PL-13-1525Inspection Worksheet
Miami Shores Village
90050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSPA 94844 Permit Number. PL- 7- 131525
Scheduled Inspection Date: July 17, 2013 Permit Type: Plumbing - Residential
Inspector. Diaz, Osvaldo
Inspection Type: Final
Owner: PUGLISI, MICHALE & SANIBRINA 'Work Classification: Septic
Job Address: 1020 NE 904 Street
MIAMI SHORES, FL 33138-
Phone Number
Project: <NONE>
Parcel Number 9122320290250
Contractor: CHAPMAN SEPTIC SERVICE, INC. Phone: (305)818.9901
Building Department Comments
ABANDON EXISTING TANK AND INSTALL NEW SYSTEM Infractio Passed Comments
WITH 1050 GAL TANK AND 400 SQ FT OF DRAINFIfGI"D INSPECTOR COMMENTS False HRS IN FILE
Inspector Comments
Passed HRS IN FILE
`50� fG --vv4W_�k. a2s3,�C-- ,ITy�I� v
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled unfit
re- inspection fee Is paid.
98L -9 L000/9000d 165 -1 -WOti3 611:90 ST,-8T-LO
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,
JUL U 9.200
Byo°mo - .- .- 00000AOOPOeo
1560D ��� -113 FBC 20
BUILDING C"5 ermit No. I2�
PERMIT APPLICATION , Master permit No.
Permit Type: PLUMBING
JOB ADDRESS:
q
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 'It' °x'23 a " 0-I b -02so
Is the Building Historically Designated: Yes
NO of Flood Zone:
OWNER: Name (Fee Simple Titleholder): V - u911 b -1 Phone #:
City: fit $&W State: r( Zip: 3-3130
Tenant/Lessee Name: Phone #:
Email:
CONTRACTOR: Company Name: AA O.AAAAAAA
/ Phone #: a F 761
Address: V`pg� q;31911
City: 4W &AA4 eJ _ , State: r' Zip:
Qualifier Name: Phone#:
State Certification or Registration #: P Mh •� � ` � i �9 � Certificate of Competency #: _
Contact Phone#: VS- `6 057' 118 Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ o2 q (50 Square/Linear
Type of Work: OAddress OAlteration UNew
Description of Work: 46g" a ," st
Work: YOO
DDemolition
Submittal Fee
Scanning Fee $
Permit Fee $ 30 & CCF $ CO /CC $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
, -
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
zip
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.....
F
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
EWPROVEMENTS 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 �,�i Signature
Own or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this g
day of 20 12,, by M-,&W ?" 6.1 day of 2013 , by C A��
who h known to me or who has produced _ p y p who y known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
w
.:o We
'��` "� ve' %' Notary Public - State of Florida
My Commissi t
. . •_ My Comm. Expires Jun 15, 2013
Commission # DD 897782
° % %, �� ���0 Bonded Through National Notary Assn.
APPROVED BY A V'T /10--t12 Plans Examiner
Structural Review
(Revised3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
as identification and who did take an oath.
NOTARY PUBLIC:
Sign.
,,,5.. V P ,se'w ,. LI.
Print: {i �: Notary Public - State
My Comm. Expires Jun 15, 2013
My Commission mss; Commission # DD 897782
Bonded Through National Notary Assn.
•��r�r,��r,���ut����,�,r�r�r xa���* ��r��a��r���a�����4e�tedear &dnkdr9ede
zoning
Clerk
Jul 16 13 04:07p Chapman Septic Service
M/16/2010i/M 04:38 Phi Contractors Payroll
1- 305 - 453 -5537
FAX No,2397686387
p.1
P, 001/002
J
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMOUlYYYY]
09/16/2013 02--43 pR
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY DR 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 cerflcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. It SUBROGATION IS WANED,
subject to the terms and conditions of the policy, certain policies may require an endorsement. a statement on this certificate floes
not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
Highpoint Risk Servieas LLC
5501 LBJ Freeway, Suite 120DaDOags
Dallas, TX 75240
coNlac: ,yyie
naciae,xe,w; (860)72 &0623 raxu,c,NOS (972)4154 -0380
POLICY EXP
DATE (IANICOA -Y)
[NSURERS AFFORDING COVERAGE
"C/
INSURER A CwPanion Property e„a C. —I-ty r--- —ae y
12157
INSURED: AMS 1,(c/ t:
CHAPMAI3 SEPTIC SERVICE INC.
BOBO NW 51ST 5T
LAUDERMLL, FL 33351
Phon=_: (30 5) 561 -0628 Fax: (305) 453 -5537
INSURER 8:
INSURER C-
EALHOCCURRENCE
INSURER O:
DAMAGE 10 RENTED
INSURER E',
MEDEKP(GryPERSONAL
INSURER F:
&AJV INJURY
COVERAGES CERTIFICATE NUMBER: ACl =- 1500813- L215713 REVISION NUMBER:
NOPlJITHST.4NDING ANY REGUIREtdENT, TERh1 OR COPA71TIOtJ OF ANY CONTRACT OR OTHER DOCONIEN7 WITH ftES'ECT TO YVF:ICH THIS CERTIFICATE N4AY OE ISSUED OR MAY
PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES CESCRIDED'HEREIN ES SUBJECT TO ALL THE TEPAtS, EXCLUSIONS AND CONDITICt4S OF SUCH ?OLICIES LIMITS SHOWN
IMY HAVE SEEN REDUCED B" PAJD CLAMS.
INSR
LTR
TYPE OF INSURANCE
A00L
INS--
UBR
WV0
POLICY NUMBER
POLICY EFF
DATE [MMrODIYY)
POLICY EXP
DATE (IANICOA -Y)
LIMITS
GENERAL LIABILITY
COM.MERCLAL GE NE PAL LNBa.rTY
CLAIMS MADE ❑ OCCUR
El
❑
P
EALHOCCURRENCE
g
DAMAGE 10 RENTED
g
MEDEKP(GryPERSONAL
&AJV INJURY
g
GENERAL AGGREGATE
#
GEN'LAGGREGATE LIN1R AFPUrS PER.
POUC`r Tof LO•C
PRODUCTS - CCMR'CPA3G
AUTOMOBILE
LIABILITY
A.W AUTO
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SCHE OULEZI AUi'OS
HREOAUTOS
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(Ea acadeM)
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PROPERTYDAWOE
(Pei ardent)
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A
EMPLOYERS' LIABILITY ,,�
ANY PROP E.RIE(ORiEXECUTNE
OFFICER.tdEM9ER EXCWDE09 N❑
(Man4atory in NN)
H yes, describe under
SPECIAL PROVISION below
WA
DPE2627274C360
04/01.f 2013
04/01/2014
x C• LI S ER
E.L.EA.CHACCCENr
$ 1'000300
E.L.OISEASE -EA EMPLOYEE
E 1000000
E.L OISE!SE- POUCYULIT
S 1000000
DESCRIPTION OF OPEWITIONSJLOCATIONSNEHICLES (ATtached ACORD101, Additional Remarks Schedule, Ifmnre space is required
1. This certificate reMains in effect, provided the client's account is in goad standing with AM]. Coverage is
not provided for any employee for which the client is not reporting wades to AIRS. Applies t0 100% of the
employees of MIS leased to CKO&MAN SEPTIC SER'vICE INC., effect_ve 04/01/2013 2. Insured is afforded Wcrkers
COMPensatlon s EmplOyers liabili :y as a co- employer under Che policy far emplcyees leased Erom AMS.
ACORu z5 Izuiuiu5► V 1988.2010 ACORD CORPORATION. Ali right reserved.
SHOULD ANY OF THE ABOVE UEECIRIBED POLICIES BE CAN CELLED BEFORE THE
Vl bbAGE OF MIAMI $ROBES
EXPIRATION DATE THERECF. NOTICE WILL BE DEUVEREO IN A.CCOROANCE WITH
P:(305) 735 -2207 F:(305) 756 -8972
BUELDIWG C•EPARTMXI'lT
THE POLICY PROVISIONS.
L0050 NE 2ND AVE
M1A14= 5110RES, FL 33138
AUTHORIZED REPRESENTATIVE , :;;r
P
ACORu z5 Izuiuiu5► V 1988.2010 ACORD CORPORATION. Ali right reserved.
DIVISION OF
Environmental Health
�® Florida Department of Health
� Miami-Dade County Health Department Q OSTDS /Well Division ISO SW 26 St. •Miami, FL 33175
Inspector Date ! — IJ 13 /
jJ:,z?.7 _ �STDS # P����� 'Z-1
Address
Comments:
Signature
Jul 1613 04:07p Chapman Septic Service
JUL /16/2013/TUR 04.33 PM Contractors Payroll
BRIM, MCI ~'MA
FAX No.2397696387
p.2
P. 002/002
CERTIFICATE OF LIABILITY INSURANCE
CerWicate Number: AC13- 1500813.1213713
EMPLOYEE ROSTER
Attached roster includes employees paid through 07/0712013. To verify employee's who may have been added since
0710712013, please call 1- 800 -728 -0623.
x Please note employee roster for this client is updated on a WEEKLY basis.
Employee List
AESCHLIMAN, JOSEPH R.
AGUTAR, ROLANDO
CHAPMAN, CHARLES J
CHAPMAN, MELODY
HALL, DAVED
HALL, MICHAEL W.
LOPE7,ROBERTO
MACIAS, LAZAR.O
MOORE, JARRAID
MOORE, ROBERT
MORRIS,TOMMY C
REYES, ALEXANDER
RODRIGUEZ, JUAN
SIMO, ANNErM
WELCH, AL
711 6120 1 3
Page 1 of I
R
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIS SYSTEM
CONSTRUCTION PERMIT �F
GJl
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Michael Puglosi
PROPERTY ADDRESS: 1020 NE 104 St Miami, FL 33138
LOT: 12 BLOCK: 2 SUBDIVISION:
PROPERTY ID #: 11- 2232 -029 -0250
PERMIT #:13 -SC- 1474376
APPLICATION #:AP1109021
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR907458
[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 New Septic Tank CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 400 ] SQUARE FEET bed configuration drainfiel SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: Top of next
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
floor, 8.57' NGVD
[ 27.20][ INCHES FT ][ABOVE BELOW BENCHMARK /REFERENCE POINT
[ 57.20][ INCHES k FT ][ABOVE BELOW BENCHMARK /REFERENCE POINT
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 42.00] INCHES
This permit was amended on 07/01/13 due to existing tank size and discovered another system.
0 Inspector to verify the existing septic tank is properly abandoned before final approval.
T *Invert elevation of drainfield to be no less than 4.30' NGVD.
H *Bottom of drainfield elevation to be no less than 3.80' NGVD.
*Install 12" of slightly limited soil under the bottom of drainfield.
E - Perimeter of excavation area shall be at least 2 ft. wider and longer than the proposed absorption bed or drain trench.
'THIS PERMIT IS NOT FOR " ADDITION(s)
R 9 /
SPECIFICATIONS BY:
TITLE: Master Septic Tank Contractor
APPROVED BY: �g� tea/ TITLE: Dade CHD
DATE ISSUED: 05/28/2013 EXPIRATION DATE: 08/26/2013
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1.1.4 AP1109021 SE899589
Page 1 of 3
DOCUMENT #: PR907458
The system is sized for 4 bedrooms with a maximum occupancy of 8 persons (2 per bedroom), for a total estimated flow of
400 gpd.
The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s.
34E- 6.013(3)(f), FAC.
r
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.
LOT 13
BLOCK 2
43.15'(P)(All)
•4
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l, E. 104th STREET
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