PL-14-1684Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-217151 Permit Number: PL -8-14-1684
Scheduled Inspection Date: November 12, 2014 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: GOLDSMITH, PETER Work Classification: Septic
Job Address: 141 NW 96 Street
Miami Shores, FL 33150- Phone Number
Project: <NONE> Parcel Number 1131010250110
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
Comments
REPLACE SEPTIC TANK AND DRAIN FIELD mrracuo Nassea comments
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS IN FILE
Failed
Correction
Needed
Re -Inspection
Fee 'S,o V2 v�
No Additional Inspections can be scheduled until
re -inspection fee is paid
November 10, 2014 For Inspections please call: (305)762-4949 Page 12 of 49
tom Miami Shores Village CRIN,PID
Building Department AUG 1.2014
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 JB
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949
FBC 2020
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑BUILDING
❑ ELECTRIC
❑ ROOFING
❑ REVISION
❑ EXTENSION
❑RENEWAL
PLUMBING
❑ MECHANICAL
❑PUBLICWORKS
[:]CHANGE
CONTRACTOR
❑ CANCELLATION
❑ SHOP
DRAWINGS
JOB ADDRESS: I (H NW ®g & Rt
City: Miami Shores County: Miami Dade Zip: 3 3 !s
Folio/Parcel#: 11 -5 10 0 2- 5-0110 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
. T
OWNER: Name Simple Titleholder): Lr
- �" �'�dn 14 -ne#:
Address:_ 144 N'is,) �(aaf -
City: FA S i2ln� State: re-� Zip: 31-1511c-
Tenant/Lessee
ulic
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: 9��' �d� (� �� "�"�t-1 Phone#: a �-G6
Address: V6(p Kl\"Kj 15 A
City:. • Coc" , State: Zip:
Qualifier Name: ( ID P -i Phone#:
State Certification or Registration #:
of Competency M
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ / Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
A
Description of Work:
Submittal Fee
Scanning Fee $
Notary
Permit Fee $ �")• CCF $ CO/CC $
Radon Fee $ DBPR $ Bond $25M. 60
Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 2-19 ( . o(�)
-ztG1. cy�j
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 occur seven (-7;h. a r the building permit is issued. In the absence of such posted notice, the
inspection will not be approve n r r gpection fee ill ed.
t&2042�==
NESignai Signature Ge
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this
this.L9 day of r X31 I 20J by
who is personally known to me or who has produced rL-A
V L4" As identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before meo05U
day of d 20�, by 4g4an2
who is p =nownor who has produced
tion and who did take an oath.
Y PUBLIC:
Sign: ''"r Sig
Print: i �°r'�s'), rant:
:aYPut� TERESA. J SOLOMON
My Commission Expires: X My Commi s'
=*• ': MY COMMISSION # EE131935
EXPIRES November 08. 2015 �yct P%Notary
public Strata of Florida
aS' `'; Joanna M Feliciano
4 My Commission FF 082753
(40 398 3 Fb7) 015AtlallotaryService.com q 018
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 44.0.0`
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project
prior to obtaining a building pennit. 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:
I . 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 rnaybe
personally liable for the worker compensation iniuries of any person allowed to work under this permit Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNIN(3 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERS'T'AND ITS
CONTENTS.
Owner
Print Name:
Signature
.. µ
State of Florida
County of Miami -Dade )
Sworn to and subscribed before me this
day of , 20(+.
By
(SEAL)_
Type of Identification produced 9-v tv �JGPr
Contractor
(��
Print Name: Teltl- ct
Signature: —O!L
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this
day of� ��/20
B ✓ P i f'�i�U�
(SEAL)
TERESA J SOLUM
.*= MY COMMISSION # EEt 20938
EXP RES November 08,
� I 1 F1*0yaN0terysery Ge.com
401) 398-0153
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Mariana Rodriguez
PROPERTY ADDRESS: 141 NW 96 St Miami, FL 33150
LOT: 11 BLOCK: 3 SUBDIVISION:
PROPERTY ID #: 11-3101-025-0110
PERMIT #:13 -SC -1547925
APPLICATION #: AP1152625
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR945061
[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 l GALLONS / GPD Septic CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 l GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps I
D [ 150 l SQUARE FEET Trench conflquration drain SYSTEM
R [ 0 1 SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: Ix] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE 12.7' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 38.40][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 74.40][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: 10.001 INCHES EXCAVATION REQUIRED: [ 36.001 INCHES
1. -Install a 900 gal min. septic tank with an approved filter.
O 2. -The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
T with s. 64E -6.013(3)(f), FAC.
3. -Install 150 sf of drainfield in bed configuration.
H 4. -Invert elevation of drainfield to be no less than 7.0' NGVD.
E 5. -Bottom of drainfield elevation to a no less than 6.5' NGVD.
6. -This permit includes the abado ant of the existing septic tank.
R � t
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: 07/16/2014
TITLE:
: Engineering Specialist II
Dade CHD
EXPIRATION DATE: 10/13/2014
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
V AP1152625 SE933559
IS'TATE OF FL OIZIUA
�E PAT-�;iLNT OF HEALTH
` F
APP( O SVVAGE "{Oi
_JF�—DISPOSAL SYSTEM CONSTP GsA W"
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�-�� �;5« Permit Applical or, INt;r,t)r � _---------
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Sca. Each biCCk represents 5 iu'et arid It inch= 50 f@r't-t Y 59t Jt'r r }
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ALL CHANGES MUST RE APPROVED BY THE COUNTY HEALTH DEPARTMENT
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