PL-13-2384
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 185357 Permit Number: PL -2 -13 -238
Scheduled Inspection Date: February 28, 2013
Inspector: Hernandez, Rafael
Owner: PACE, BRUCE
Job Address: 69 NE 98 Street
Miami Shores, FL 33138-
Project <NONE>
Contractor: SUBURBAN PROPANE
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060131150
Phone: 305 -891 -8393
Building Department Comments
INSTALL GAS LINE
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
February 27, 2013
For Inspections please call: (305)762 -4949
Paae 17 of 35
SUBURBAN PROPANE -1770 PO BOX K WHIPPANY, NJ 07981 -0170 305- 891 -8393
RSN:046 INStALL -TANK
* SET 00LB DO FIAL FOR RANGE *
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
WO# 36085 SLOG >142 /20/13 09:23 <SCHED >02/25/13 07:29 Tech: 02
ACCT #:127797 S# :1 DIV:1 TYP:1 ZONE:33138 15:38 22- Feb -13
LYLE CHURCHILL TEL: (917)797 -5884
69 NE 98 STREET
MIAMI SHORES, FL 33138 SCY: 92 LTX PTX
* **
SAD: LYLE CHURCHILL 69 NE 98 STREET MIAMI SHORES, FL 33138
SVC INST: COD CUSTOMER
CALL DATE: 02 /18/13 DATE IN:
RSN:006 MISCELLANEOUS
CALL DATE: 02 /18/13 DATE IN:
RSN:006 MISCELLANEOUS
02/18/13
02/18/13
CALL DATE: 02 /18/13 DATE IN: 02/18/13
SIZE
FNCT 6
FNCT 9
FNCT 25
WO #:% 4184112
WO#:% 4184111
W0#:418411
EQUIPMENT DATA
IBS WATER
WATER
CAP
238
357
476
714
1000
LBS LP
100
GAL
DOT
28
0
ASME
GWC
DOT
ASME
GWC
POT ASME
# GWC
150
200
42
57
0
0
❑
300
85
420
200V
120
57V
420V
120V
125
250
325
500
1000
0
DESCRIPTI
OTHER
VFRR+FL TYPE
0
C
YR
5
❑ C
❑ T
C
MFG DATE
RECERT DATE _-
MO/YR
YR
MO/YR
T
No Mark
RECERT TYPE ❑ 2 °S°
❑ 3 °E'
SCHEDULE FOR
SERVICE
MO/YR
❑ 1 °No Mark°
❑ 2 °S°
❑ 3 °E°
TANK/CYUNDER INSTALLED
MFG. SERIAL NO.
TANK/CYLINDER REMOVED
MFG.
MO/YR
❑ 1 °No Mark°
❑ 2 "8°
❑ 3 °E°
Time
In
Time
Out
Total
Hrs.
Total Material
SERIAL NO.
CHECK HERE IF
ADDITIONAL SHEETS
FURNACE
MAKE / MFR
MODEL NO
SERIAL NO
DATE
FULL
Total Labor
T/C # 1 Serial No.
TIC # 2 Serial No.
T/C # 3 Serial No.
Material /Labor Tax
Gals. Propane Q $
SYSTEM TESTS
SINGLE/
INTEGRAL'
1ST STAGE
PAYMENT TYPE CASH ❑ VISA ❑
CHECK ❑ M/C ❑
BOILER SPACE HEATER
Sales/Local/Muni Tax
PLEASE PAY THIS AMOUNT
DISC ❑
AMEX ❑ CC Authorization #
WATER HEATER
RANGE CLOTHES DRYER
FIREPLACE LOGS
OTHER
SINGLE STAGE
LEAK TEST (3 Min.)
START
INTEGRAL TWO STAGE
FINISH
EQUIP. USEDMANT/ TB / OTHER
TIME L1,
1 Iwc ❑Psi
PRESSURE TEST (10 Min.)
START
FINISH
EQUIP. USED HP GAUGE
TIME
❑ PSI
THREE STAGE
OPERATION TEST
EQUIP. USED vaN'Y HP GAUGE / OTHER
;WC FLOW
❑ PSI LOCKUP • -_-'
2ND
STAGE
3RD
STAGE
EQUIP. USED MAN / TB /OTHER
TIME
❑ WC ❑ PSI
EQUIP. USED HP GAUGE
TIME
D P-81
EQUIP. USED MAN / HP GAUGE / OTHER
❑WC FLOW
❑ PSI LOCKUP
EQUIP. USED MAN / TB / OTHER
TIME
❑WC ❑PSI
EQUIP. USED HP GAUGE
TIME
❑ PSI
EQUIP. USED MAN / HP GAUGE / OTHER
❑ WC FLOW
❑ PSI LOCKUP
DISCLAIMER: The scope of Suburbans work is set forth above. It does mt 1) include an inspection of equipment, piping, the internal workings of sealed equipment and /or
structural components for latent, manufacturing or other defects; 2) cover items not visible and accessible to the service technician; 3) attempt to determine if any item is subject to
a recall. Customer further acknowledges that Suburban% work cannot be construed to detect or prevent future defects or happenings arising from aging, use, casually or otherwise.
Regulator Data
Singll51st Stage 2nd Stage 3rd Stage
Mfg. c°
Model
The undersigned: Knows how to turn off
the propane gas supply valve in case of
emergency. Has smelled propane and
can detect its odor. Understands the
service that has been performed. Has
read and understands the above
statements and the safety information on
the back of this form.
PLEASE SEE REVERSE SIDE FOR IMPORTANT SAFETY INFORMATION. Thank Youl
(1) Office Copy (2) Customer Copy (3) Employee Copy Item Number 1522813 OPR -5212
1009
CUSTOMER: READ AND PROVIDE THIS IMPORTANT SAFETY INFORMATION TO ALL END USERS!
WHAT IS PROPANE? Propane is highly flammable when mixed with air (oxygen) and can be ignited by many sources, including operr flames,
smoking materials, electrical sparks, and static electricity. Severe "freeze bum" or frostbite can result if propane liquid comes in contact with
your skin. '�
IF YOU SMELL, HEAR OR SEE GAS: 1) IMMEDIATELY put out all smoking materials and other open flames. Do not operate lights,
appliances, telephones, or cell phones. 2) IMMEDIATELY LEAVE the building or area where you suspect gas is leaking. 3) SHUT OFF
THE GAS at the main gas supply valve on your propane tank if it is safe to do so. 4) REPORT THE LEAK from a neighbor's home or another
nearby building away from the gas leak. Call your propane retailer, 911 or your local fire department. 5) DO NOT RETURN TO THE
BUILDING OR AREA until it is determined it is safe to do so. 6) GET YOUR SYSTEM CHECKED by your propane retailer or a qualified
service technician for leaks before you attempt to use any of your propane appliances.
CAN YOU SMELL GAS? Propane smells like rotten eggs, a skunk's spray, or a dead animal. Some people may have difficulty smelling
propane due to their age (older people may have a less sensitive sense of smell); a medical condition; or the effects of medication, alcohol,
tobacco, or drugs. Consider purchasing a propane gas detector as an additional measure of security.
ODOR FADE is a reduction in the concentration of propane odor making it difficult to smell. Although rare, several situations can cause odor
fade: • The presence of air, water, or rust in a propane container. • The passage of leaking propane through soil. • The exposure to building
materials, masonry or fabrics. Since there is a possibility of odor fade or problems with your sense of smell, you should respond
immediately to even a faint odor of gas. To familiarize you and your family or employees with the smell of odorant, call Suburban at
1- 888 - 223 -0029 to request a Scratch and Sniff sample of what propane smells like or order any Propane Education & Research Council
pamphlet.
PROPANE GAS DETECTORS: Propane gas detectors can provide an additional measure of security in homes with little -used areas or with
occupants who have difficulty smelling propane. • Buy only units that are listed by Underwriters Laboratories (UL). e Follow the manufacturer's
installation and maintenance instructions. • Never ignore the smell of propane, even if no detector is sounding an alarm.
CARBON MONOXIDE (CO) - WHAT IS IT? You can't taste or smell CO, but it is a very dangerous gas, produced when any fuel burns.
High levels of CO can come from faulty appliances, or from a venting system or chimney that becomes blocked. CO CAN BE DEADLY! High
levels of CO can make you dizzy or sick (see below). In extreme cases, CO can cause brain damage or death. Symptoms of CO Poisoning
include: • Headache • Shortness of breath to Dizziness • Nausea • Fatigue
IF YOU SUSPECT CO IS PRESENT, ACT IMMEDIATELY! • If you or a family member shows physical symptoms of CO poisoning, get
everyone out of the building and call 911 or your local fire department. • If it is safe to do so, open windows to allow entry of fresh air, and turn
off any appliances you suspect may be releasing CO. • If you suspect that CO is present, call your propane retailer or a qualified service
technician to check CO levels and your propane equipment.
TO HELP REDUCE THE RISK OF CO POISONING: • Have a qualified service technician check your appliances and related venting
systems annually. • Install UL- listed CO detectors on every level of your home. • Never use portable heaters indoors unless they are designed
and approved for indoor use. e Never use a barbecue grill indoors for cooking or heating. • Regularly check your appliance exhaust vents for
blockage. SIGNS OF IMPROPER APPLIANCE OPERATION THAT CAN GENERATE HIGH CO LEVELS; • Sooting, especially on
appliances and vents • Unfamiliar or burning odor e Increased moisture inside of windows.
LIGHTING PILOT LIGHTS: If a pilot light repeatedly goes out, or is very difficult to light, there may be a safety problem. DO NOT try to
fix the problem yourself. It is strongly recommended that only a QUALIFIED SERVICE TECHNICIAN light any pilot light that has gone out.
YOU ARE TAKING THE RISK of starting a fire or an explosion if you light a pilot light yourself. Carefully follow all of the manufacturer's
instructions and warnings concerning the appliance before attempting to light the pilot.
DON'T RUN OUT OF GAS: SERIOUS SAFETY HAZARDS, INCLUDING FIRE OR EXPLOSION CAN OCCUR. Prior to refilling an
empty propane container, a leak test must be performed by a Qualified Technician prior to turning on the gas to determine if any equipment or
lines remain open after the run out. Suburban is not liable for injury or property damage resulting from a supply run out.
EQUIPMENT AWARENESS: KNOW HOW TO SHUT OFF THE GAS SUPPLY to your premises and where the valve(s) is located.
Tank and cylinder valves must be turned to the right (in a clockwise direction) to stop the flow of gas.
MANUFACTURER'S INSTRUCTIONS are included with all propane appliances and equipment. Keep and consult them for correct operating
and maintenance procedures. Contact the appliance manufacturer for replacement instructions, if needed. DO NOT STORE PROPANE
CYLINDERS OR CONTAINERS INSIDE BUILDINGS.
FLOODING — if flooding is predicted for your area or your gas -fired appliance(s) or equipment have been submerged: • Turn off the gas valve
at the container. • DO NOT turn the gas back on until a qualified technician has checked the system.
HEAVY SNOW OR ICE— Heavy snow or ice on propane equipment may cause damage resulting in a leak. Regulator and appliance vents must
remain clear of snow and ice, expecially appliance vents on roofs of mobile homes. When removing snow: • Use care around tanks, piping,
tubing, valves, regulators and other equipment to prevent damage. • Use a broom instead of a shovel. • Do not shovel snow from roofs onto
propane equipment.
SAFE ACCESS: Provide structurally sound access to propane equipment free from snow, ice, debris or other obstructions.
FURTHER CONSUMER SAFETY INFORMATION: - This is an abbreviated version of Suburban's Safety Tips. We urge you to visit
www.suburbanpropane.com for the full text and for Consumer Safety Information prepared by the Propane Education & Research Council
(PERC). Pamphlets called "Important Propane Safety Information for You and Your Family," "Important Propane Safety Information for Users
of Small Cylinders" (including cylinder transportation, storage and inspection procedures), an expansive "Propane Safety" booklet,
weather /natural disaster information, and Suburban's Material Safety Data Sheet (MSDS) may be read and downloaded online. These documents
are also available free of charge by calling Suburban at 1 -888- 223 -0029 or can be purchased through PERC at 1- 866- 905 -1075 or
www.propanecatalog.com. Each pamphlet contains a Scratch and Sniff Test to learn what propane smells like.
Para informaci6n de seguridad en Espanol, llame al 1 -888- 223 -0029 Item Number 1522813 OPR -5212 1009
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:
L0A
FBC 20 o
Permit No.
Master Permit No. p-L, 3 Z 32(
City: Miami Shores
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
County: Miami Dade
zip: 3 3/3 r
Flood Zone:
OWNER: Name (Fee Simple Titleholder): (/. 14___ 0 till C-17t Phone#: I7 77 5
Address: iti,q e)rE
City: ftl1M" frI2 S State: Pr
Tenant/Lessee ,ame:
Email: - (at" c jctkoo Covi,
Phone#:
Zip:
CONTRACTOR: Company Name: S,'1---z) /'ft' v-e- Phone#: go C (i15 /
Address: /4IC/ A/67- /w-
City: TV ./.12 irr" State:
Qualifier Name: ge,166/41,1.--) Driev/A-0,
State Certification or Registration #: /../X 401/5 Certificate of Competency #:
Contact Phone#: 1-5 (-1-3 5'3 Email Address:
Zip:
Phone#: er r/-77.
3
DESIGNER: Architect/Engineer:
Value of Work for this Permft:
Type of Work: °Address
Description of Work: _..rez.cti
$ 4/ePe 44-
°Alteration
'Phbtia:
..,•;,, i,
'‘f:,',., ),,,
,„ in C. iUi- ;;',"1-:(II: , ifif■11 C., t,,i,..1
Square/Lin 98* ,,F.: .....,1111)tmr, 7,
e of woric.
tr/1ep1a
UNew
e) --Q.)
Submittal Fee $ S Oc3rtaL__ Permit Fee $ /00 --- CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Tndning/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 0 (D
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 WITI! 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 whi occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be app s+ a and a reinspection fee will be charged.
Signature
wner or Agent
The foregoing instrument was acknowledged before me this 61
day of [et, 20 LL, by 1-111€ Ctte4(1 Lil
who is
o me or who has produced
an oath.
NOTARY
Sign:
Print
My Commission Expires:
ROGEUO 00E0E00
Notary Public - State of Florida
My Comm. Expires Jul 4, 2013
C i;: iI >:,:ion di DD 888981
Notary Ana.
Signature 4, .
Contractor
The foregoing instrument was acknowledged before m this&
day of rr +n 209' ,bySU111vUQ f�1errn
Who is personally kno to m ` or who has produced
as identification and who did take an oath.
NOTAR UBLIC:
Sign: 2/
Print: CQ r' rY) e
My Commission Expires
o
�oFC�o� �
421. !Q
Y' ffi EE
EXPIRES: June 15, 2015
mimed ThN Bu el Wary SeMoss
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APPROVED BY !'
Plans Examiner
Structural Review
(Revised3 /12/2012)(Revised 07110 /07)(Revised 06/10/2009)(Revised 3/15/09)
Zoning
Clerk
11,,zPi) Co
ri-dat 0`)
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19'1 d /Z VA) ‘ G1„v e
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CITY
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Propane
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1"'i'il fa E. 130th Stye t
N. M am , FL 33151
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D'AYILA & ASSOC. SERVICES, INC.
1800 W. 49tH ST. SUITE 201
HIALEAH . FL.33012
PHONE :(305) s12 -3?to BOUNDARY SURVEY
.ep753e
PAGE 2. OF 2
NOT:VAUD WITHOUT PACE 1 OF 2
JOB NO. 1 1- 01 15154 --
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Ci G. .r. ems & (BITTER P.I. . PANT OF INTERSECTION 4 - CENTRAL ANGLE
- ELEKATt0N ,..94.R.' / SET WON ROD P.R.0 • PORT tW REVERSE CURVE ^ //— - W000 FENCE (6' HIGH)
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C.B.S. - CONCRETE BLOCK STRUCTURE I.F.E. • LOWEST FLOOR ELEVATION P.C.P. • PERMANENT CONTROL POINT SEC. • SECTION
CH. . CHORD DISTANCE LP. • LIGHT POLE P.C. . PAGE S.I.P. . SET IRON PIPE
CL • CLEAR (M) . MEASURED P.O.B. . POINT OF BEGINNING STY . STORY
C • CENTER LINE (R) - RECORD PA • PROPERTY LINE SWK • SIDEWALK
CONC. . CONCRETE 01 & M) • RECORD & MEASURED N.T.S. • NOT TO SCALE UE. • UTWTY EASEMENT