PL-14-761Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 210906
Scheduled Inspection Date: April 17, 2014
Inspector: Diaz, Osvaldo
Owner: GOMEZ- BASSOLS, ISABEL
Job Address: 137 NE 92 Street
Miami Shores, FL 33138 -
Project: <NONE>
Contractor: CHAPMAN SEPTIC SERVICE, INC.
Bunding Department comments
ABANDEN EXISTING TANK. INSTALL 1050 GAL AND 667
SQFT DRAINFIELD
Permit Number: PL -4 -14 -761
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number
INSPECTOR COMMENTS False
1132060133170
Phone: (305)815 -9901
April 16, 2014 For Inspections please call: (305)762 -4949 Page 24 of 30
Inspector Comments
Passed
HRS IN FILE
t�[
Cy—
Failed
S
V'P C( (�
Correction
Needed
Re- Inspection
Fee
, �1
No Additional Inspections can
re- inspection fee is paid.
be scheduled until
1132060133170
Phone: (305)815 -9901
April 16, 2014 For Inspections please call: (305)762 -4949 Page 24 of 30
-'S. �b P
Miami Shores Village v '
am
�•� APR i62614
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 =^ I j-
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949'
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
FBC 20 U' 11
Permit No. P L- I q `7
Master Permit No `i 1
JOB ADDRESS: 13'1 p4j.
City: Miami Shores County. Miami Dade Zip:
Folio/Parcel#: L d • 3 ®ID B ��J "3 (Ti�
Is the Building Historically Designated: Yes NO ✓ Flood Zone:
OWNER: Name (Fee Simple Titleholder): TrS A a-&-Vv *2- Phone #:
Address: /S1 Y;e �bV
City: XL&440 StateX Zip: -M-1 �.r7
Tenant/Lessee Name: Phone #:
Email:
CONTRACT R: Company Name: + -FAV '{ Phone #: 4d �e Uv - tIO1
Address• _ 9-b X331 / - ^
city: fft
Qualifier Name:
sz.Z!3 zip:
Phone #: 3b�' �} S7 1W
State Certification or Registration #: fA& - Qq•GG(0•7 Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ d1bQ _,Se/Linear Footage of Work:
Type of Work: OAddress UAlteration iNew, ORepair/Replace
Description of Rork: "*Pz " 1(ALs' "6441- ZMK41.j% sgnn- of
Submittal Fee $ Permit Fee $ jf 3 'S�. CCF $ CO /CC $ -a—
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
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.....
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Own Agent Contractor
The foregoing ' trument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of {t, 20 /+ , by I$ a L BaSS6 day of QQt4 20 L, b
who is personally known to me or who has produced who is personally known to me or who has prod
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
My Commission Expires:
NOTARY PUBLIC:
My Commission Expires:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised3 /12i2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Apr 151401:17p
Chapman Septic Service
1- 305 -453 -5537 p.1
ACORN® CERTIFICATE OF LIABILITY INSURANCE
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41212014
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 pollaypes) must be endorsed If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, Certain policies may require an endorsement A statement on this certlficate does not confer rights to the
certificate holder in lieu of such andorseme s).
PRODDER Alliance Insurance Solutions LLC
7405 N Tamiami Trail
Sarasota, FL 34243
CNGANMTN:CT
PHONE 949- 308 -3077 FAX 727497-1281)
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ADDR
INS AFFORDING COVERAGE
NAIL V
INSURERA`SI)NZ Insurance Company
34762
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sssential HR, Inc., Essential HR II Mc
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INS URER a Asoen Ile - Landon - Best Rating "A"
INSURER C : Catlin Syndicate - Lloyds -Best Rating "A°
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INSURER 0: Brit Syndicaba - Ucyds - Best Rata 'W'
1AED EXP (Any one on
251 O'Connor Ridge Blvd
Suite 370
Irving TX 75038
INSURERE:
INSURER P
COVERAGES CERTIFICATE NUMBER: 19713646 REVISION NUMBER_
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TIBIA 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 IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IVm
TYPE OF INSURANCE
POLICY NUNBER
POLI
1 POLICVEXP
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE 7 OCCUR
EACH OCCURRENCE
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PREM S ce
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This � for informational purposes
and nothing shall Create any right
under such reinsurance.
Dr- WROMON OF OPERATIONS I LOCATIONS I WERICLE9 (ACORD 101. AddMorM Remarks Schedule. may be aftched It more syace to numbad)
Coverage provided for all leased employees but not subcontractors oft. CHAPMAAI SEPTIC SERVICE INC.
Effective date: 10/1/2013
Village of Miami Shores
10050 NE 2nd Avenue
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 POLICY PROVISIONS.
AUTHORIZED REPRESFDSiTAT{YE
1K
C.lnn t r11�Fci�,...
TION. AN rights resemed.
^%aw,mi au kAm -mu 11
I ne AUVK0 name and logo are registered marks of ACORD
CEIET NO.. 29713646 Todd Trowbridge 41'2/2014 10:38:42 AX Page 1 of 1
STATE OF FLORIDA
DEPARTHIENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Ise Gomez
PERMIT #: 13-SC-1462967
APPLICATION #: AP1102025
DATE PAID:
FEE PAID:
RECEIPT #:
wcum 1T #: PR902314
PROPERTY ADDRESS: 137 NE 92 St Miami, FL 33175
LOT: 1819 BLOCK: 23 SUBDIVISION:
PROPERTY ID #• 11- 3106 - 013 -3170 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBM]
IOR TAX ID NUMBER]
SYSTEM MUST BE CCNSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STA )ARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERBORMANCE 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 I
1,050 ]
GALLONS / GPD Septic
CAPACITY
A [
]
CQ%LLONS / GPD N/A
CAPACITY
N I
]
GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK: 3.250 GALLONS]
K I
]
GALLONS DOSING TANK CAPACITY I
IGALLaNS 01 ]DOSES PER 24 HRS #Pumps I
D [ 667 1 SQUARE FEET
R I ] SQUARE FEET
A TYPE SYSTEM: Ix]
I CONFIGURATION: [ l
N
F LOCATION OF B=CHMARK:
SYSTEM
N/A SYSTEM
STANDARD I ] FILLED I ] MOIIAID I I
TRENCH Isl BED I ]
Crown of Road 9.85' NE 92 Street
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED: 1 0.00 1 INCHES
0
T
H
E
R
1 10. 20 ] I INCHES FT ] I ABOVE iBELOW BENcHM;uwREFERENCE POINT
[ 40.20][ IIdCHE3 FT ]I ABOVE BELOW BENCHMARK /REFERENCE POINT
EXCANATICH REQUIRED: [ 72.001 INCHES
I.-Install a 1050 gal min. septic tank with an approved filter.
2. -The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
with s. 64E- 6.013(3)(0, FAC.
3.4nstali 667 sf of drainfield in bed configuration.
4.- Install42" of slightly limited soil at #4 bottom of the drainfield.
5.- Perimeter of excavation area shalt be at least 2 ft wider and longer than the proposed absorption bed.
(Comments Continued on Page 2.)
SPECIFICATIONS BY: Charles J Chapman
TITLE: Master Septic Tank Contractor
APPROVED BY: TITLE: Engin8sriug Specialist II Dade CHO
Nicole V Gofts
DATE ISSUED: 05130/2013 EXPIRATION DATE: 11/30/2014
DH 4016, 08/09 (Obsoletes all pxwAcus editions which may not be used)
Incorporated: 642- 6.003, FAC Page 1 of 3
v 1.1.4 AP1102025 SES99864
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT: Ise Gomez
APPLTCATION #:AP11 126
HERMIT #:13` yC 1462967
DOCUMENT #: F19501.5-7,'_..
DATE PAID :03/25/2013
FEE PAID :375.00
RECEIPT #:13 -PID- 2106731
AGENT- r hgmmnn. Ccnfir_ -
FL 33175
BLOCK: 23
ON*
ID #: 11- 3106 - 013 -3170
IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED,. -.
] 121 [ l
Concrete [ ]
[ ]
N ] [ l
[ l
2. [ 1
[ l
[ l
[ ]
] SQFT [ ]
1 _ HEADER X I 7
1. 9.00 2. [ ]
SETBACKS
[27]
SURFACE WATER
. -.FT
[281
DITCW,S �y
-- FT'
-��FT
[291
PRIVATE WELLS
1
[301
P17BLIC WELLS
FT
rQA
IRRIGATION WELLS
FT
[32]
POTABLE, WATER
sch40 /2 FT
[33]
ID #: 11- 3106 - 013 -3170
IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED,. -.
] 121 [ l
Concrete [ ]
[ ]
N ] [ l
[ l
2. [ 1
[ l
[ l
[ ]
] SQFT [ ]
1 _ HEADER X I 7
1. 9.00 2. [ ]
SETBACKS
[27]
SURFACE WATER
. -.FT
[281
DITCW,S �y
-- FT'
-��FT
[291
PRIVATE WELLS
[301
P17BLIC WELLS
FT
[31]
IRRIGATION WELLS
FT
[32]
POTABLE, WATER
sch40 /2 FT
[33]
BUILDING FOUNDATIONS
5 FT
[341
PROPERTY LINES
°10 FT
[35]
OTHER _ _
-FT
FILLED / NOUND SYSTEM
[361
DRAINFIELD COVER
-_.-
[371
SHOULDERS
[38]
SLOPES
[39]
STABILIZATION
{ ADDITIONAL INFORMATION,
BELOW ]BM 7.92 [ ] [40] UNOBSTRUCTED AREA: n
(V1
O 0 w [ ] [ 41 ] STORMWATr.'.i +. -W., . L'
'!�[ l [42] ALAP.i+lS
�� S [ 1 [43] MAINTENANCE AGREEMENT
�j E 3 [ l [44] BUILDING AREA
M Q Q [ ] [45] LOCATION CONFORMS WITH SITE PLAN rA V [ ] [46] FINAL SITE GRADING
[ ] [471 CONTRACTOR Charles J Chapman (Chapma
[ ] [48] OTHER '•
ABANDONMENT
[ ] [ 491 TANK. PUMPED 03/31/2014
[ ] [261 REPLACEMENT MATERIAL I I [501 TANK CRUSHED 6 FILLED Q3/3112044-
Comments: Comments are on page 2.
CONSTRUCTION [ APPROVED
DISAPPROVED l:
FINAL SYSTEM [ AppRO / DISAPPROVED ];
(Explanation of Violations on following page)
DH 4016, 08/09 (Obsoletes all previous editions
Incorporated: 64E- 6.003, FAC
EH Database v 1.0.1
Dade CHD DATE: 03/31/2014.
A Health In Dade Cou - -
Da0e CHD DATE: 04/14/2014
ofwi -al r n bade Co
� r may not be used)
102026 EID1462967
Page 2 of 3