PL-14-2285Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number. INSP-222857
Scheduled Inspection Date: January 20, 2015
Inspector. Diaz, Osvaldo
Owner: GOLDENBERG, PAUL
Job Address: 905 NE 92 Street
Miami Shores, FL 33138 -
Project <NONE.>
Contractor. STATEWIDE SEPTIC CONNECTIONS
nuuamg ueparanent comments
REPLACE DRAIN FIELD
Permit Number: PL -10-14-2285
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Drainfield
Phone Number
Parcel Number 1132060050010
Phone: (954)963-0082
INSPECTOR COMMENTS False I
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-221762. HRS IN FILE
SOD REQUIRED
NO SIDE WALKS
Failed
Correction
Needed ❑ %ov
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid
January 16, 2015 For Inspections please call: (305)762-4949 Page 9 of 32
Scanned by CarnScanner
'VES
,(A�__�\,t(i
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECT'ION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
FBC 20
Permit No. PL - 22
Master Permit No.
JOB ADDRESS:_q 0 G N'C q 2- S–�-
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: l ( ---t� a C E - cc) 5- C) G( `-
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): Ftk u j G .; I Phone#: q1-7- 569- q3
Address: ( 641+ 5 Ci,� k t v-) S ' ?4 -2 q
City: sjn n0 d t &(es State: % Zip:
Tenant/Lessee Name: Phone#:
Email:
3 St 6 e^
CONTRACTOR: Company Name: SA"'` e'.0, Cte, St pt, c- 6g,"J' (-)C Phone#:
Address: F',�, !�C�X 213 b e g
City: 4�0 (w � C-� d State
Qualifier Name:
State Certification or Registration #: 51"109-11Z6 -Z- Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this, Permit. ,$ 3 5 U Or Square/Linear Footage of Work:
Type of Work: ❑Address OAlteration ONew &epair/Replace
'Description
of Work: e, cc,[)',cc? t h -�
ODemolition
Submittal Fee $ `� ` Permit Fee $ 1/60 0 X 7 CCF $ . `� CO/CC $
Scanning Fee $ Radon Fee $® "23" _ DBPR $ Bond $
Notary $ 19.E Training/Education Fee $$ )" t P Technology Fee $ :F:> _ 2-0
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 12-4-90
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 ce ' ed copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7 ays after the building permit is issued. In the absence of such posted notice, the
inspectio ill no a approved and a reinspp6tionfee will be charged.
N,,_� Owner or Agent
The foregoing instrument was acknowledged before me this 10
day of ®C4- , 20(4 by rAi 1 6c l dC.,)10er-O'1
,
who is personally known to me or who has produced
� r c"S As identification and who
NOTARY PUBLIC:
�'�,
Sign:
fl1
o
Print: I Axuc- J,;Z)
e'
My Commission Expires:
a o S2
z Co
O
M
Lf
APPROVED BY sem/ �o r1'f Plat
Signature �.
Contractor
The foregoing instrument was acknowledged before me this
day of 6 M , 20 LY , by —1:CQ-E-5l- -,: jb .-,N0 iJ
who is personally known to me or who has produced_
Lt t`;E�_:7t S tF- as identification and who did take an oath.
Structural Review
(Revised3/12/2012XRevised 07/10/07XRevised 06/10/2009XRevised 3/15/09)
NOTARY PUBLIC:
Sign: s�ozrerueoeeu a
fd w
Print: zoiew swis
My Commission Expire '
Zoning
Clerk
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 M 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 Contractor
Print Nam Pte, r. `t+- Print Name:
(.Signa e: ' W =�. Signature:
State of Fon I { State of Florida )
County of Miami -Dade) ,. o m County of Miami -Dade)
Sworn to and subscribed before me this Cly ca C Sworn to and subscribed before me this
day of �-Ir , 20JL+. o N_ day of 0 , 20
0
By �, ® B
o n' ®n
m m Sindia Me=
(SEAL) O (SEAL) � imsslm FF t
Tvpe of Identification produced w Z Type of Identification pro luc�'i� rr 09312018
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
OSTDS Repair
APPLICANT: Paul Goldenberg
PROPERTY ADDRESS: 905 NE 92 St Miami, FL 33138
LOT: A BLOCK:
PROPERTY ID #: 11-3206-005-0010
PERMIT #:13 -SC -1666313
APPLICATION #: AP 1162903
DATE PAID:
SUBDIVISION: Golden Gate Park Addn
FEE PAID
RECEIPT #:
DOCUMENT #: PR963180
[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 649-6, 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
T [ 750 ] GALLONS / GPD Existing Septic tank to remain CAPACITY
A [ 0 l GALLONS / GPD CAPACITY
N [ 0 1 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 Bed configuration SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ I
I CONFIGURATION: [ I TRENCH [x] BED I I
N
F LOCATION OF BENCHMARK: F.F.E., 14.10' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 27.001[ INCHE3 FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 67.0011 INCHES FT ][ABOVE BELOW BENCBMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.003 INCHES EXCAVATION REQUIRED: 140.001 INCHES
"Invert elevation of drainfield to be no less than 9.01' NGVD.
O 'Bottom of drainfield elevation to be no less than 8.51' NGVD.
T 'THIS PERMIT IS NOT FOR " ADDITION(s) ".
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 par bedroom), for a total estimated flow
H of 400 gpd.-,
E required drainfield area based on rule 64E -6.015(6)(c)2.
Install a new drainfield to achieve Drainfield size requirement.
R ,
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4016, 08/09
Incorporated:
TITLE: Master Septic Tank Contractor
TITLE: Dade CHD
10/16/4`
` a tractor ;or designee} is required to perform a
(obsoletes all ed
tiXlR�d�d=a�e roac,�ldar�t�t7
the
64E-6.003, FAC time of Tina! ii+5pi �tlG±i.riGi i.: v Ina'. App
ihs� ,16r shall wetness ltie d k,gj 3ard compare the
results to the uriglnal site evaljatiun submitted. A
reinspection tee +raid be ass .ssu=� ii tine contractor is not
at the jobsiia ut the ana+igcd Time.
EXPIRATION DATE: 01/14/2015
SE940845
Page 1 of 3