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PL-14-2378Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-222651 Scheduled Inspection Date: November 04, 2014 Inspector: Diaz, Osvaldo Owner: TUBBS, WILLIAM AND VICTORIA Job Address: 273 NW 92 Street Miami Shores, FL 33150 - Project: <NONE> Contractor: NU BLACK SEPTIC & DRAINFIELD COMPANY sunning Department comments Permit Number: PL -10-14-2378 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number (786)376-2959 Parcel Number 1131010331150 Phone: (954)410-2589 INSTALL 200 SQ FT DRAIN FIELD AND REPLACE THE Infractio Passed Comments OLD ONE I INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-222499. HRS IN FILE SOD REQUIRED Failed Correction Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. November 03, 2014 For Inspections please call: (305)762-4949 Page 26 of 33 DIVISION Of EnAmnnmtal Health .Florida Health Miami-Dade County OSTDS/Well Diion 11805 SW 26- Street • Miami, FL 33175 �® Inspector os eAr r Date 102 Address 2-7 3 N q 2V— OSTDS # A"r 1 3 70 Comments: Signature s Miami Shores Village - RL2014 C Building DepartmentEBYK-1- INSPECTIONOCT 2 10050 N.E.2nd Avenue, Miami Shores, Florida 33138Tel: (305) 795-2204 Fax: (305) 756-8972 LINE PHONE NUMBER: (305) 762-4949 FBC 2010 BUILDING Master Permit No.? L N — 2 _ V PERMIT APPLICATION Sub Permit No. ❑B'UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL 0�#LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP A CONTR,4CTOR DRAWINGS A ay J. [ r Q �cV-5-t. JOB ADDRESS: r71 l � /\i •_W •� ` �� City Miami Shores County Miami Dade Zig): 3315_0_17o 3 v Folio/Parcel#:� _ .� I CJ (- Q 3 3 _ l 15 Cb Is the Building Historically Designated: Yes NO V" Occupancy Type: Load: Construction Type: OWNER: Name (Fee Simple Titleholder): �i g[ Q Address: � � 3 _ J' god Zone: BFE: FFE: nA ° Flog t2o- X15-0-- a30 City iVl_f ($ aY1 �VIoG� S _ State: Zip: Tenant/Lessee Name: Phone#: Email: ��—e`` ��4r-1 CONTRACTOR: Company Name: /14 U MCI] t i!a I`" ♦ • Qualifier Name: State Certification or Registration#: Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: 95q J 4q7-140 Address: City: State: Zip: Value of Work for this Permit: $ .In�b 06 Square/Linear Footage of Work: a lJ Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: C' a S o 0 ( c d d 5t Specify colocr of color t ru tile: Submittal Fee ® Permit Fee $ —1' z7 CCF $ CO/CC $ Scanning Fee $ 4"71 2 Radon Fee $. DBPR $ Notary $ Technology Fee $ Training/Education Fee $ G ' Double Fee $ Structural Reviews $ Bond $ 175DO • 4 C --r Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address Zip city State 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 $2.500, 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. OWNER The foregoing instrumentwasacknowledged before a this day of ®C+y IpC� t' , 20 by 1� Q U14 4CIL 4 Q • . who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: t" 0"J. Print:ll`l1,c.bo f' Ate6fa,Lj ata ,6 S gna�ure CONTRACTOR The foregoing instruments acknowledged before this A day of �QG 1 37 L� t— , 20 by 3IA 6%l d MU L4 -Sa- , who is personally known to - M@ or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign ad KziG ✓� C� Print: i-nic-haq / �lr tAi-e.4 C� �S Seal' Seal: MICHAEL AUBM ONNE3 MICIMEL AUBRSY GAINES MY COMMISSION 0 EE191 M MY COMMMION 11 EE191132 EXPRES Apt! 19.2018 **ssas* �9i9*+�*ss�r*rrsmss.*e*Kimr+r* . �srr *sr+ra�xs*�xr saeo�s3 APPROVED BY Plans Examiner Zoning Structural Review Clerk REGISTERED SEPTIC TANK CONTRACTOR BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2414 THROUGH SEPTEMBER 30; 2015 DBA: Business Name: DAVID NUBY NU BLACK SEPTIC `GAWK Receipt #:189-4258 DRAIN Business Type:ALL (SEPTIC TANK TYPES CONTRACTOR Owner Name: DAVID NUBY Business Location: 27 NW 4 AVE Business Opened: o 8/ o 1/ 19 8 9 DANIA BEACH fAt91County/Cert/Re9:SR931118 Business Phone: 954-927-4090 Exemption Code: Rooms Seats Employmm 2 Number of Machines: For vending euslnee® !t27.00 unt Transfer Fee NSF fee ;y-_� Pena►ly 0.00 0.00 2170 Machines Professionals Prior Years Collection CostTotal Paid 0.00 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Froward County and is non-reWHEN VALIDATED and zoning reequlatory iremen, This BusinesYOU Must s Tax all CRueceipt must be transferred when Municipality planning the business Is sold, buGhess name has changed or you have moved the business location. This Wolpt does not indicate that the business is legal or that It is in compliance with Stet0 or local laws and regulations. Mailing Address: DAVID NUBY 401 SW 12 AVE DANIA, FL 33004 2014 ®2®15 Receipt #OiA-14_00000083 Paid 10/03/2014 29.70 e DAVID NUBY, SR � 401 SW 12TH AVENUE t'. DANIA BEACH, FL 33004 - NU -BLACK SEPTIC & DRAINFIELD COMPANY Business Authorization: SA0111766 SR0931118 Registration Expires on September 30, 2015 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2414 THROUGH SEPTEMBER 30; 2015 DBA: Business Name: DAVID NUBY NU BLACK SEPTIC `GAWK Receipt #:189-4258 DRAIN Business Type:ALL (SEPTIC TANK TYPES CONTRACTOR Owner Name: DAVID NUBY Business Location: 27 NW 4 AVE Business Opened: o 8/ o 1/ 19 8 9 DANIA BEACH fAt91County/Cert/Re9:SR931118 Business Phone: 954-927-4090 Exemption Code: Rooms Seats Employmm 2 Number of Machines: For vending euslnee® !t27.00 unt Transfer Fee NSF fee ;y-_� Pena►ly 0.00 0.00 2170 Machines Professionals Prior Years Collection CostTotal Paid 0.00 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Froward County and is non-reWHEN VALIDATED and zoning reequlatory iremen, This BusinesYOU Must s Tax all CRueceipt must be transferred when Municipality planning the business Is sold, buGhess name has changed or you have moved the business location. This Wolpt does not indicate that the business is legal or that It is in compliance with Stet0 or local laws and regulations. Mailing Address: DAVID NUBY 401 SW 12 AVE DANIA, FL 33004 2014 ®2®15 Receipt #OiA-14_00000083 Paid 10/03/2014 29.70 e FLORIDA DEPARTMENT OF HEALTH CERTIFICATE OF AUTHORIZATION we] q, SEPTIC TANK CONTRACTING ?'he Florida Department of Health hereby certifies the business or entity named below has satisfied the requirements of Part III, Chapter 489, Florida Statutes, for septic tank contracting and has been duly authorized by the Department to provide septic tank contracting services under the name of.- NU-BLACK f NU-BLACK SEPTIC & DRAINFIELD COMPANY SAO 111766 Authorization Number Rick Scott, Governor DOH 4079. 1. 1997 April 10, 2013_ Date Issued March 31, 2015 Expiration Date CERTIFICATE OF LIABILITY INSURANCE °A 02o�14 PRODUCER JW Insurance Services Miami Shores Villages THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 100 North State Road 7, # 106 THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE -NO OBLIGATION OR LIABILITY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Margate, FL 33063 AUTHORIZED REPRESENTATIVE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Phone (954) 583-7213 Fax (954) 583-2045 INSURED Nu- Black Septic & Drainfield Company, Inc INSURER A: Axis Surplus INSURER B:INSURER 401 SW 12th Avenue Dania Beach, FL 33004 C: INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L INSRO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE WDD POLICY EXPIRATIONLTR DATE M/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE 100,000 COMMERCIAL GENERAL LIABILITY FLGLN00514AX 05/28/14 05/28/15 DAMAGERENTED REM SES TOoccurence MED EXP (Any one person) 5,000 ❑ ❑ CLAIMS MADE ❑d OCCUR A ❑ ❑ PERSONAL & ADV INJURY 100,000 ❑ GENERAL AGGREGATE 200,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 100,000 Fire Damage Liability 50,000 © POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO COMBINED SINGLE LIMIT (Ea accident) ❑ ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTOS El NON OWNED AUTOS BODILY INJURY (Perperson) BODILY INJURY (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ❑ ❑ ANY AUTO ❑ OTHER THAN EA ACC AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE ❑ ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND❑ EMPLOYERS' LIABILITY WC STATU- ❑ OTH- TO E.L. EACH ACCIDENT ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under E.L.DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS **** SEPTIC TANK - INSTALL / SERVICE / REPAIR **** CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001/08) OF © ACORD CORPORATION 1968 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Miami Shores Villages 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2nd Avenue THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE -NO OBLIGATION OR LIABILITY Miami Shores, FL 33138 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE FAX- 305-756-8972 --_._ ACORD 25 (2001/08) OF © ACORD CORPORATION 1968 10/27/2014 12:05 5615336170 SOUTHFLORIDACASUALTY PAGE 01/01 �►C®& CERTIFICATE OF LIABILITY INSURANCE110/27/2014 LLTTRR 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 8Y 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: H the cerdflcatc holder Is an ADDITIONAL. INSURED, the policy(los) must be endorsed, If SUBROGATION IS WAIVED, Subject to the terms and contlTtlorts of the policy, certain policies may require an endorsement. A statemefit on this uertlfleM does not confer rights to the certificate holder In lieu of such emdorsemont(s). PRODUCER SOUTH FLORIDA . CASUALTY 415 North. -4th -Street Lantana, FL 33462 NANIAIUI ME, PHOME Ext1: '-61)533-6144 FAX Arc No J561) 533-6170 ,wDREss.Elan.ne@southfloridacasualtv.com INURER(s) AFFORDING COVERAGE N/Uca INSURER A: SCS & I Fund INSURED NU—Blaak .Septic & D rainfield Company 27 . NN 4th Ave Dania Beach, FL 33004 954-927-4090 INSURER 9: INSURER C: INSURER D: INSURER E: (NSURiRR F RfIVFRA/-.FC I-=0TIFIr:ATF IUIIRARFR• RFVISIrIN TII IMHFR! 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, TERM 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, LLTTRR TYPE OF INSURANCE 1 POLICY NUMBER aOP(YYY M D= LIMIT$ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-1 OCCUR EACH OCCURRENCE S PREMISES F.s ocm+ anew MED EXP (Arty oro+ Pc rson) 8 PERSONAL & ADV INJURY S GENERAL AGGREGATE $ GsEWL AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS - COMPIOP AGO $ S AUTOMOBILE LIABILITY ANYAUTO ALL SCHED AUTOS�D AUTOSULED NON -OWNED HIRED AUTOS AUTOS Fa aeeitlerH} % BODILY INJURY (Por person) S BODILY INJURY (Persoddent) $ Par aemklent $ 93 UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ Deb RETENTION $ $ A WORKERS COMPENSATIONWC AND EMPLOYERS' LVIBILITY YIN ANY l FRS R��ARIPARcT� 1DCEGUTIVe ❑ Imymuldmv NMI DEe, dow1be SCRIPTION OF OPERATIONS below NIA 10650868 10/31/14 10/31/15 ATU- UIH- 'x ! I I IT^ E E L. EACH ACCIDENT $ 3.0 0 , 0 0 0 C L DISEASE - EA EMPLOYEI' $ 100,000 E L DISEASE -POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AlIeCtt ACORD 101, Aftionni RRmarkn Schedule, H more Wce Is r MIMd) Septic Tarok Miami Shores Village Bldg Department 10050 HE 2nd Ave Miami. Shores, FL 33138 T:305-795-2204 F:305-756-8972 A ^nanny 1►,w—.1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, _ AUTHORIZED ®1988-2010 ACORD CORPORATIOI(.All rights reserved. __ 1 nes muumu name ana logo are reaglstored marks of ACORD STATE OF FLORIDA DEPARTNJENT OF HEALTH ONSITE SEWAGE TREA2NENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: I�1i;vy� OSTDS Repair APPLICANT: William Tubbs PROPERTY ADDRESS: 273 NW 92 St Miami, FL 33150 LOT: 151 BLOCK: 135 SUBDIVISION: Miami Shores Sec 6 PROPERTY ID .#: 11-3101-033-1150 PmcrT #=13 -SC -1566101 APPLIcwiom #: AP1163370 DATE PAID: FEE PAID: RECEIPT #' DEMENT #: PR953628 (SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAIL 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 PERFORK1USTCE 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 APPLICATICK. SUCH MDIFICATICNS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EIMtdP'T THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 750 ] GALLONS / GPD existinq septic tank to remain CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY (b=IMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps D [ 200 ] SQUARE FEET new bed confiq. drainfield SYSTEM R [ 0 I SQUARE FEET SYSTEM A TYPE SYSTEM: [s] STANDARD [ ] FILLED [ ] NOUND I CONFIGURATION: [ I TRENCH [XI BED [ I N F LACATICH OF BENCHMARK: Top of bottom floor. 12.8' NGVD I ELEVATION OF PROPOSED SYSTEM SITE E BOTTCH OF DRAINFIELD TO BE L D FILL REQUIREd: [ 0.00] INCHES O T H E R [ 26.40 I I INCHE3 V FT ] [ ABOVEFw—mmbBENC@RARK =F RRNCE POINT [ 56.4011 INCHES FT I ( ABOVE / BELOW P BENCHMARK/REFERENCE POINT EXCAVATION REQUIRED: [ 30.00] INCHES 1-E>astin al septic tank, certified by "Nu-Black"f5f2014 to remain. 2.-Insta sf f drainfield in bed configuration. a� 3. -Pe ' of excavation area shall be at least 2 ft wider and longer than the propos absorption bed or drain trench. 4.4nvert elevation of drainfield to be no less than 8.60' NGVD. 5: Bottom of drainfield elevation to be no less than 8.10' NGVD. The system is sized for 2 bedrooms with a maximum occupancy of 4 persons (2 per bedroom), for a total estimated flow of 200 gpd. THIS PERMIT IS NOT FOR ANY ADDITIONS. SPECIFICATIONS BY: Yudeiey Martin TITLE: Engineering Specialist II APPROVED BY: TITLE: Engineering Specialist II Dade CHD Yudelsy Martin DATE ISSUED: 10/22/2014 EXPIRATION DATE: 01/20/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC v 1.1.4 AP1163370 SE941267 Page 1 of 3