PL-12-1288 IF.0
Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-175756 Permit Number: PL-7-12-1288
Scheduled Inspection Date: January 07,2013 Permit Type: Plumbing - Residential
Inspector: Hernandez, Rafael Inspection Type: Final
Owner: MENDOZA, MARIEDY Work Classification: Septic
Job Address:10667 NE 11 Avenue
Miami Shores, FL 33138-2120
Phone Number
Parcel Number 1122320280310
Project: <NONE>
i
Contractor: A.B.T.SEPTIC SERVICE, INC Phone: (305)218-8883
Building Department Comments
NEW SEPTIC TANK INSTALLATION
Inspector Comments
Passed hrs in file
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
January 04,2013 For Inspections please call: (305)762-4949 Page 5 of 25
Miami Shores Village
"RECEIVED
Building Department JUL I I IM
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
i �rQ INSPECTION'S PHONE NUMBER:(305)762A%9
3� MG Permit No. PL-11 ( 2$ '
PERMIT APPLICATION Master Permit No
FBC 20
OWNER:Name(Fee Simple Titleholder):i/1 f f/r/4rie°Qg, Aft.4 QeZ 4 Phone#: 305 2/9 /26 S
Address: 1 (9 (Ac.f7 t-jL l(mow•
City: Iv!r�4 State: Ft-
Tenant/lessee Name: "Phone#:
Email
JOB ADDRESS: /D G G
y , �
I
City: Miami Shores County: Miami Dade Zip: 3 3 /3
Folio/Parcel#: 0310
Is the Building Historlcally Designated:Yes NO t/ Flood Zone:
A
CONTRACTOR:Company ame: �r cv�..
PAY r Phone#: 30r 217 USa
Address: 15170 k'
City: vh" ^+: State: zip: 33e
Qualifier Name: A d+ Phone#: 3°T Z I�'$'J73
State Certification or Registration# S/ll o "g`S 1'1-7 Certificate of Com/p�menc�+`#
Contact Phone#: 30s 2-1 R YY3 Email Address: Q b+ CL `'� �� . �•-n
DESIGNER:Architect/Engineer: phone*
00
Value of Work for this Permit:$ (A 10 $quanA inear Footage of Work: �h1 t
Type of Wy�ork��..: OA dr s tiopn� ONew 13Repair/Replace ODemolition
c u! !
✓�S d'yLryY(:A 47 X8:4^.°(i
EW,
Submittal Fee$ Permit Fee$ 3C CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
Bonding Ctorfpany,s Name(if applicable)
n t" ` .
Bonding Company ts Address
r
..' 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
constriction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL'WORK,1?LUMBING,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 COM [ENCEMENT."
Notice to Applicant. As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicammust
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 Signature
Owner or gent Contractor
The foregoing instrument was acknowl ged_before me this t The foregoing instrument was acknowledged before me this,- f
day of A*—20 ,by a �4 day of 3'c.� �Y .20 lti;by 14/x..,1 of,'•^ A
who is pers ly known to me or who has pr uced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLI
Sign: Sign: '
-Fib Ffft Print Print:
si C
f My Commis My o
� d �. •. ! N
APPROVED BY ��� Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
STATE OF FLORIDA PERMIT #: 13-SC-1360890
' •�
DEPARTMENT OF HEALTH APPLICATION #:AP1042377
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
SYSTEM FEE PAID:
CONSTRUCTION PERMIT
RECEIPT #:
DOCUMENT #: PR850471
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Mariedy Mendoza
PROPERTY ADDRESS: 10667 NE 11 Ave Miami,FL 33138
LOT: 3 BLOCK: 3 SUBDIVISION:
PROPERTY ID #: 11-2232-028-0310 [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 / GPD Septic CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K I ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 667 ] SQUARE FEET bed confiquration drainfile SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: CL NE 11 ave.,7.30'NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 13.20][ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 27.20 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 4.00] INCHES EXCAVATION REQUIRED: [ 14.401 INCHES
0 *Invert elevation of drainfield to be no less than 5.50 ft. NGVD.
`Bottom of drainfield elevation to be no less than 5.00 ft. NGVD.
T -The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
H with sec.64E-6.013(3)(f). F.A.C.
E
R
SPECIFICATIONS BY: Carlos M Icaza TITLE:
a��q 8 ��
APPROVED BY: TITLE: _ (`�VvYQ�, �` Dade C
Carlos X Ioaza
D.
�a�`�oQ��R�'ION DA 1/26/2013
DATE ISSUED: 07/26/20111
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC • Page 1 of 3
v 1.1.4 "1042377 SES4885
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one(21)days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN#A02, Tallahassee, Florida 32399-1703. The
Agency Clerk's facsimile number is 850-410-1448.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order
will constitute a waiver of your right to an administrative hearing, and this order shall become
a'final order'.
Should this order become a final order, a party who is adversely affected by it is
entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings
are governed by the Florida Rules of Appellate Procedure. Such proceedings may be
commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the
Department of Health and a second copy, accompanied by the filing fees required by law,
with the Court of Appeal in the appropriate District Court. The notice must be filed within 30
days of rendition of the final order.
05-14-2012
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CERTIFICATE OF ELECTION TO BE EXEMPT 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: 05/14/2012 EXPIRATION DATE: 05/14/2014
PERSON: MIRANDA ADALBERTO
FEIN: 200996759
BUSINESS NAME AND ADDRESS:
A B T SEPTIC SERVICE INC
15870 SW 250TH ST
HOMESTEAD FL 33031-2048
SCOPES OF BUSINESS OR TRADE:
1- SEPTIC TANKS
IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer pt a corporation who elects exemption from this chapter by filing a certificate of election under this
section may not recover benefits or compensation udder this chapter. Pursuant 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 440.05(13), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject 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 shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section. "
f
DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-160
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA IMPORTANT
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who
CONSTRUCTION INDUSTRY 0 elects exemption from this chapter by filing a certificate of election
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this
WORKERS'COMPENSATION LAW
D chapter.
EFFECTIVE: 05/14/2012 EXPIRATION DATE: 05/14/2014
PERSON: ADALBERTO MIRANDA H Pursuant 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
FEIN: 200986759 R the notice of election to be exempt
BUSINESS NAME AND ADDRESS:
.. A B T-SEPTIC-SERVICE-INC .."... E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
15870 SW 250TH ST and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
HOMESTEAD:"FL"33031'=2.048 certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this
I- SEPTIC TANKS section.
QUESTIONS? (850) 413-1609
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
FROM :JL-.HERNANDEZ& ASSOC FAX NO. :305 378-9056 Jul. 18 2012 10:50AM P1
CERTIFICATE.OF LIABILITY INSURANCE DA0/18/12 Y,
•PRODUCER J.L..Hemandez 8 Associates,Ina THIS CERTIFICATE IS.lift AS A MA ER OF INFORMATION
18839 S.W.117th Ave. ONLY AND CONFE=RS NO FLIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES Nol AMEND,EXTEND OR j
Miami,FL 33177 l ALTER THE CQ1/ERAGE AFFORDED BY E POLICIES BELOW. I
Phone(305)238.7676 Fax (305)378-9056 _`INSURERS AFFORDING COVERAGE I NAIC 0
INSURER,a SCOTTSDALE it�SURANCE OMPAN a1'S+
INSURED ABT SEPTIC SERVICE INC./Adalberto Miranda
f I(V$URER B,",ASCENDANT CC'MMI=RCIAL' NSURAN
15870 SW 250th Street
'''• ' (USURER C.
Miami,FL 33031 ,••
j INSURER:D: '
INSURER E: i
INSURER F:
(I6�01.IGIES OF•INSURANCE LISTED HAVE B @EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOCI INDICATEA• NOTWITI•1STANDING
I `ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH"-HIS OFERTIFICA rE MAY BE ISSUED OR
'&q PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS O CONDITIONS OF SUCH �
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
li sdl Aooti POLICY EFFECTING POLICY EXPIRATIOAI' LIMITS : .I
I;Lrlt tNSRO I TYPE.OF INSURANCE _ POLICY NUMBER_ DATE()#,M/DWM I RATE(FAWDQW) I
GENERAL LIABILITY I EACH OCCUR ENCE I 2,000,Q00'
IVI 06MMERCIAL GCNERAL LIABILITY DAMAGE TO Ft NTED 50,0001
ICPS1321884 04/18/12 I OM78/13 PREMI$ES(Ea renoe)
+c T "ED EXP(Any+ nA person) 5000.
!,:•'• I II I'
CLAIMS MADE h/J OCCUR I '.e .. f
:A'I IVI PERSONAL$ DV INJURY 1,000,0001
II
'•i'r I GENERAL AG REGATE 1,000,0001
PRODUCTS MP/OPAGG 1,000,0001
GEN'L AGGREGATE LIMIT APPLIES PER' 4 {
F I P&ICY I I PROJECT ( J LOC
AUTOMOBILE LIABILITY �µ �^ COMBINED 811 IGLE LIMIT"
• ,;y•� I I' AIv,Y AUTO i• (Ea acohlentl
III f I ALL OWNED AUTOS BODILY INJU
IB 1 I IT SCHEDULEDAUTOS (.�Pwperson)..
HIRED AUTOS BODILY NON OWNED AUTOS
INJU
(Per
1. .1
I PROPERTY GE I I
c 1
(per aoddeno ". I
GtAR44 LIABILITY AUTO ONLY- ACCIDENT
..
•�^. ���° OTHER THAN EA ACC
AGO
..
i I AUTO ONLY:
1+'' EXCE$3tUMBRELL.A LIABILITY 4..
EACH OCCUF RENCE
• j1.:j
1 n #UR J CLAIMS MADE AGGREGATE
DPUCTIBLE
` I J DETENTION 3 i^rz t
tt " WORK8R8CbIRPENSATIONAND r $TA `. i 0711-
I.B i EKPLOYBR4h'4JABILJTY _„roum S ER
ANY PROPRI OR 1 PARTNER/EXECUTIVE ! E.L.EACH AC (DENT E
!%''• OFFICER 1 MEM$ER EXCLUDED? E.L DISEASE EA EMPLOYEE
If SP yes, P 15"IONS below E L DISEASE POLICY LIMIT
OTHER• ... .
. EQUiPMEf\Il FLOATER _ CPS1321884 1 04/18/12 Q4/18/13 65000 JOH AEERE B 041WX156878•
6 4cmPTlou OF•, ,(?ERATION$f LOCATIONS f VFFIICLE$f EXCLUSIONS ADDED BY ENDORSEAAENT J SPECIAL PRO JISION9
ISEPTIC TANI-INSTALLATION AND REPAIR,VERTIFICATE HOLDER IS ALSO NAMED INSURED
" .0tTIFICATE HOLDER CANCELLATION
<,•ar,:.. : I SHOULD ANY OF THE ABOVE 6nCRIBED FOLIC S BE CANCEIJ E0 BEFORE THE i
EXPIRATION DATE THEREOF,THE ISSUING INSU E WILL ENOEAV TO MAIL..,.,:,i
MIAMI SHORES VILLAGES 30 mAYs wRITTEN NOTICE TO THE C TE HOL rN ED To 1
10050 NE 2 AVE THE LEFT,BUT FAILURE TO DO Sad SH NO O R LIAo,,,,1,.t<�
''• OF ANY KIND UPON THE INSURER, AG S R S-
MI AMI SHORES,FL 33138
AUTHORIZED REPRESENTATI
I,r, 9i7E;:758-8972 i J.L. HERNANDEZ �
:�ACORD 29(211(11/08)OF � CDR[]CORPORATION 1981p••'