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PL-15-89I Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-228470 Permit Number: PL -1-15-89 Scheduled Inspection Date: April 09, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: MANGAS, GRACE Work Classification: Drainfield Job Address: 94 NW 94 Street Miami Shores, FL Phone Number Parcel Number 1131010340230 Project: <NONE> Contractor: MR C'S PLUMBING & SEPTIC INC Phone: (305)651-7859 Building Department Comments DRAIN FIELD INSTALLATION. intractio rassea comments INSPECTOR COMMENTS False nspector Comments Passed CREATED AS REINSPECTION FOR INSP-226543. HRS ON FILE SIDE WALK REPAIR REQUIRED TRIP HAZARD SOD REQUIRED Failed I Correction4�-- Needed ❑ . Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 08, 2015 For Inspections please call: (305)762-4949 Page 7 of 33 n O�1a6�2�t� �i Miami Shores Village M� BUILDING PERMIT APPLICATION 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 JAN VE 2015 FBC 20 Master Permit No 9 Sub Permit No. ❑ REVISION - ❑ EXTENSION ❑RENEWAL ■PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP I-\ f CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: /! " 3161 - 03(^ - 030 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: _Flood Zone: BFE: FFE: OWN Addr City: Tena Emai CONTRACTOR: Company Name: Address: .4n!SO` AOw JffK City: No �—State: /---Zip: Qualifier Name: &,'h 151flet Phone#: State Certification or Registration #:. :9 d�l � Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Arldrece• e . f/7 o . Ci • State: Zip: Value of Work for this Permit: Type of Work: ❑ Addition Description of Work: . W , Altgration 7 . D. C.d➢Q;.f4 Py ndri . 11;1119 b4i:eP3t ;^ Specify colo ►f c ilbk t��e� ." Submittal Fee S Scanning Fee $ Square/Linear Footage of Work: — fey l� ❑ New 0 Repair/Replace ❑ Demolition Radon Fee 5 0 Technology Fee $ Training/Education Fee $ Structural Reviews $ _ (Revised02/24/2014) CCF $ _ CO/CC $ DDDR $ Notary $ Double Fee $ Bond $ - TOTAL FEE NOW DUE $ A I 61 :� 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..... .p 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 amestimated 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 11 Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this tw day of V A9 All 20 �� . by day of 0t 20 _` O by I/" &670px who is personally known to ,If o is ersonally known to me or who has produced CTL 2 as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLI NOTARY PUBLIC: Sign: Sign: Prin . &W CX Print: Seal: Seal: :• SHERYL A MENDES „""„ r nLGERMAN C. OCAMPO * ° = : _Notary Public -State of Florida a`�•L Notary Pu01lc � f;t� of Florida C om. Ex0rea Oct 23, 2018 8'las�n My Comm. Expires Apr 23, 2017 138597 o. APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) MRCSS-1 OP ID: AL CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) 01/14/2015 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 endorsement(s). PRODUCER Phone: 305-477-0444 Combined Underwriters of MiamiPHONE 8240 N.W. 52 Terr, Suite 408 Fax: 305-599-2343 Miami, FL 33166 RONALD M. LASTER NAONMEACT FAX ac N Ext): A/C No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:AIX SPECIALTY INSURANCE CO. INSURED Mr. C'S Plumbing 81 Septic Inc. Attn: Michael Cocking P.O.Box 693239 INSURER B: INSURERC: X COMMERCILL GENERAL LIABILITY Miami, FL 33269 INSURER D: INSURER E: 01/11/2015 INSURER F: PREMISES Ea Nota encs $ 100,000 r.wcew_. o /%CnTICV^ATC 6111aaDCD. KI-VINKAM NUMM-K: 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. INSR LTR TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN POLICY NUMBER MMIDD EFF MMIDD EXP LIMITS Miami Shores„ FL 33128 GENERAL LIABILITY _r EACH OCCURRENCE $ 1,000,000 A X COMMERCILL GENERAL LIABILITY LlJA191626 01/11/2015 01/11/2016 PREMISES Ea Nota encs $ 100,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE a OCCUR PERSONAL & ADV INJURY $ 1,000,000 BLANKET ADDL INSURED GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 1,000,000 $ POLICY PRO LOC AUTOMOBILE LIABILITY =SINGLE LIMB $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per aooldent UMBRELLA LIAR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB HOCCUR CLAIMS -MADE DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITYTORY ANY PROPRIETORIPARTNERIEXECUTIVE Y WC STATU- OTH- LI ITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ OFFICERIMEMBER EXCLUDED? (Mandatary in NH) N / A E.L. DISEASE - POLICY LIMIT 1 $ IIdescribe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Septic Tank Systems -installation,... r Akln=! 1 AT1"M VCRI lr IHMIG 17VVVGn � —��� — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Miami Shores„ FL 33128 AUTHORIZED REPRESENTATIVE _r V T`JiftB-2UTU A6UKL/ VUKrvlwl /vim. ~ iuji to,vow, vwu. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE I THIS CERTIFiC4TE IS ISSUED AS A MATTER OF INFORMATION ONLY ARD CONFERS SIO RIGHTS UPGIt1 THE CEER77FICATE HOLDER, THIS CERTIFICATE IDES NOT AFFIRfAATIVELY € R NEGATIVELY AMEND, EXTEND OR ALTER THE cOVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF 114SURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AAUTHORInD REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It #Ie 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 tIVIs certificate does not confer n9W to the certificate holier in lieu of such endears s) PrODUCER SUNZ Insurance Solutions. LLC. D. TLR Nn : ` Aimee Gray �.� nc 700 CeRrldral Ave Bonita, 500 Salt, Petersburg, OL 33701 -pmuizEn a: Aspen Re - London - Best Ra ' W TTLR of Bonita, ;Inc dna Enterprisel-II INSaIRER c : Catlins to - LID - Best R oA Encore BusinSolutions, Inc iaa�Lle � -Best Rail SAW and its Subsid es URr� D: est i'y� n 700 Central Ave Suite 500 INSURER E: --r— St. Petersburg'k 33701 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED mmtu ,aL.vvt rv-mr inc rwwr , INDICATED. Not -WITHSTANDING ANY REWREMENT, TERM OR COWPON OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WtilCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, FXCLUSIONS AND COMNTIONS OF SUCH POLICIES LIMITS SHM%W MAY`HAVF BEEN REDUCED BY PAID CLAWS `----'?y-�eat FDLLCY PORKY EXP g TYPE PF WSURANCE ' POI.S$:Y NUm � COMMERCIALGEdERALUASILrrY r i 64^HC;rtIRREA4 € g DAItl k TO #R i TLS OCCUR E PREMISES IES ocamencet � g CLAIMS -MADE I.tEi7 EXP (,9,`cy Qr4 �fvn) ' S }k--'{� I PERSONAL & ADV t4,LFURY � S ENL AGGREGATE LIMIT. PPUESPER: 4 GENERALliC3t3RECfiTE —7 POLICY',— u JPERO � LOC j PRODUCTS - COMPfOP AGG S I j COMBINED LI&11T 3 AUTOWBILE LJAM iTY 1 r , BODILY I14joRY (per Petson) is ANY AUTO ALL DINNED SCHiDt1LED BODILY INJURY (Pat accident) S j AUTOS — AUTOS { �P�7F' Gr dr�Sa cy D j HIRED AUTOS u AUTOS 1—}1 Il € i S j � f I. UkBBRELLA UAB OCCUR EACH CCCURRE�FCE S i-- EXCESS LIAR CLAIMS MADEi S AN0Efa1PLOYER9'UASUJTY YiNi ANY PROPRIETOR' RTNER"6CUTNE orFiCERmwaEREXXGLUDEDf ❑IN1A (Mandatary in NH) EL. EACH ACCMENT 5 E.L. DESEASE-EAEMP10YE S � j E.! DI.�EA�-POLICY UtArf � 5 ?Thio is far intnrrnational purposes t3 ivVorrcers tQmWrisxrac,r, C Exp Coverage ! and rTaittirR< 5haf{ create any Q 4 under such reinsurance. DESCRynoN OF OPERIATIOIds I LOCATIONS f VEHtC8.ES (ACORD 101. AA9!¢l U al Rematk>r Schedule, may be zdaclMd if mare Spam Is regwre4 Coverage Provided for all teased employees Int not dors ot: ter V's Plurit ft & se*-" Inc SR -061536 Client Effective: 1014 Miami Shores Village SIIouLn P34Y OF THE ABovr= DEscRa FD Pout s BE CANe o -ED ElIVoRE THE MWIRAT110te DATE THEREOF, NOT= Tlwu. BE DELIVERED Ili 10050 NE 2 Ave ACCORDANCE "STH THE POLICY PROVISIONa Miami Shores, FL 33928 AUTHORI2ED REPRESENTATIVE , �. Glen J Distefano ©1988-2014 ACORD CORPORATION. An rlghlt reserved. ACORD 25 (2014MI) The ACORD name and logo are registered marks of ACORD CIMT NC,.: 21947:78 AiEree Gray 1199`20:.5 11:65;25 AN ;CSS) Pana i cx i STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Luis Manga PERMIT #:13 -SC -1579493 APPLICATION #: AP1171224 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR960376 PROPERTY ADDRESS: 94 NW 94 St Miami, FL 33150 LOT: 14,13 BLOCK: 168 SUBDIVISION: Miami Shores PROPERTY ID #: 11-3101-0340230 [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 I 900 1 GALLONS / GPD existing septic tank to remain CAPACITY A [ 0 1 GALLONS / GPD CAPACITY N [ 0 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] ON DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 300 SQUARE FEET new bed confiq. drainfield SYSTEM R [ 0 1 SQUARE FEET SYSTEM A TYPE SYSTEM: [x1 STANDARD [ ] FILLED [ 1 MOUND I ] I CONFIGURATION: [ ] TRENCH Ix] BED I ] N F LOCATION OF BENCHMARK: FFE 12.8' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 19.201[ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE 169.241[ INCHES T FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: 10.001 INCHES EXCAVATION REQUIRED: [ 62.001 INCHES 1. -Existing 900 gal. septic tank, certified by "Mr.C's Plumbing" on 01/07/2015 to remain. O 2. -Install 300 sf of drainfield in bed 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 R SPECIFICATIONS BY\,B\ \,\*r C'_�s Plumbing APPROVED BY: deidy Martin DATE ISSUED: 1/12/2015 TITLE: TITLE: Engineering Specialist II DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Dade CHD EXPIRATION DATE: 04/12/2015 v 1.1.4 j"1171224 S&947496 Page 1 of 3 DOCUMMU #: PR960376 vert elevation of drainfield to be no less than 7.53' NGVD. ottom of drainfield elevation to be no less than 7.03' NGVD. system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of gpd.THIS PERMIT IS NOT FOR ANY ADDITIONS. STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATION APPLICANT: Luis Manga CONTRACTOR / AGENT: MrC LOT: 14.13 BLOCK: 168 SUBDIVISION: Miami Shores ID#:11-3101-034-0230 APPLICATION # AP1171224 PERMIT # 13 -SC -1579493 DOCUMENT # SE947496 TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.22 ACRES TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ] AUTHORIZED SEWAGE FLOW: 549.99 GALLONS PER DAY [ 1500 GPD/ACRE OR 1 2500 GPD/ACRE ] UNOBSTRUCTED AREA AVAILABLE: 450.00 SQFT UNOBSTRUCTED AREA REQUIRED: 450.00 SQFT BENCHMARK/REFERENCE POINT LOCATION: FFE 12.8' NGVD ELEVATION OF PROPOSED SYSTEM SITE 19.20 [ INCHES / FT ] [ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: FT DITCHES/SWALES: FT NORMALLY WET: [ ]YES [ ]NO WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON -POTABLE: FT BUILDING FOUNDATIONS: 8 FT PROPERTY LINES: 2 FT POTABLE WATER LINES: 20 FT SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO] 10 YEAR FLOOD ELEVATION FOR SITE: FT [ MSL / NGVD ] SITE ELEVATION: 11.20 FT [ MSL / NGVD SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2 USDA SOIL SERIES: Urban land Munsell #/Color Texture Depth 10YR 3/1 Sand 0 To 6 1 OYR 5/4 Sand 6 To 28 1 OYR 5/4 Oolitic Limestone 28 To 72 USDA SOIL SERIES: Urban land Munsell #/Color Texture Depth 1 OYR 3/1 Sand 0 To 6 10YR 5/4 Sand 6 To 28 1 OYR 5/4 Oolitic Limestone 28 To 72 OBSERVED WATER TABLE: INCHES [ ABOVE /BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ] ESTIMATED WET SEASON WATER TABLE ELEVATION: 92 INCHES [ ABOVE /F1ELOW ] EXISTING GRADE HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Replacement 4-FS/0.60 DEPTH OF EXCAVATION: DRAINFIELD CONFIGURATION: [ ] TRENCH [X) BED [ ] OTHER (SPECIFY) r REMARKS/ADDITIONAL CRITERIA SITE EVALUATED BY: Mr C"s Plumbing, (TMe: ) (Mr C"s Plumbing) DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC 62 INCHES DATE: 01/07/2015 Page 3 of 4 AP1171224 EID167%93 v 1.0.2 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN # A02, Tallahassee, Florida 32399-1703. The Agency Clerk's facsimile number is 850-410-1448. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order.