PL-15-866Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-232370 Permit Number: PL -4-15-866
Scheduled Inspection Date: May 06, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: DIAZ, ANGEL Work Classification: Drainfield
Job Address: 9917 N MIAMI Avenue
Miami Shores, FL 33138- Phone Number
Parcel Number 1132060131250
Project: <NONE>
Contractor: JOE LEWIS SPECIALTY SEPTIC Phone: (305)662-7979
Building Department Comments
REPLACE DRAINFIELD
Infractio Passed Comments
INSPECTOR COMMENTS False PP__
\�10— s1
Inspector Comments
PassedF
HRS APPROVAL ON FILE
Failed
Correction
Needed ❑
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
May 05, 2015 For Inspections please call: (305)762-4949 Page 19 of 50
Miami Shores Village
10050 N.E. 2nd Avenue N
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address Parcel Number Applicant
9917 N MIAMI Avenue 1132060131250
ANGEL DIAZ
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
ANGEL DIAZ 9917 N MIAMI Avenue
MIAMI SHORES FL 33150 -
Contractors) Phone Cell Phone
JOE LEWIS SPECIALTY SEPTIC (305)662-7979 (786)343-9958
Type of Work: REPLACE DRAINFIELD
Type of Piping:
Additional Info:
Bond Retum :
Classification: Residential Scanning: 3
Fees Due
Amount
Bond Type - Owners Bond
$500.00
CCF
$1.80
DBPR Fee
$2,25
DCA Fee
$2,25
Education Surcharge
$0.60
Permit Fee
$150.00
Scanning Fee
$9.00
Technology Fee
$2.40
Total:
$668.30
Valuation: $ 2,100.00
Total Sq Feet: 225
Pay Date
Pay Type
Amt Paid
Amt Due
Invoice #
PL -4-15-55188
04/14/2015
Check #: 675
$ 500.00
$ 168.30
04/14/2015
Credit Card
$ 50.00
$ 118.30
04/24/2015
Cash
$ 118.30
$ 0.00
Bond #: 2671
Available Inspections:
Inspection Type:
HRS Approval
Final
Review Plumbing El
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume respons ility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PjdUMBIN ; MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: 16ertify, fat all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning Fut ore, I authorize the above-named contractor to do the work stated.
24, 2015
Owner / Applicant / Contractor / Agent
Building®Department Copy
April 24, 2015 1
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Villagec -
Building Department APRT 20b
10050 N.E.2nd Avenue, Miami S rida 33138 3,
Tel: (305) 795-2204 Fax
756-897
INSPECTION LINE PHONE NUMBER: 762-4949
FBC 20 1
Master Permit No -T:--1_— 115 `P/CU6
❑ ROOFING ❑ REVISION
[/LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
Sub Permit No.
CONTRACTOR
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
JOB ADDRESS: �c1
City: Miami Shores County:— Miami Dade Zip: / J
Folio/Parcel#: `\f U2.�J �11) — lam,\ Is the Building Historically Designated: Yes NO I
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Address: `J -A I 1 1V , \� jC,,�I 'N'zV�
City: � i d)C1 k State: zip:��
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: sP :� , U_�Q_ Phone#: 3� /q��
Address ---�2 J Iy 9 F
City: \ c°Y g I State: Zip: 3 I y
Qualifier Name: A ! Phone#:
State Certification or Registration #:1 1J�� D / % 9 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City: State: Zip:
Value of Work for this Permit: $ 01 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ Newepair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile: e _4 `
Submittal Fee $' a-*) Permit Fee $4 156 L -7 CCF $ c0/CC $.
Scanning Fee $
Technology Fee $,
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
x
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 C14
l
OWN GENT CONTRACTOR
The foregoing instrument was acknowledged before me this
— 104-" day of 'D LI .20 �.� , by
,00,fA who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 0 c'�'
Print: --- I r
Seal: ;._ ,.�' •�. +untary 0ub4: Stab o"t All
I teridda Lewis a
r ' MY C&hrnission FF ISM?
cxprr*& 02/05/2019
The foregoing instrument was acknowledged before me this
day of 20 f , by
�l✓ IF , who i eonally known o
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sig
Print: Print: (�
N
Seal: , orery PuWe stare o► Florio
Trencella Lewis
10� MY Comm4sion FF 196307
_ ao Expires 02/05/2019
APPROVED BY q'/ Plans Examiner
Zoning
Structural Review Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAII SYSTEM .
CONSTRUCTION PERMIT
REPAIR
MIAMIrn I€ ' W-40-0, OMANI*~
CONSTRUCTION PERMIT FOR: OSTDS Repair
PERMIT #-13-SC-1696769
APPLICATION # : AP 1182579
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR969783
APPLICANT: Ange; Diaz
PROPERTY ADDRESS: 9917 N Miami Ave Miami, Fl_ 33175
LOT: 12 BLOCK: 9 SUBDIVISION;, s
PROPERTY ID #: 11-3206-013-1250 , [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAY( ID NUMBER]
0':
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 T1148. 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 k RAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS .
T I 900 I GALLONS / GPD Se6fic. (Existincf) .y 4 CAPACITY
A [ 0 I GALLONS / OPD 4 CAPACITY
N I 0 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ 7 GALLONS DOSING TANK CAPACITY I ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ l
D I 225 SQUARE FEET Trench Confiquration _SYSTEM
R I 0 I.SQUI�RE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ I, FILLED [ ] MOUND I ]
I CONFIGURATION: [xl TRENCH [ ] BED I I
N
F LOCATION OF BENCHMARK: FFE 13.69' NGV[ - .
I ELEVATION OF PROPOSED SYSTEM SITE 127.201E INCHES 'FT ]' AkVE.BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE I.11- 67.24 'I r; INCHE$ , FT I [ A•BOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED : I 0 00 ] INCHES j ` EXCA R
NATION UIRED: C 40.001 INCHES
'*`THIS PERMIT IS NOT FOR ADDITIONS -
0 1. -Existing 900 gal, septic tank, certified by "Lewis Septic on 03/27/15" to remain.
T 2. install 225 sf of.drainfield in trench configuration.
H 3. -Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed.
4. -Invert elevation •of drainfield to be no less than 8.59' NGVD.
E 5. -Bottom of drainfield elevation to be no less than 8.09' NGVD.
R 6. -Water line within 10 ft of septic system to be Sch 40 PVC or sleeved in accordance with FAC Ch 64E -6.005(2)(b).
SPECIFICATIONS BY: J 3. T�TLEr '
c�
APPROVED BY:.
DATE ISSUED:
DH 4016, 08/09
Incorporated:
TATTLE
F1
Engineering Specialist II Dade CHD
EXPIRATION DATE: 07/01/2015
(Obsoletes all Previous editions which may not be used)
64'Z-6.003, FAC The crntrac.or i,cr designee) is required to perform a soil
v1.bcc: adjacent to 2x'.;34?i!-onati'1:? �:rldl
insp-2ctioii. P. for i'o f=inal A prv�c.m\ !, tiles' I: ?n} i inspeic-tor shall
Witness thle 3011 > ((lig ag1C9 4ru 'fi r : thf- t !r;!tb to lip. rjY!linal
site ewalu i icnn i: —1-A, ° `',s. ;:.:y iC4 Q :' f '- ',v' � sessetl
if the s?r} f stgf i , rp t a% 'r t ; moi; 4Z vio grringed time.
Page 1 of 3
REGISTERED SEPTIC TANK CONTRACTOR
JOE LEWIS, JR
2325 NW 96 STREET
E
MIAMI, FL 33147-
'= JOE LEWIS SPECIALTY SEPTIC
Business Authorization: SE0081499.
SR0081699
Registration Expires on September 30, 2015
Local Business Tax Receipt
Miami -Dade County, State Of Florida
THIS IS NOT A BILL -OO NOT PAY
7172421
BUSINESS NAME/LOCATION RECEIPT NO.
LEWIS JOE SPECIALTY SEPTIC NEW BUSINESS
LLC 7451361
2325 NW 96 ST
MIAMI, FL 33147
OWNER SEC. TYPE OF BUSINESS
LEWIS JOE SPECIALTY SEPTIC LLC 198 SPECIALTY PLUMBING
C/O JOE LEWIS MGR CONTRACTOR
Worker(a)
SE0081499
PAYMENT RECEIVED
BY TAX COLLECTOR
75.00 06/25/2015
0224.14-006016
This Local Business Tax Receipt only continua payment of the Local Business Tax. The Receipt Is not a license,
penult or a cerdRcation of the holder's qualifications, to do business, Holder must comply with any governmental
of nengovemmemei regulatory, laws and requirements which apply to the business.
The RECEIPT NO. above must be displayed oo all cornmene181 vehicles - IWleml-Dade Code Sec Be -276,
For more information, visit maw. mlam Aude aovkaxeoih ctar
CERTIFICATE OF LIABILITY INSURANCE
1011012014•
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGIM UPON THE CERTIFICATE MOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTnVM A CONTRACT BETWEEN THE MI ING INSURER(S), AVIHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IxORTANT: Ifthe hoer aq ADD7TiONAI.INSURED, ev P0ff y(€es) mast be 040med. WSigW0GAT1Oid IS W"A-WED, sU�tb
the terms anal Conditions of fate poky, owtan n may regalre an endorswesent. A sUftment an bats mMkWe dow ootcomer r stothtt
holder in flea of Such s).
PRODUCER
Admiral Insurance, Inc. PHONE No, (WS)6214370
17340 NW 27th Ave
Miami Gardens, FL 33055 - sFF;1 G COVERa _ .- • _ -:-_-- G —_�
Phone (305)21-1370 LLOYDS OF LONDON
INS URED
LEMS SEPTIC ViSttftERc c
.._.. _..---------- --__ _.- - --- _ - ---- ---.
3075SW61 Ave a� ------_-----._----_...___---�.
MIRAMAR. FL 33023-
94SURER F :
ER:
COVERAGES _ _ CERTIFICATE NLtMBER: -_-_ . _._. _REMION NUMB
THS IS TO CERTIFY THAT THE POLICES OF INSURA=E LISTED BI t.ONV HAVE BEEN ISSUED TO THE �SURE_D NAMED ABOVE FOR THE POLtCYPER�_ ------ ---_ -'
WDICATED. NOTIMTHSTANMG ANY REQUtREmE T TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT MVITH RESPECT TO WHICHTHIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SLIM POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAI? CLAIMS.
— TYPEOFBF$UI4ANCE ADDL8UBR` POLICY OtjCyEXp -
GEt L1A8lidiY _. INSR : wvf) _ . .. PO= 1 R
EACH OCCtt_RREtdCE
CO RCIAL GEt1ERAL LIABILITY DAMAGE TO RENTED � lflii 0I� 00
PRE18SEs(ftP=0MfM-__
Q CIAIkk9 -WDE RE OCCUR GUCOI HIED tArgr cmc A�scmi . w -.5-000-00
} 1011412014 101i=DIS
PERimtAL & AIw wuRy S 100.019000
GENERALAGGREGATE s 200,000.00
GEWL AGGREWE i IMTAPPLES PER.PFtOCiUL7S-cOIaPrGP Ac,G S 10tI.1 .01d
- -- - -- ----- -
AUTOMOBILE LLABILIY
ANY AUTO BODILY tFLf M tPer PMWI S
�OVMED
{!—�L�t SCHEDULED PBODILY INJURY (Per fin} S
HIREDAUTOS TJ AUUTOS4l VED
a
WORELLA LM
t�44 L CUR EACH OCCURRENCE
EXCESS LIas 17 CL WSUADE ACG»aF a
"RKERSCOMPENSATION
AND EMPLOYER&LIABUM YINANYPROPRIE
OFFICERuMM fSRIPARTUER C.0 YflfE ED?PI to EL EACH ACCIDENT -S
{t atocy b HH)
I . E.L. DISEASE - EA EMPLOYEE 5
3� awe � rift
SCA
'Tom DF OPERATIONS ta�,7 - _- - E L DISEASE - POLICY LUT: S, _
DESCRI TMOFOPERAYiI3 ILOCi4TWMIVENICLES._ _ _.--;._�_.__..__--.• .--
IAftaettACORD191,AddttiooalRettrarksSei%;I<more6PHseisrequlredj
Florida Septic Tank Contractor
Septic Tank Contractor License Na SR00815"
cERTrFlCATE HOLDER
Miami Shores Village
Building Department
10050 NE 2 Ave
Miami Shores Village FL 33138
ACORD 25 (2010/85) QF
CANCELLATION
SHOULD MY E,. MIOVE 13ESCYAW POLICES Li CAORMLLM DEFORE
N
ACCORDANCE VM THE POLICY PROVISION&
AUTHORIZED
ANGELO R.
OINB-2MOAC d" nsertfe&
'- YT"wW fto am fegbtemd vmft of ACORD
K
" 03-27-2014
Jeff Awater STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS` COMPENSATION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 03/27/2014
PERSON: LEWIS
FEIN: 262647 579
BUSINESS NAME AND ADDRESS:
LEWIS SEPTIC SERVICE LLC
3075 SW 61 AVE WORTH APT.
MIRAMAR FL 33023
SCOPES OF BUSINESS OR TRADE:
1— DRAINAGE
EXPIRATION DATE: 03/27/2016,
2— SEPTIC TAROKS
m
IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05114, F.S., Certificates of election to be exempt... apply only within the
scope of the business at trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice of
certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
QUESTIONS? (850) 413-1609
VC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06
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
3 Sfr'a`.. •.. 3 .
Ilorida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allow,, corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtairing 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 .ontractor 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, Miami Shores Village does not require verification of
x%orkcrs' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CON"ENTS.
Signa ure:
Ow to
State >f Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of A , 20AS .
By �( ` who is personally known to me or has produced
as identification.
Notar� �o�
SEAL: V%_^MPA^^
JrwcelfttLewls
1-4)(PMa 1512010
JOE LEWIS SPECIALTY SEPTIC
2325 NW 96 STREET
MIAMI, FL 33147
PNN: 786-343-9958
EMAIL: LEWISSEPTICc@HOTMAIL.COM
Dater 1 `1 S
State of ' F1 4C., Q
County of Qd e—
Before me this day personally appeared = %S who, being duly sworn,
Deposes and says:
That he or she will be the only person working on the project located at:
3�s � 5 (�)
Sworn to (or affirmed and subscribed before me this day of =1�, by
V .. � �
1..
jec— L-,,,,
Qualifier
Personally know
OR Produced Identification
Type of Identification Produced
Print, Type or Stamp Name of Notary
ENoNq =00F-**cPv JITrernMy c
Municipal Contractor's Tax Receipt
Miami—Dade County, State of Florida
-THIS IS NOT A BILL - DO NOT PAY
CC NO: SEP081599
BUSINESS N"EILOCATIAM RECEIPT NO.
JOE LENS SPECIALTY SEPTIC LLC
2325 NW 96 ST 7466074
MIAMI, FL 33147
MC
EXPIRES
SEPTEMBER 309 2015
OWNER TYPE OF BUSUVESS
JOE LEWIS SPECIALTY SEPTIC LLC 5PEOALTY PLUMBING CONTRACTOR
C/O JOE LEWIS MGR
Restricted to City of NNW Shores
weforme visit
Pursuant to County Code
Set 14-24
PAYMHVT RECEIVED
BY TAX COLLECTOR
18.75 05/04/2015
0221-15-005474
DIVISION or
Environmental Health
�0 Florida Department of Health
®� Miami -Dade County Health Department 0#��
4� OSTDS/Well Division
11805 SW 26 St. • Miand, FL. 33175
Inspector.t/In I"c�Q Date
Address ()r')1 OSTDS #
Comments:
Signature