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PL-14-2281Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-221740 Scheduled Inspection Date: January 27, 2015 Inspector: Diaz, Osvaldo Owner: MANZAN, DINA Job Address: 10217 N MIAMI Avenue Miami Shores, FL Project: <NONE> Contractor: MIAMI DADE ENVIROMENTAL Building Department comments INSTALL A 300SQ FT DRAINFIELD Passed Failed Correction ❑ Needed Re -Inspection a Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Permit Number: PL -10-14-2281 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1132060131630 INSPECTOR COMMENTS False Inspector Comments HRS IN FILE Phone: 786-251-4099 January 26, 2015 For Inspections please call: (305)762-4949 Page 4 of 29 DIVISIONOF Environmenefttal Health Florida Health , y�O Miami -Dade County ANCO OSTDS/Well Division �O 11805 SW 26d Street - Miami, FL 33175 t Inspector .� Ca.... -Lc Date Address (�2 17 ryjIrM. )0AZ—:` - OSTDS # Comments:.-'_ �Q � r Signature Og I'M Miami Shores VillageITT- Building� p Department ' OCT 16 20% 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 20 BUILDING Master Permit No. )`4 — 2 Z' 3-1 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC F-1 ROOFING ❑ REVISION EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: d o 2 --1 -1 • Q rl (IQ 4,k L O -o e— City: Miami Shores County: Miami Dade Zip: 3 II SZ) Folio/Parcel#: 11- 32412,0 i4 20 Is the Building Historically Designated: Yes NO I� Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: U OWNER: Name (Fee Simple Titleholder): i I1 lk Phone#: - r` '1 , Address:_ 10247- P- K( We City: He"( S b�okq State: Zip: Tenant/Lessee Name: O'n., llwgt Phone#: l Email: CONTRACTOR: Company Name: -&&14! A -be, Wj ookat7ml Phone#: A5250" 9 Address: %-2-9 City: -State: Zip: Qualifier Name: Phone#: State Certification or Registration #:r, - CRI 12� 7 Certificate of Competency #: 5a *-©r)* /7 DESIGNER: Architect/Engineer: / 4Ef- Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: :goo Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: I �jS-rm U 14- ipo©olga re�0 iti A -I if Ft Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Technology Fee Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) !' Mortgage Lender's Address 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 $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. Signature &- ,, Signatu OWNER or AGENT The foregoing instrument was acknowledged before me this day of OLD2 6 Ci , 201 by who is personally known to me or who has produced �Ct� lL^ar �- as identification and who did take an oath. NOTARY PUBUC: Sign: Print, C �� Seal: ng instrument was acknowledged before me this day of L—r-4 47Jf . 20 / 61— , by JO -C& Rol 0.,W � , who is personally known to me or who has produced/0 1; o 4 rR ®L� identification and who did take an oath. NOTARY PUBUC: Print: Seal: IdY4Ff19D ��Rf,�'•• g�d7l�ir�Y APPROV / ) r:,a� _� y Plans Examiner Structural Review (Revised02/24/2014) ,r -'r . -r - - - 40 ft Notary Public State of ft6da a4' �Cn Joanna M Feliciano My Commission FF 082753 Expires 01/1212018 a . Zoning Clerk Miami Shores V11age 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 anKperson 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: 1 h,(.-, L" Signature: State of Florida ) County of Miami -Dade) Sworn to a pkg me day ofr ,� _ IISSI N i FF I &W2 By EkP1AE3: Octo�re, 2t) (SEAL) Type of Identification produced Contractor Print Named wL -Ry Signature: State Florida ) County of Miami -Dade) N1�11� Sworn to and subscribed before met$is day of ® C-7120, ..... By (SEAL) T of Identification roduced � 9 �� ''�•�� L OAR iva`�``�\� From 10/17/2014 13:13 0722 P.001/001 OR� CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYY1) 10/17/2014 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 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: If the certificate holder Is an ADDITIONAL INSURED, the policy(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 endorsemen s PRODUCER ADVANTAGE INSURANCE OF AMERICA 4520 NSP 7th St Miami, FL 33126 GENERAL LIABILITY PHONE(305) 649-5566 FAX MAIM Afo (,x:(305) 649-5559 ADDRESS:jackiebatista 749@hotmail.com INSURES AFFORDING COVERAGE NAtci INSURERA: GRANADA INSURANCE INSURED MLAXX DADE ENVIROHMMAL SERVICES, INC INSURER B: PROGRESSIVE AMERICAN INS CO INSURER 0: 8290 LAKE DRIVE STE 334 MIAMI, FL 33166 INSURMD: INSURER E : INSURERF rCCV1Q1V1Y INUPAOCM: 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 MAYHAVE BEEN REDUCED BYPAID CLAIMS. hLTRR TYPE OF INSURE DL BR PCILJGY EFF POLICY EXP POLICY NUMBER MMtDD D UMITS GENERAL LIABILITY EACH OC NCE $ 1'.000,000 X CCIM ERCIAL GENERAL uAiNuTY CUMMS-MADE E] MM PREMISES s =rexe $ 100,000 MED EXP (MY me person) $ 51000 PERSONAL & ADV INJURY $ 1,000,000 0185FL00037668-2 07/22/14 07/22/15 ORAL AGGREcIaT> 1; 2, 000, 000 CENL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO $ POLICY LOC $ AUTOMOBILE LIABILITY COMBINED NGLE Ee eoddeha S 500,000 ANYAUrO ALL OWNED SCHEDULED I30DiLY INJIAtY(Per pesm) $ TOS XAUTOS PED 02257915-7 08/26/14 08/26/15 BODILYINJUI2Y(T�erecddert!) $ AUTOSXFIRED AUTOS PRO'El� Per dd.0$ UMBRELLA OCOM EXCESS UABB EACH O $ AGGREGATE $ (LAIMS-MADE DED RETENTION $ $ wcRKERSAMCN AND EMPLOYERS* LIABILITY wcsrATu YIN ANF PRIMEMS R BOOLLUED)ECXlTNE IXd.UDED7 ❑ NIA TO UM ER E.L. EACH ACCIDENT $ (Mandatory (Mandatory in NH) H E.L. DISEASE - EA If ye96 describe holder DESCRIPTION E.L. DISEASE - POLICY UMIT $ OF OPERAnCNS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aftech AC(XRI) 101, Additicnel Rer mfr Sd>eagst it two qme is re*&ed) Septic Tank Systems Cleaning/Installation/ Servicing or Repair 2000 FORD RANGER 1FTYR14C9YTA89368 1996 FREIGHTLINER TANK TRUCK 1PUPDSEBSTE623682 CFRTIFICATP HAI nmo MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI SHORES, FL 33138 FAX: 305-756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2010/05) The ACORD name and logo are registered 111af ACORD Ali rights reserved. Kt3lS.M.W SEp-M TANK CONTRACTOR JOSE BOCANOS 8no LAKE DRIVE, SUITE 334 DORAL, FL 3MW MIAMI DADE ENVIRONMEWAL SERVICE, INC. SA0091617 Business Authorization: RRO971276 Registration Expires on September 30, 2016 8210 LAKE OR 334 DORM FL 33165 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS PwBtnd to 44&05(14 M. an al=ata amt who sleds amnom Ilam ads by" a , IM Ia afalecUoro utd a Uds =C§on may Trot rsoororben i ft or�oompettaeiet undw Uf : PuMWd 40 t 440.5(14 R.S., CWMWMos of abeam to be ertarrVt... "* M* WHIlb ft 90ape offt buslassarbaft NOW man rt18o,offtt tMbea Pu WMtIDChapter4QJW13LF.S..NadmofdtecOwtobe m111 "and o' 101 fes ofelecloatoloviescuptshy be& tD18Y01 d1�. 81y p9ta afeUlllgOfUlftleffiOearfthawOeaffta B. ate person maned on aye radco oraerON 11, no brW a m is ate of Utis =don for im moa of a P, 61 it,.Thede- Ie d she/ aewde a CERTIFMTE OF ELECIM TO BE EXEMPT REVISED 07.12 QUE8TK W (850)413-'189 13 �1■iiiiiiiii■iiiiliiiii■ ■i'■fi -- -- lls— `► atail Hii■i ..■ :� arw`��tu p-MAJ0M NONEmumsi t i■ii■0' 1s0U20V I MENNEN IN ME ME i,1!� •ta �r#�� ®iii iiN ■■iiiE �■i s ■ �■1■ � ■i& ■■11 .i Ems 011001011110 111SAWPAR ■■l-,ovls Nosy � ENgENEMEN �■ ..! Solo V. 10 Mid A ■NESEMMES ISIMN&ATRIA ■ MEN in �! poll,%� 2 4L man i■■■EF .■..■■■ q■■■■iol ®NF-- ! i� i■i�s■ii�■■■i:� ,ii■i■1111 ■1101di s�� ■�iiiii■ii�ii■i■■i�■ii�, ■�■■�■�■ MAN son NONE Ems No rsa�eu.eii�a �llllllOslO�� STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SHNA(Nm TrSAMONT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: ul ... a ... , OSTDS Repair PERMIT >#:13-8C-1564657 APPLICATION #: API 162536 DAIS PAID: FRE PAID RECEIPT $• DOCUMENT #: PRO63056 PROPERTY ADDRESS: 10217 N Miami Ave Miami, FL 33150 LOT: 1112 BLOCK: 12 Allan SION: PROPERTY ID 4: 11-3206-013-1620 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] (OR TAX ID NUM9=1 SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD E)08ft Septic tank to remain CAPACITY A [ 0 l GALIANS / GPD CAPACITY N [ 0 l GALLONS GREASE INTERCEPTOR CAPACITY Dwamm CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS Dosnn TANK CAPACITY [ ]GALLOWS I[ ]DOSES PER 24 HRS SPWWG [ ] D I 300 ] SQUARE FRET Bad confitguallon SYSTEM R [ 0 1 SQUARE FRET SYSTEM A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] mom I ] I CONFIGURATION: [ ] TRENCH [XI BED [ I la F LOCATION OF BENCHMARK: Finish Floor Elmr.,13.30' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 25.201 IIdCHEB FT ]IABOVE /� POINT E BOTTOM OF DRAnumm . To BE [ 49.20 ] INCHE$ FT I [ ABOVE POINT L D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 24.001 *Invert elevation of drainfield to be no less than 9.60' NGVD. O 'Bottomof dmhftld elevation to be no less than 92rMVD. T 'THIS PERMIT IS NOT FOR a ADDITION(a) N C""3 bedrooms wfth a maximum oompancy of 6 persons (2-W Ism), for a tote(. ated flow' PPAq*Wdred "WE draintield area based on rule 64E -.015(6)(c)2. R Install a new drainfleld to achieve Drainfietd size rquireme� SPECIFICATICNS BY: Jose l...;. �. DATE ISSUED: TITi.E: Registered Septic Tank Contmotor TITLE: Dade CED DH 4016, 08/09 (Obsoletes all Previous editions which may not be used) Incorporated:. 64E-6-'=3;P;A1%C or `"r psiJliE s, t IilrLi!';iJ rrY is,; 3 Fs3i! bQCiF4^ ,2i��9E12i.3L° u�i� ura�t:isft; 2KGi,?ff�¢1L' tiro of ii! };.? F1.1W ' u jH ZKPIR1kTION DA : 01/1312015 &8940750 Page 1 of 3