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PL-14-2280Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-221727 Permit Number: PL -10-14-2280 Scheduled Inspection Date: January 13, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: TUDELA, ALBERTO & JAVIERA Work Classification: Drainfield Job Address: 537 NE 96 Street Miami Shores, FL 33138- Phone Number (954)465-8915 Parcel Number 1132060171570 Project: <NONE> Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082 oUIIUIIIU VC'JCUl11RM VVIIIIIICIIW repair of drain field for septic tank INSPECTOR COMMENTS False Passed EJ, Inspector Comments HRS ON FILE Failed Correction Needed ❑ Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. January 12, 2015 For Inspections please call: (305)762-4949 Page 8 of 29 Scanned by CamScanner BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ❑ BUILDING ❑ ELECTRIC ❑ ROOFING FBC 20 RD Master Permit NoP 1 ' 1212 b Sub Permit No. ❑ REVISION ❑ EXTENSION [:]RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: ? '_� CF 1) (� J City: Miami Shores County: Miami Dade Zip: 1 Folio/Parcel#: i 17_QC G (1 - I --S 16 Is the Building Historically Designated: Yes NO , Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): M64Ltv 1 UaAa— Phone#: Address: 5;Yt NE Cttol"- S% - City: Wa%mlk �&nvofes State: Fl— Zip: Z-�)133 Tenant/Lessee Name: Phone#: Email: ^-tt'w�� Irtt~0 �,r'tr'r�%�.r -3 CONTRACTOR: Company Name: Phone#: Address: Pc 6,3(x 3'b 6S ,^ City: `►`'�-i..�� �. State: I Zip:C.*+ Qualifier Name: ( S "C -- State Certification or Registration # DESIGNER: Architect/Engineer: hone#: S �AL) 1 (_ Z 6 2 Certificate of Competency #: Address: City: State: Zip: Value of Work for this Permit: $ 135'>Square/Linear Footage of Work: 22-5 Type of Work: ❑ Addition ❑_,(Alteration F-1New19 Repair/Replace El Demolition Description of Work: T 1� &C IIVN Rite I'�1G:� XA%4_ Specify color of color thru'_61e. Submittal Fee $ ) Permit Fee $ CCF $ CO/CC $ _V/ Scanning Fee $ . c , Radon Fee $ DBPR $ - Notary $�,1 Technology Fee $ , s `�-4. Training/Education Fee $ t� G O Double Fee $ - Structural Reviews $ Bond TOTAL FEE NOW DUE $ iZ (Revised02/24/2014) *" 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 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 Signature aj� C I INNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before cmee this The foregoing instrument was acknowledged before me this day of Ccf - , 20t ( T by day of O QJ- 20 , by 9tS4 � ^C�, CL04 who is personally known to - i G QUto Nle 0 , who is personally known to me or who has produced Do V L ce,, as me or who has produced r -L— ,_'p r--1 \A]� LXW-ViF identification and who did take an oath. NOTARY PUBLIC: Sign: G (A� Print. Seal: identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Notary UNC State Of on a Seal: Sindia Alvarez My Commission FF 156750 w Expires 09/03/2018 IER - l.lJ11111v1ISSION # CC+, 31935 1,9F51;,.' EXPIRES November 08, 2015 APPROVED 407) 398-0153 F Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk ♦ RFS EVEN Miami shores Village . Building Department It 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 L 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 any person allowed to work under this ermit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability, 13Y SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Contractor Print Name: a- Print Name:_.,'I t4-f �L ;�_ Signature: , Signature:`. State of Florida) State of Florida } County of Miami-Dade) County of Miami-Dade ) Sworn to an� �su scribed before me this � Sworn to and subscribed before me this day of (�,C o 20�. da of Y 6E� . ; 2014.- 0 0 i 4 . By $y _ Notary Public i1 of fI@fid9 PLAVIA G ESRINOIA (SEAL) * * MY COMMISSIONII EE 196199 MY Canmi f<f i§�i§@ (SEAL) e► ExW�j 0lLA9/g946 Type of Identcation roduced : May 7, 2016 T e of Identification nr u e MIAMI-OADE CO'Ll:y- Ty HEAL-TH rPFPARTMFNT STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Alberto & Javiera Tudela PROPERTY ADDRESS: 537 NE 96 St Miami, FL 33138 PERMIT #: 13 -SC -1563099 APPLICATION #:AP1161R95 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR952195 LOT: 15 & 16 BLOCK: 99 SUBDIVISION: Miami Shores Sec 4 PROPERTY ID #: 11-3206-017-1570 [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 existinq septic tank to remain 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 new trench confiq. drainfie SYSTEM R ( 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [X] TRENCH [ ] BED [ ) N F LOCATION OF BENCHMARK: FFE 8.8' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 2.40 ][ INCHES FT ][ ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 42.36)[ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 40.001 INCHES 1. -Exist' 9 ga' septic tank, certified by "Statewide Septic" on 9/30/2014 to remain. O 2. -Inst it 225 sf dra'nfield in trench configuration. T 3. -Perim of excavation area shall be at least 2A wider and longer than the proposed absorption bed or drain trench. H 4. -Invert elevation of drainfield to be no less than 5.77' NGVD. 5. -Bottom of drainfield elevation to be no less than 5.27' NGVD. E The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of 400 gpd. \ V R SPECIFICATIONS BY: Yudeisy Martv— M vv TITLE: APPROVED BY:(� � / /\,� r / �yd�ITLE:- Dade CHD DATE ISSUED: 10/06/2014 EXPIRATION DATE DH 4016, 08/09 (Obsoletes all previous editions which may -not be used) Incorporated: 64E-6.003, FAC •r 1.1.4 AP1161.625 SE939964 01/04/2015 Page 1 of 3 D�PART'MENT OF HEALTH 1 s� Ai 'i_ICF\ ION FOR ONSITE DISPOSAL SYSTEM EDfi CrJi rSTF�Ci JI„I �,,�f � » y5 = Permit Applical on INiu-n°b,_11 — - - --- - --- P' IT II -SITE PLAN!------ — --- - -- - -- Scare Ea ch block represents 5 teet asci 1 inch = SO feet. -4 jr-Ir C, X41.. f _ - ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEP4.RTI MEN r 40 • 5. M173 Repla�A; wili^n :nay ba uaedJ ��: iUr[(xX:57ddCf?_-6U'i�•&i t7%,n-.-`} �..- CERTIFICATE OF LIABILITY INSURANCE DATE F 100/16/1116/14 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(ies) 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 endomemen s . PRODUCER Blaize & Tyson Insurance 5955 SW 21st Street Hollywood, FL 33023 Phone (954) 989-9324 Fax (954) 989-5998 CONTACT NAME: PHONE F� No . 'MAIL ADDRES UCER PRODCUSTOMER ID #: INSURERS AFFORDING COVERAGE NAIC # INSURED Statewide Septic Connections, Inc 13640 NW 19TH AVE BAY 15 OPA LOCKA, FL 33054 (954)963 -0082 INSURER A: WILSHIRE INSURANCE CO INSURER B: INSURER C : INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. ILTR TYPE OF INSURANCE INR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTE15- PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 A F—] F—]CLAIMS-MADE0 OCCUR F-1 CL00034762 10/07/2015 PERSONAL10/07/2014 PERSONAL & ADV INJURY $ 300,000 ❑ GENERAL AGGREGATE $ 300,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 300,000 d❑ POLICY ❑ PE 0- ❑ LOC $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIREDAUTOS COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) ❑ NON -OWNED AUTOS $ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ AGGREGATE $ ❑ EXCESS LIAB ❑ CLAIMS -MADE ❑ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y /�ORYLIM WC STAT T ORTH- E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If as, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SEPTIC TANK INSTALLATION, REPAIR AND SERVICE CERTIFICATE HOLDER CANCELLATION MIAMI SHORES 10050 NE 2ND AVE MIAMI SHORESM FL 33138 F.305-756-8972 ACORD 25 (2009/09) OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD