PL-14-2213Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-221254 Permit Number: PL -10-14-2213
Scheduled Inspection Date: November 06, 2014 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: LUBINSKI, STEVEN Work Classification: Septic
Job Address: 100 NE 95 Street
Miami Shores, FL Phone Number (305)345-4629
Parcel Number 1132060132860
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
duliiaing Department comments
REPLACE SEPTIC TANK AND DRAIN FIELD.
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS IN FILE
OV—
Failed
Correction ❑ � � ��
Needed
Re -Inspection ❑ ,b
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
November 05, 2014 For Inspections please call: (305)762-4949 Page 12 of 35
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Miami Shores Village
BuildingDepartment ^'
p EICEINTED
0 l o 8 204
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 _- °
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FB C 20
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
nnONTRACTOR DRAWINGS
JOB ADDRESS: ® C3 `t Co
City: Miami Shores County: Miami Dade Zip: 33 1319
Folio/Parcel#: 11 ` 52-067- 10 (?j d 28 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple
1Tiittlleholdder): � - Fc_y 2 .� i Yt S b� C Phone#: 305-3`f5- �� 2 l
1' Address: /0 ® /v !— c S_ St
p
City: M t u VSI, k o V P -S State: FL Zip: 3 31 3 D
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name: � '���2� e ico �'` I "IC Phone#:
Address:)
f 30 4p N w 1q &vy, s
City: ®e. LoC6'`ck State: - Zip:
Qualifier Name: � 41 Phone#:
State Certification or Registration #: CAA <:) I 7 I 'LC 2 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 0.9 Square/Linear Footage of Work: 2 Z S
Type of Work: ❑ Addition ❑ Alteration ❑ New Xi Repair/Replace ❑ Demolition
Description of Work: C_ nce, S -c2 -T, C., 4 -Ar) )C-
ar,4 f -eI d
Specify color of color thru tile:
Submittal Fee $ CO Permit Fee $ 00, CCF $ b _® CO/CC $
Scanning Fee $ C�7 , CD Radon Fee $ �� DBPR $ Notary $ �J
Technology Fee $ - Training/Education Fee $ I ' Double Fee $
Structural Reviews $ 019 Bond $
TOTAL FEE NOW DUE $ ?,9j2 e G O
(Revised02/24/2014) 'z� B 2 -,GO
_i
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
r.?•
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.
Alk Signature A;a�a
OWNER or AGENT
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
The foregoing instrument was acknowledged before me this
0 day of At
�-Ii 14-1 , 20 , by
day of
, 20 1 . by
t who is personally known to
%1".
who is s na y no�,to
me or who has produced
— as
me or who has produced — as
identification and who did take an oath. g :•-'So
identification and who did take an oath.
NOTARY PUBLIC:
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NOTARY PUBLIC:
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APPROVED BY
Plans Examiner
Zoning
Structural Review
(RevisedO2/24/2014)
Clerk
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Miami pores Ve
9illa
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 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 SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner
Print Name: J �, h
Signature:
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this
day of ()C` , 20 .
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(SEAL) Pz-�. 19-, kf t A
Type of Identification produced
Contractor
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Print Name.
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State of Florida )
N1 ;
County of Miami -Dade) ► I I I n!+ //'�
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Sworn to sybs�cribed befo�`in this
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dayLU
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By
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Type of Identification produced
/�i/�/ll! 11l I 111114��`t�
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'
— ' �e� PERMIT #:13 -SC -1557756
APPLICATION #: AP1158421
STATE OF FLORIDA
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPO — SEE PAID:
CONSTRUCTION PERMIT.�T��.-' r (' '
RECEIPT #:
OCTAs 2014, Do�mENT # : PR949682
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Steve Lubinski
PROPERTY ADDRESS: 100 NE 95 St Miami, FL 33138
LOT: 1314 BLOCK: 21 SUBDIVISION:
PROPERTY ID #: 11-3206-013-2860 [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 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 [ 225 ] SQUARE FEET trench configuration drainf SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE 12.6' NGVQ
I ELEVATION OF PROPOSED SYSTEM SITE [ 31.20][ INCHES FT ][ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 69.24][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 38.001 INCHES
1. -Install 900 gal in. septic tank with an approved filter.
0 2. -The li contractor installing the system is responsible for installing the minimum category of tank in accordance
T with s. 6Perof
3(3)(f), FAC.
H 3.-Installof drainfield in trench configuration.
4.-Perimxcavation area shall be at least 2 ft wi erJ,,,.nd longer than the proposed absorption bed or drain trench.
E (Comments Continued on Page 2.)i
R I t [',
SPECIFICATIONS BY: Yudeisy Martin )� TITLE:
i
APPROVED BY: TL': _. a D;?�2 CHD
DATE ISSUED: 09/08/2014 EXPIRATION �DATE 12107/014'"'
DH 4016, 08/09 (Obsoletes all previous editions which may not: be used)•'
Incorporated: 64E-6.003, FAC Pagel 0,^3i
V 1.1 4 AP1158421
DOCUMENT #: PR949682
5. -Invert elevation of drainfield to be no less than 7.33' NGVD.
6. -Bottom of drainfield elevation to be no less than 6.83' NGVD.
7. -This permit includes the abandonment of the existing septic tank.
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
300 gpd.
THIS PERMIT IS NOT FOR ANY ADDITIONS.