPLOYERS* Luosiury Y t N ANY PROPRIETOR /PARTN44 avexEcuTivs qF�T CERIMEMBSR EXCLuoun pAarWatory In NH) r f� NIA jr IP�T, ION under oPERATioNS h8� L 10/10/2012 110/10/2013 DESCRIPTION OP OPERATIONS) LOCATIONS 1 VEHICLES (Attach AOORD tnt, Additional Remarks Su-+edule. it more apace Is requiem SEPTIC TANK INSTALLATION, SERVICE AND REPAIR UERTIFICATE HOLDER CITY OF MIAN•I SHORE VILLAGE 10050 NE 2ND AVE MIAMI SHORE VILLAGE, FL 93138 FAX 305- 756 -8972 ACORD 25 (2010/06) QF CANCELLATION Ecl �'' ►M sT —oTI- am_ EACH OCCURRENCE E s 300,000_00 MACS TEND PSM4SES i a oaor! b )_ $ /00,000.00 MED EXP (Any one person S 5,000.00 PERSONAL & ADV INJURY $ 300,000.00 GENERAL AGGREGATE $ 300,000.00 PRODUCTS • COMP/OP A J S 300,000.00 S COMBINED aedlar SINGLE uM� -$ C SIN BODILY INJURY Per person) $ODILY INJURY (Par amino p PB0PERTY lte DAMAGE EACH OCCURRENCE AGGREGATE S E.L. EACH AOCIOENT• 5.L DISEASE- EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1$ SHOULD ANY OF THE ABOVE THE EXPIRATION DATE DESCRIBED POLICIES 8E DELIVERED N BEFORE ACDQRDANCB W1TN THE POLICY PROV NOTICE SE oEL1Vt;RED IN AUTHORIZED REPRESENTATIVE• 01995 -2018 ACORD CO RATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a super septic tank ATE OF FLORIDA .Vs'iI27M,Ei1TOF FINANCIAL SERVICES NIVISION.OFWORKER COMPENSATION ,CONSTRUCTION IIW USTRY • t CERTIFICATE OF l :.ECTION TO BE EXEMPT FROM FLORtOA t. WORKERS' COMPENSATION LAW • i• EFFECTIVE 03/01/2012 EXPIRATI0M DATE: t • PERSON: ANDREW t4 ZERO • 1 FEIN, .650455404 • BUSINESS NAME AND ADDRESS: A SUPER StrlC.rANK 1NC 7701 W 1 871•t LANE- (' HIALEArt, FL 33014 t SCOPE OF BUSINESS. OR TRAM SEP7IC TANKS 3053640349 r . • .. _ IMPORT/kW i ..iw PL 1101 to Chapter 446.4'5{14). F.S., no officer o° a Ctaraoretien •s'ho ir eis.s s e::erro :Zoo from oils chapter by filing c.- tificate, t t election j 1% � t' undr r this section may ant re�:over benefits or s�npsasatioh under this `p cnai ter. 03/01/2014 1f. Pura actor to Chapter 440.05(12}. F.S.. Certificates of election to be 1.' exe opt_ apply only within the scope of the businesa or trade fisted on t, the nr,.tic of election to be exempt. i E Pur matt to Chapter 440.0513), P.S., Notices of election to be exempt I- and certificates o` election o !+e exempt shall be subje-i; to revocation I: t >. if, at, any time attar the filing of the notice or to issuance of the car df'Oato, tit'= .Person named on 'dm notice cr atrtifico:�•� no luager meats 1.1 the ratiui: trient3 =.1 this section for issteancs of a certificate. The • delartn : shall revokr• a certificate at any time. for fai.ure of the I:, .; pal son :.r a ned :an the certificate to meet Inc jeciiiremente . Of tVis al STIONS? (&5O) 413 —igilS p.1 Se 114'6 •