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ELC-15-306Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-232545 Scheduled Inspection Date: April 17, 2015 Inspector: Devaney, Michael Owner: LEONI, TODD Job Address: 9636 NE 2 Avenue Miami Shores, FL 33138 - Project: <NONE> Permit Number: ELC-2-15-306 Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition/Alteration Phone Number Parcel Number 1132060132500 Contractor: TYCO INTEGRATED SECURITY Phone: (954)266-5063 Building Department Comments BURGLAR ALARM INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-228081. No access at 3:50 p. 1z' m.. 9640 NE 2 AVE Failed Correction Needed ❑ ��- �� Re -inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 16, 2016 For Inspections please call: (305)762-4949 Page 26 of 33 � 1-4 CA 5 Sb q O --t, chckSe mic'Sho((S BUILDING Miami Shores Village Building Department 10050 N.E.2nd Avenue, Mlam( Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FEB 11 2915 �--:_ FBC 20LD Master Permit Noi,' ®� PERMIT APPLICATION Sub Permit No. BUILDING 2f ELECTRIC ROOFING ❑ REVISION EXTENSION [-]RENEWAL PLUMBING ❑ MECHANICAL MPUBLICWORKS © CHANGE OF [:] CANCELLATION [-1 SHOP Q CONTRACTOR DRAWINGS JOBADDRESS:_ 7�V�Y1iJ� City Miami Shores County 0A Miami Dade Ztp: -331 r61 _ Folio/Parcel#: 1i 3�(p ^ ©k3 ^ ZJ�D Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): PC&\ G'�O L rL-(Phone#: Address: Po e)0Y., City: ivy 1 Q rrn t State: Zip: 32� Tenant/Lessee Name:. rnN Phone#: 2.0, S�'lJ� ':54 Email:?)ni 1 i p CONTRACTOR: Company Name: :2zr n 15 Phone#: qv (Oc'� R W Address:t.�� 33 Cpm fn e Irc e- l wit City: � Y �, CCA Ma tate: Ziip:: 31�Soz;s— n GQ �/ Qualifier Name: C- q2Phone#: J ka- `1 O to State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State, Zip: Value of Work for this Permit: $ ,,��//�Q Square/Linear Footage of Work: Type of Work: ❑ Addition LJ Alteraattion^ (� /�❑New ❑ Repair/Replace El Demolition Description of Work: ! u l CY i .IJCC -r^�� Specify color of color thru tile: Submittal Fee $ Permit Fee $ A0,0, 0P CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ _ (Revisedo2/24/2014) DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 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 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 he annroved and n reinsoectinn fee will he charged. V ---Signature —�4z,/� OWNER or AGENT The foregoing Instrument was acknowledged before me this J daofi;?�Va .20 Ir , by vj �� (C h is p rsonally awn t me or w spro dced'4- 0 i as identification and who did take an oath. Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of :L� 120 JS by wh personallyknown to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: -�i.�d&4 Si mss° Sign. Sign - Print: Print: a flat ` A Print:r•• '� P ua, PAULA t. MRA Seal: KARINA VILLALTA Seal ��" ,Pe fly COMM, kpjt %J"R � Notary Public Commies" # RE 1699@ State of New Jersey Bonded T111490 N11111111111 Nit" All qF APPROVED BY Plans Examiner Structural Review (Revised02/24/2014) Zoning Clerk TYCO ALARM PRIMO TOOL JPMorgen Chum Orden Form AO Markets Rohm Exhibit to Wtvm.nem site Naos Mkml shares 13910OP010359 Addume 8640 KE turd Acre POO PhTotal City Man. shams Coat Ctr 6 Fax State PL sates Tax Rate Votat Rate Locator 0.00% E.E.Snaet � site Phots TyCopmtd 116889390 -/ �P7 /n[CgrafEtderCvrity OPPB Data. 11/42014 or ehammeed�tvco can Contract Labor Rede S Before Sekm Tart $ tem Dhnaarm Sub Totes a No Tax $ tumid Tata) a 6&00 AO 3,3af.00 - 3,387.00 Explain AO -Extra Labor° In m0 below No. of Tye* Tedd to Compete, job? Atwaye Amok tN and OUT with JPtforgan Cham Programming Depsrte- phos a 877.886-0728 Enter Scope at Work In Deteli with All Special Instructions In cell: humvat(wne. Remove KUBs. &wl m per prim. matte 2 EBK% KP, TCK re-sta01 HUBs (mum.a nored NUBS) otn7. Rem QTY ffmudamW pmt Number Descriptlsn Unit Equipment Cam Extended Equo mmm Coat Unit Labor Homs Unit labor cost Extended Labor Coat Total goer Somaity Control Paned Eplimmat . 1 OMP KRJPMC-NRWCN8T Network Aima-7R50W&-G-aamtsWg et: $ 2,061.00 8 7&0 $ 93.00 S $ 2 DMP KIT-JPMC-ATM Almm-Pamt C ommawakd &dgbormis9ng oF. $ 883.00 $ 2.0 $ 93.OD $ $ 3 DMP KfrJPMC4ErrORE Network AWm V BWn-O for tmmre Stas S 1,886.00 S 8.0 $ 83,00 $ S 4 OMP 714-IOPC8 Zone Expansion Card, 16 murex 1K EOL It 170.00 S 1.0 1 8 93.00 S S 6 1 amp 70WN-1 Keypad, LOD 32 Character, Wary $ 118.008 118.00 1.0 It 93.00 a 93.00 S 211.00 6 DMP 70 M-1 Keypad, LOD 32 Chanter With 4 Zones (Isle ATB) $ MOD $ 1.0 $ 93.00 $ $ 7 OMP 600 Keypad Stand For Odnrewp AIMS S 27.00 S 0.6 $ 91.00 S a Back Up ftub3meat 6 T.- Kit KO-JPMC-SM Tek ar JPMC Kb-Ce@uiar Buok-up , Transformer, Telco Jeck/Cord, 12V Bdtery, Tamper, Amarum, Lock Set $ 367.00 $ 1.6 $ 93.00-S $ Devices, B Ad®co 270R HUB Holdup Butums S 16.00 It 1.0 $ 93.00 $ $ 10 8mttrol 95M Door Conant-Wide Gap wArmored Cable $ 28.00 8 1.0 S 4300 $ 8 11 Smtrol SR•1078O-w Door Comost 3/4• Meal Doom Reomuad S 12.00 S 1.0 8 93.00 S $ 12 Santrol SR•1075-W Door Correct 3B• Wood Dons Reeessed $ &00 $ 1.0 S 93.00 S a 13 San") SR•1087T-W Door contact surface Mamt $ 12.00 S 1.0 $ 91.00 $ $ 14 Visuals OUD-240 Motion Detector Calling Mount a 74.00 a 1.0 8 9100 S 8 16 aaIDsenm CK-DT7a3ST Motion Demeter Wall Macon S 46.00 $ 1.0 8 93.00 a S 16 Vkmlc VS-CH1000 Motion Deaator-Curaln Motion $ 83.00 S to $ 93.0018 $ 17 Hometivell Ft ISS Oats Beak with T $ 49.00 S 1.0 S 93.00 a $ 18 Bosch Os ISNSMS1) 8earnls Sensor for Smes, ND, ATM 5 16&00 $ 1.0 8 83.00 S It t9 Chamber its am Kest Dateeror S 13AD S 1.0 1 $ 93.00 S a 20 Por[m VSA-2K Vault Boats System $ 631.00 $ 2.0 $ 83.00 $ $ 21 Potter YSd Yauit Sound System Extra Hans S 8200 $ to S 93.00 S a 22 ADI RP-28L Rmnots-.kers-MA $ 20.00 S U S 93.00 8 a 23 OMP 1100XH-W OMP VAM) M RWDKW $ 168.00 $ 1.5 S 93.00 S S 24 DffP 461 Expansion Board for 110o1CH•W $ 75.00 $ 1.0 a 8300 a $ 26 DMP 1102-W Unh aul Wbelese TuanemIder m $ 84.00 It 0.3 S 93AO 8 8 26 DMP HM413W VeiCo Mount-g rw 1172 W (above ken 8 4,00 S S 9100 S $ 27 kMMWs FA210 Trerramitar Rednmad Sim S 47.00 93.00 a $ 28 Inovanka FA206O Wheats Pendmd HOWUP Davkx-SIC a 6&00 $ 83.00 8 S 29 Connection Labor Existing nlgM drop devices (2•PO $ OO $ -f-- 30 Cameorbn Leben Existing ATM devices -POC & So nitight) S 83.00 a 1'!' 9300 S - $ 31 Connection Labor Existing ado hest. seismic, & contact (2. POC & Seawfib) $ 53.00 S 9300 $ $ 32 1 Com -tion Labor Existing TCD or TCR (2-POC) $ $ 93.00 $ 9300 S am 33 2 Connection Labor Existing Sea Service Banker (2-POC) $ - S 93.00 S 28&00 S 1611.00 34 canrostknn Labor E:IMUM Vault heat 8& door Mftd (2-PO $ S 1.0 $ 93.00 8 $ 35 1 Conecume Labor Existing Instant Ixammos Meehine (I-POC) $ - $ 1.0 $ 83.00 S 91.00 8 San 38 Connection Labor PerabR Reader Trapper Connection (1-POC) $ - $ 1.0 $ 9.00 S $ 37 Conneetlsn Leben FUTURE ATM Pre Who S - S 2.0 $ 93.00 It 8 38 2 Wise 484483 12OMc per 100° Pknnun*w caduit It 18 S 32.00 1.0 S 83.00 $ 100.00 S 21&00 39 3 WW- 494469 22GA12C per 108• Plesum/no conduit It 46 $ 1 .00 1.0 $ 83.00 $ 279.00 S 41.00 40 wits Poke 100000 JATM sunup Cuba Paige a 160080 pm 100' $ 88 $ 1.0 S 9300 $ It 41 Installation Labor per 207 PlWaWsD CordUR $ 18.00 $ 1.0 S 93.00 $ S 42 TVva Labor ICAD Drawings $ 1.0 8 9300 S 8 43 ADI Wise Masa wits Mold -saned perW S 39.00 S 0.5 $ 9100 $ $ 44 1 Program Component ft. Program and test $ S 1.0 $ 9100 a 59.00 S 9300 10 Removal Dlseomoo Removal or disconnect of device It $ edit $ 9300 $S 46 1 Re-stall Labor rehidd HUB- $ 8 1.0 8 9300 It also $ 83.00 47 Trip Cl rg. Over 80 adlm Based upon Map Quest- AOT office W0 be supplied S $ 1.0 $ 9300 $ 8 48 Trip Cog. Under till MOM Any work abler 4 ire. $ S 1.0 S 93.00 $ a 49 Tyac Labor anew orewhegs / PM The $ It 2.0 $ 83.00 S a 60 T Shipping OvmnlW Shipping 8 $ 0.0 $ moo a - S 51 1 ITVW Permit $ 150.00 S 160.00 0.0 S 93.001S $ 160.00 62 T City lnspewars $ 4.0 $ 93.00 $ a 63 1 T Dlscameot V OT $ &0 $ 9300 $ 896.00 S 008.00 54 1 T $ 2.0 $ 9100 S 18&00 8 to&00 00 1 OT labor - 2nd $ to S 93.00 S 744,00 8 744.00 N 1 DMP 714-16 18 tens atm nodule w/eab loaf[ arid key (need tamper) $ 267.00 S 267.00 1.0 $ 9.00 $ 9.00 S 390.00 57 1 DMP 387-5 Tamper, suav aroma $ 6.00 S &00 0.0 S 9300 S $ &00 88 Tyco Other E lU Other Equipment s • S 0.0 $ 9300 S S 60 Banoh Labor 1@ Wrafn-g, project Management s - 8 4,0 8 93.OD a 8 80 Tyco ATM Labor Kit &T61ftogram, Devi- Teoft% System ActivationS - $ 4.0 8 8300 8 $ 61 ITOTALS $ W Is 2,697.00,111 3.387.00 hsa0atlsn otabove aempensme Will be pedmmed per Terms and Conditions in Schedule 1 agreed upon between JPMC and Tyco -awated SMN4. Schedule 1 is an addanormn to the Mein procurement Agreement doted October 1. 20115 betwean JPMC and Tyco--grated Saemtly T REPREBEM'ATNE Jaen McKenna Exhibit REV 131-13 Miami Shores 9640 NE 2nd Ave, Miami Shores, FL 33138 DND Number 11722 RM Approval DATE DEVICE LEGEND rplC env ERY. knvpufll .- ,Uirmi_.r. keyuscl x .I ® BUROIARMIARM CONTROL PANEL ®BUROIARALARN KEYPAD ® CELLPHONESWI4UPDWLER © DOM CONTACT ® NOIBUP BUTTON REMOTE INDICATOR UGHT MOTION DETECTOR Qd] 3W MOTION DETECTOR /�\® POWTOFODMenom ® DEVICE-TOEEREMOVED OEACE- rznu1 RBE W ED ma FERE ® DEVICEmm CHASE() RETAIL DISTRIBUTION NETWORK ® o =011100MMM1111112NIZEMM:M10 EXISTING +/- 4325 S.F. � � ■n�■ iii■ ■■ p�■ ■■ ;i�■ ■■ IRS .•.. II�U SII1�� u LD ■ ■ ■ ■ Y�F�1 PROPOSED ---- EI moRmamREREMDV® +1--4325 S.F.—=TINOFURNRUR M$EDYREI=XEO NET NEW ---- NEINSIGNAMIMARK MO Fun, FLOOR PLANS Confidential. JPMorgan Chase Bank, N.A. Proprietary Information. DESIGNER. DKIAC 2014-10-09 PAGE 1.0 � -a g'`"l_ Inspection Worksheet Sv Miami Shores Village 1 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-229087 Permit Number: PL -2-15-429 Scheduled Inspection Date: April 07, 2015 Inspector: Diaz, Osvaldo Owner: LAGOMASINO, JUAN Job Address: 1021 NE 93 Street Miami Shores. FL Project: <NONE> Contractor: STATEWIDE SEPTIC CONNECTIONS nuuaing uepanment comments DRAINFIELD EAST SIDE Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number INSPECTOR COMMENTS False Inspector Comments Passed El Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. 1132050150070 Phone: (954)963-0082 April 06, 2015 For Inspections please call: (305)762-4949 Page 17 of 63 �02.2 DIVISION OF Environmental Health @10Florida HealthMiami-Dade CountyeQ OSTDS/Well Division 11805 SW 26th Street • Miami, FL 33175 O Inspector ;� os e�� 1 V P -d' �e r Date 3 Address lD� 1 N� 43 OSTDS # �4 F ! 177 Comments: Signature 11 -..N~ W/2:9116 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 PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING F�BCpp 20 l(,) Cl Master Permit No. l_..1 '"� /__ I Sub Permit No ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL E] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 0 City: Miami Shores County Miami Dade Zip: Folio/Parcel#: ki - 3",5 - 0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 90 1,-)V NO CUP CA �� `'�C phCi one#: fho Address: IC "-JE 9'-?s� City: M � rViI 'S �-xr's State: k' Zip: 5311 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: &tbjteL h C:, C',1 �y°� I C Phone#: 3,0 6 6,-5 Address: V w w tc1 64 41S City: L� State: Zip: 3330 Qualifier Name: T ��1 - O� Phone#: State Certification or Registration #: 6moq co Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address City: State Zip: Value of Work for this Permit: $) `` Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑NewRepair/Replace ❑Demolition Description of Work: 4 ► 1 fi (�W S iCe Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Technology Fee Structural Reviews $ Radon Fee $ / S O- ' CCF $ CO/CC $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Bond $ Q Q TOTAL FEE NOW DUE $ — I • lJ (Revised02/24/2014) �o tai' •ci 0 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 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 on 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. 'g Signature -,Z Signature WNE rAGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of RA 20 15 by cC(O MTA kl— , who is personally known to me or who has produced Ft^ DSV � as identification and who did take an oath. NOTARY PUBLIC: The foregoing instrument was acknowledged before me this day of zG , 20 (5 , by 'C�-Duk►o is personally known to me or who has produced l as identification and who did take an oath. \\0\k '0 NOTARY PUBLIC: Structural Review Clerk (Revised02/24/2014) Sign: _ Sign: ® -�`v','= � `C�,"" Print: Print: •- Seal: ,*�.�:,:'Yt✓j �. 9SA J SQMQ Seal: %�� `,`` �, WCOMIMISSION #Bid ; APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) FEB -27-2015 03:02 From: To:3057568972 Pa9e:1"1 Report Viewer page of I J A JEFF ATWATM � CHIEF FINANMAr_o ICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKMS CO PENSATION CERTIFICATE OF ELECTION TO 13E EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW " CONSTRUGnOl 4 INDUSTRY EXEMPTION J This Certifies that Oho incf1vWUaf listed below has elected to be exempt from Florida Workers Compensallon law. EFFECTIVE QA'E; 8127/2014 EXPIRATION DATE: amem01e PERSON: SWEATANTHONY FEIN: 45 7b408 BUSINESS NAM 1. AND ADDIJ98s.- STATEWIDE SEf TIC CONNECTIONS INC 93840 NW 19 AVE RAY Ix15 ORA LOCKA FL 330554 SCOPES OF DU II INESS OR TRADE: SEWER CONSTRUCTION ALL OPERATI FI°1i'erd ro Ch�p�� 0.119j R2., .'HI aIGGOtda noy at tew/OrLOOOOr9 tgn➢en:afranundor COF"ro0atw6oww.er mytt■n rrom tl la el�pe..lyp�purw■ac....._at■ m7tON OeC iwp■ dila bir OSSA Trod• • ddsibal ac Fy 0213- CHOPW 440AR12L F,&GeNMat axernp iCtls re bka anl0aaa o txbnlo 00 axant r.Ofoketimemha axtmpLa onV !>N7 Cad 4olltPualr. ui Ote4fat to ha �ern9nAf shnnbo■u tl AL pmnlanl fo CDap{arQ4Cd511 F.^s.,,lb4ces of Ota lA■p■mon nLnladontRC M■ie•aearli no 10f19,v1114aL'�11107 UdOlfrnplk d...• �P Lilli aIll. orIDalfSa=Or NCM+ACft '" of a oodulaote. Tao d■p. "d Shap mom a 0F'&F2-DW0-252 CC'TIFICATEOP QLWr10N TO � . pXMMFrRE%nSED 07.12 QUEET10Nti7 1.—..... II. n el +n 1 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 and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Nfi mi" sho—res Y'illage- oes not require verification o wor ers' compensation Tasurance cova`rage from the contractor's company for day labor, part-time employees or subcontractors.. Therefore, you may be mrsonally liable for the worker compensation iniuries 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. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Signature: State of Flofda V, County of Miami -Dade The foregoing w acknowledge before me this day of By U MAS� b�1 70 who is personally known to me or has produced co L y 0 a) z as identification.Ll .v�uUy. Qr'^T. ® g6p 0 W Contractor Signature: �] State of Florida County of Miami -Dade The forego' as acknowledge before me this day of , 201-> . By 6ar--- S LiL(3-Y j who is personally known to me or has produced0%%uuuu��i/ as identifi n. °° • '� cv l,4Uliuy. Or AT ,�, '�'� o ". :E! r`v Cry = 10111 till, STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair, APPLICANT: Juan Lagomasino PROPERTY ADDRESS: 1021 NE 93 St Miami, FL 33138 LOT: 1112 BLOCK: 2 SUBDIVISION: PROPERTY ID #: 11-3205-015-0070 PERMIT #:13 -SC -1588736 APPLICATION #:AP1177253 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR965609 [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 T [ 750 ] ONS /GPD existing septic tank to remain CAPACITY A 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 confid. drainfe SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [x] TRENCH [ ] BED [ ] N F LOCATION OF BENCHMARK: FFE 9.13' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 9.24 ][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 61.20][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 64.00] INCHES 1. -Existing 750 gal. septic tank, certified by "Statewide Septic" on 2/18/2015 to remain. O 2. -Install 225 sf of drainfield in trench configuration. T 3. -Install 12" of slightly limited soil at the bottom of the drainfield. H 4. -Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench. (Comments Continued on Page 2.) E RI SPECIFICATIONS BY APPROVED BY: DATE ISSUED: DH 4016, 08/09 Incorporated: J Solomon i Martin 5 TITLE: Master Septic Tank Contractor TITLE: Engineering Specialist II Dade CHD EXPIRATION DATE: 05/27/2015 (Obsoletes all:.prexious„eciiona which may not be used) 64E-6.003, FAC - v 1 4 gi$1Y77253r SE952338 31 �I Page 1 of 3 DOCUNF T #: PR965609 5. -Invert elevation of drainfield to be no less than 4.53' NGVD. 6. -Bottom of drainfield elevation to be no less than 4.03' NGVD. 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.