PL-14-1678Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-217099 Permit Number: PL -7-14-1678
Scheduled Inspection Date: September 09, 2014 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: BLUMBERG, EDWARD Work Classification: Drainfield
Job Address: 130 NW 103 Street
Miami Shores, FL 33150 -
Project: <NONE>
Phone Number
Parcel Number 1131010220020
Contractor: A AMERICAN SEPTIC & PLUMBING Phone: (305)866-5600
tsunaling uepanment comments
DRAINFIELD Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS ON FILE
Failed '
e'-7 �
Correction
Needed ❑ CP'k_-_
Re -Inspection ❑�
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
September 08, 2014 For Inspections please call: (305)762-4949 Page 9 of 28
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Sep 04 14 09:24a Billy Williams
770-529-1117 p.1
Invoice
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795-2204 Fax: (305)756-8972
For Inspections please call: (305)7624949
eturn to:
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Bill To
FEDWARDLUMBERG
AYNE Boulevard 28023152
Invoice Number.
PL -744-52470
Invoice Date:
J!41y.31.,:.2074_
Permit Numb er:
PL -744-1678
Bond A�rnber:
r'%
mments:
Date
Fee Name
07/31/2014
CCF
Fee Type
Fee Amount
07/3112014
DBPR Fee
Calculated
$1.80
07/3112014
Permit Fee
Calculated
$2.25
07131/2014
Technology Fee
Percentage
$150.00
07131/2014
Scanning Fee
Calculated
$2.40
07/31/2014
Education Surcharge
Calculated
$9.00
07/31/2014
DCA Fee
Calculated
$0.60
Calculated
$2.25
Total Fees Due:
$168.30
Thursday, July 31, 2014
Sep 04 14 09:24a Billy Williams 770-529-1117 p.2
c a 11e) or
Miami Shores Village ' Jul 31 W4
M Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20tO
BUILDING (waster Permit No.
PERMIT APPLICATION Sub Permit No. I l �1
[-]BUILDING ❑ ELECTRIC ROOFING ❑ REVISION [] EXTENSION ❑ RENEWAL
[PLUMBING ❑ MECHANICAL [-]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Specify color of color thru We:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revisedo2/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
CONTRACTOR DRAWINGS
JT_
G `Ir
JOB ADDRESS:
City: Miami Shores County:
Miami Dade Zip:
Folio/Parcel#: Iyt — 31® I ^ 0 `Z � n0 0-0
Is the Building Historically Designated: Yes NO )—
Occupancy Type: X Load: X Construction Type:
Flood Zone: x BFE: K FFE: k
`� loz-r Phone#:
OWNER: Name (Fee Simple Titleholder): tom//' If -%G
�
Address:
City: State:
��,,
F--0
Tenant/Lessee Name: I`" c a ' 4 '� ty' w OU ,
Phone#:
Email:
CONTRACTOR: Company "r` cg p
i c `f � L` W'n P ne#: 30S ?4(9- 51000
Name:
Address: 12556 CJ' s c" hZ 61 -id + 9, au
City: 0 i 6-vvt I State:
�ti Zip: I
++
Qualifier Name: I0 � � ll an t f,'v 1y Ali
Phone#:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer: 0 IA'
Phone#:
Address:
City: State: Zip:
Value of Work for this Permit: $ ® •
Square/Linear Footage of Work: 9 'dl y i r
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru We:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revisedo2/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable) �p
Bonding Company's Address
City State np ZIP
Mortgage Lender's Name (if applicable) R
Mortgage lender's Address
city State
Application is hereby made to obtain a permit to do the work and installations as Indicated. 1 o>trtiiyt 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 ELECTRIC, PLUMBING, SiGNS, POOLS,
FURNACES, BOILED, HEATERS, TANKS, AIR CONDMONERS, ECC..».
OWNER'S AFFIDAVIT: 1 certify that all the foregoing Information Is accurate and that an work will be done in compliance with all
app0cable Taws regulating construction wW toning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT iN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERYY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Natke to App!leart As a cm thin to the issuance of a buk ft permit with an estlmoted value ftwaft 52500, the appNcant must
promise to good" dart a copy of the rice of commencement and construction sten yaw brochure w2i be deRvered to die person
whose property is subject to attachment Also, a certftd copy of the recorded notke of cornmeruement must be posted at Me Jab site
for the lbst inspection whkh occurs seven M days after the bukft permit Is Issued. in the absence of such pasted rmtke, the
inspection wifi not be approved and a re&npection fee will be charged.
Signature
ER or
the foregoing instrument was admoiMedged before me this
S$$
day of 20 1A . by
N Ll Ii14who Istersonallky knvwn jo
Signature
CONTRACTOR
The foregoing instrument was admowiedged before me this
t day of tA�l 20 , by
me or who has produced as me or who has produced as
identification and who did take an oath.
Identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print:�N"'" •, JESSIDFLOM Print aL
a �x Notary Publicida SosY PuSeal: myComm, ib 115 Seal: a : ,. ,H ifARBARA ZEEt8ANComadssto**EX COMMISSION TEE 860109
�,EXPIRES: February 15, 2017
Beaded areugh san. ��o BoW lieu Sa"
����gaq�t��ggq ggNNgiq���/�ggSirri�gt�q�gi�t�e�gHq�H�q�N�gN gq�q���ggiiq��N��q1
APPROVED BY -7'- 1 Y Plans Examiner
Structural Review
(Re*eAV24/W14)
zonhtg
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITB SE>IitAGE TREpiMONT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTICH PERMIT FOR: OSTDS Repair
APPLICANT: Edward Blumberg
PROPERTY ADDRESS: 130 NW 103 St Miami, FL 33150
LOT: 4 6 BLOCK: 1 SUBDIVISION:
PERMIT #:.13 -SC -1561394
APPLICATION #: AP 1154715
DATE PAID:
FEE PAM:
RECEIPT #:
Docm4mT#: PR946232
PROPERTY ID #: 11-3101-022-0020 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE
WITH SPECIFICATIONS
AND STAMARDS
OF SECTION
381.0065, F.S., AMID 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 EX04P P
THE APPLICANT FRdM COMPLIANCE WITH OTHER
FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATICNS
T [ 900 I GALLONS / GPD existinq Septic tank CAPACITY
A [ 0 I GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ IGALLONS S[ IDOSES PER 24 HRS #PIMPS [
D [ 200 ] sgamm FEET trench configuration drainf SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ I
I CONFIGURATION: [xl TRENCH [ ] BED [ ]
N
F LOChTICN OF BENCHMARK: FFE 12.4' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 22.80 M INCHES FT I[ABOVE BELOW BENCM4iRK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 64.80][ INCHES FT IIABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 42.001 INCHES
0
T
H
E
R
1. -Existing 900 gal. septic tank, certified by "A American Septic & Plumbing" on 7/25/2014 to remain.
2. -Install 200 sf of drainfield in trench configuration.
3. -Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench.
4. -Invert elevation of drainfield to be no less than 7.50' NGVD.
5. -Bottom of drainfield elevation to be no less than 7.00' NGVD.
(Comments Continued on Page 2.)
SPECIFICATIONS BY: William M Woodard TITLE:
APPROVED BY: TITLE: Engineering Specialist II Dade CHD
Betsy- Lange-01MU--
DATE ISSUED: 07/28/2014 EXPIRATICH DATE: 10/26/2014
DH 4016, 08/09 (Cbsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1154715 SE934661
DOCLUMM #: PR946232
system is sized for 2 bedrooms with a maiamum occupancy of 4 persons (2 per bedroom), for a total estimated flown of
9pd.
's PERMIT IS NOT FOR ANY ADDITIONS.
:) 07/31/2014 4:27 PM Fax Services 4 13057568972 0 1
AAMER-1 OP ID: YL
CERTIFICATE OF LIABILITY INSURANCE DATE(RAMIDDIYYYY)
07/31/2014
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 POLICIO
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 poilcy(les) 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 certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Ocala
AME: 13ARTOW
01 SW College Rd Suite 3N0.
Ocala, FL 34474
E,nt: 352-237-2700 ac Ne 352-237-5$84
BARTOW
E-MAIL ..) .._.___............. :...
AppREss;.._.................. ........... ... ....................... ..
...... INSURER(SI AFFORDING CpVE!}AOE _ • ..._•...... __•_ I• NAIC la
- _......_
INSURED A American Septic & Plumbing
INSURER A: Federated National Insurance"
Inc
INSURER 5: .Southern Insurance Co
.. .......... ti
12555 Biscayne Blvd Ste 970
INSURER C,:
North Miami, FL 33181
INSURER O: ........... ... _ ._ _ ._....
....... ................
rNsuRER c ;
COVERAGES reo rrrn.. ......... _
INSURER F - '
STED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE OR THE POLICY PERI D
THIS 15 '('O CERTIFY THAT THE POLICIES OF INSURANCE LI
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T IS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEFL S,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LSR TYPE OF INSURANCE
POLICY NU1R®ER M99lDD/Y Y UMITS
A X COMMERCIAL 66NSRAL LIABILITY
g EACH OCCURRENCE 5 1,.000,00+
I
CLAIMS -MADE C eccuR GL -0000021685-00 bAMA65 ` 0�4F=NT€5 ..-_.._..._.......
104/1312014 04/13/2015 1001004
MED EXP p
............. (�Yor� ersony...... $ 5.001
"' ; PERSONAL &ADV INJURY ,_,• ,$ 11000,001
GEN'LAGGREGATf I.NAiTgt'PLli:EI'Ek ..... _..-••
X POLICY 1 PRO GENERAL AGGREGATE $ 2,000 001
kcl LOC ! ......
PRODUCTS -COMP/OP AGG S 2,000,00(
OTHER —••
AUTOMOBILE LUUSIUTY
M81 $
La
ANY AUTO ..._.,
ALL OWNEDBODILY
SCHEDULED
INJURY (Per person)
$
At1T03
AUTOS
NON OWNED
-- �_—• --
BODILY INJURY (Per aCCltlent)
S
HIREDAUTOS
AUTOS
PiSOPERTY DAMAGE;
"
UMBRELLA UAB
OCCUR
EXCESS LAB
I I
CLAWS -MADE
EACH OCCURRENCE
s — µF
DED I RETFNTInwn a
At.GRE.GAT9:
.................. .... ... ........
. $
AND EMPLOYERS' LIABILITY
B :ANY PR0PRIFTn3R/PAPTmran
:11mandsloM in NHI
if yes de=1be and
_2014 ! 02103/Z
STAT r OTIi
!NIA `PWC008812-14 02/03/016 EL EACH ACCIDENT
Y�
i..._._
El DISEASE -EA EMPLOYEt S 1
DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLE8 (ACORD 101, Additional Remarks schedule, may De attached It more sPaca Is required)
4illiatti Woodard Excluded from Workers Compensation Coverage
tegistered S®Ptic Tank Contractors
AMISH
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE
Miami Shares, FL 33138 BARTOW
ACORD 25 (2014101 01988.2014 ACORD CORPORATION. All rights reserved.
1 The ACORD name and logo are registered marks of ACORD