PL-14-2025Miami Shores Village
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
BUILDING
PERMIT APPLICATION
❑ BUILDING ❑ ELECTRIC ❑ ROOFING
FBC 200
Master Permit No. e I L4-
Sub Permit No.
IN
1.6 2014
❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: G 3 ME 01 'St
City: Miami Shores County Miami Dade Zin: 33 y3 y
Folio/Parcel#: 11 ® 5ZO ro 0 013 —V 12-0, Is the Building Historically Designated: Yes NO �
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):, sr I A. N:j. Phone#: 7&6 S 64441 S
Address:_-G"3a NE Ott ST
City: t 1(k 1 v-ej State: pt— Zip: 3 2� t 3 t?
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: �-�) G Gljy-'� i -IC Phone#: 3®S-6,61 '66_3�;
Address: `�S CA"Q N ORi ic, e)L4,., *is
City: Q pc, Lo c K_ 4 State: Zip:
Qualifier Name: TeiP-s1 cm(00re%.0-moo Phone#:
State Certification or Registration #: &M ® "O -I 12-6 z Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address City: State: Zip:
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration i ❑ New fl Repair/Replace ❑ Demolition
Description of Work: 'Zt2 A C Q
Specify color of color thru tile:
Submittal Fee $ GO '010 Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $_
DBPR $
CO/CC $ °
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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.
r
Signature Signature
, NERorAGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of Ste e- orb O , 20 1C1- , by /9t7 day of -S& f -J • '20 , , by
(1,vAa Pti+�g .who is personally known to �a-: S'dlayy'? who is personally known to
me or who has produced �� �� tV L _` eeAW as me or who has produced -
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:�J
Print: T c-
Seal• ` .'., TERESA J SOLOMON
_�• r MY COMMISSION # EE131935
,.:Ir
, .r EXPIRES November 08, 2015
Seal:
APPROVED BY 16�7`F Plans Examiner
Structural Review
(Revised02/24/2014)
ow "P4 _
Notary public Stat
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SOF eo1` Ex -smmission FF 082753
p a 01112/2018
Zoning
Clerk
SEP -04-2014 21:37 From:
Report Viewer
To:3057568972
ZF AlWA7sR
CHIEF FNtANCIAL oppk"
STATE OF FLORIDA
DEPA
ERVICES
DIVISION OF OR ERS'COMPENSATION
*" CERTIFICATE OF WXCTTON TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW •
CONSTRUCTION INDUSTRY EXEMPTION
This Ceffirms that the ind4dUai Ilsted be►W has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: aW2014 EXPIRATION DATE: 8/2412096
PERSON: SOLOMON TERFS
J
FEIN: 460.475464
BUSINESS NAME AND ADDRESS:
STATEWIDE SEPTIC CONNECTIONS 1NO
13840 NW 99 AVE BAY #10
OPA LOCKA FL 33054
SCOPES OF BUSINESS OR TRADE:
SEWER CONSTRUCTION
ALL OPERATI
M"F2.0ikc 851 CERTIMCrATr; OF ELWTIONTO EE EXW"REVIS#M 07-12
—9ft o
QUESTION- JfiWMt3.jM9
Pase:1/1
Page 1ofI
F 1
• rC . � f
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Carla Peters
PROPERTY ADDRESS: 63 NE 91 St Miami, FL 33138
LOT: 19 20 BLOCK: 1 SUBDIVISION:
PROPERTY ID #: 11-3206-013-0120
PERMIT #:13 -SC -1559696
APPLICATION #: AP1159510
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT # : PR950"8
[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 [ 900 ] GALLONS / GPD existinq septic tank to remain 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 [ 300 ] SQUARE FEET new bed confiq. drainfield SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ I. FILLED [ ] MOUND
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: FFE 13.7' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 25.20][
E BOTTOM OF DRAINFIELD TO BE [ 63.24][
L
FT ][ABOVE 4p4LOWj BENCHMARK/REFERENCE POINT
FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: 138.00] INCHES
1.-Existin I. septic tank, certified by "Statewide Septic" on 9/9/2014 to remain.
O 2.-InstU3 drainfield in bed configuration.
T 3. -Pers r 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 8.93' NGVD.
H 5. -Bottom of drainfield elevation to be no less than 8.43' NGVD.
RThe system is sized for 3 bed with a max occupancy f 6�arson (2 per bed), for a total est flow of 400 gpd.
THIS PERMIT IS NOT FOR ANY ADDITIONS.
SPECIFICATIONS BY: Ygdeisy Martin \AMTITLE:
APPROVED BY:
DATE ISSUED: 09/15/2014
DH 4016, 08/09 (Obsoletes all previous editions which majt not be used)
Incorporated: 64E-6.003, FAC
Dade CHD
EXPIRATION DATE 12/14/2014
v 1.1.4 AP1159510 SE938416
Page 1 of 3
'rz _ATE OF FLORIUA
DLE-PARTM[_:_:NT OF HEALTH
APPLICATION FOR
1jC TION PCR-Mcf-
ONSITE SEVVAGEL DISPOSAL SYSTEM GOINSTF: I
Permit Applical on tNunibef
L
-- ---- — PARI II -SITE PLAN - 1-W
Sca-te'- Each block represents 5 feet arid inch = 50 feet.
91 a I
SitE Plan submitted by:
Plan Aboriiived
By-
.�� It q
re
Not Approved _
C VY.C410-111-
Ttk,
D at P,
, I En
—ounty Health Depart rv�
ALL CHANGES MUST BE APPROVED BY TETE COUNTY HEALTH DEPARTMEINT
9L( 40'5. 101 )5 (ReplarAG which may be tv;wj)
I
.5turk Wfrixx: 574A Cr.2.4015.61
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project
prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate
officers or members of a limited liability company (LLC) in the construction industry may
elect to be exempt if:
1. The officer owns at least 10 percent of the stock of the corporation, or in the case
of an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members
are allowed to be exempt. Construction exemptions are valid for a period of two years or until
a voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your
insurance carver since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Contractor
Print Name: ea vM Print Name:: Ee,
Signature: Signature:_e c
State of Florida) State of Florida)
County of Miami -Dade) County of Miami -Dade) ®�
Sworn to and subscribed before me this Sworn to and subscribed before me s N 0. in
day of , 20 ��- day o , 20 ; ; C
w„m
By Q r la re gr_S By`®`� �`' m c T
(SE ) C_ J`�
Type o tification produced Y TERESA J SOLO fIdentifi o uc
='i '*: MY COMMISSION # EE131935
�' _•�_ EXPIRES November 08, 2015