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PL-15-930Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 inspection Number: INSP-232935 Permit Number: PL -4-15-930 Inspection Date: May 05, 2015 Inspector: Diaz, Osvaldo Owner: DOWSON, ALFRED & NANCY Job Address: 289 NE 102 Sfrppt Miami Shores, FL Project: <NONE> Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Drainfield Phone Number Parcel Number 1132060134970 Contractor: A SUPER SEPTIC TANK, INC. Phone: (05)364-0113 Buildina Department Comments INSTALLATION OF 300 DRAINFIELD. infractio Passed comments INSPECTOR COMMENTS True Passed Inspector Comments HRS ON FILE Failed Correction Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. For Inspections please call: (305)762-4949 May 06, 2015 Page 1 of 1 Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 r1V�O{il r,YYl Ciiii Parcel Number Applicant 289 NE 102 Street 1132060134970 Miami Shores, FL Block: Lot: ALFRED & NANCY DOWSON Owner Information Address Phone Cell ALFRED & NANCY DOWSON 305 NE 91 ST MIAMI SHORES FL 33138-3129 Contractor(s) Phone Cell Phone A SUPER SEPTIC TANK, INC. (05)364-0113 Type of Work: INSTALLATION OF 300 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: $ 2,200.00 Total Sq Feet: 300 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -4-15-55260 04/20/2015 Credit Card $ 50.00 $ 618.30 04/21/2015 Check #: 2966 $ 500.00 $ 118.30 04/22/2015 Check #: 6666 $ 118.30 $ 0.00 Bond #: 2681 Available Inspections: Inspection Type: HRS Approval Final Review Plumbing 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 responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL , PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing info tio�krate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the abovcamed contraft to do the work stated. April 22, 2015 Authorized Signature: Owner / Applicant / Contractor / Building Department Copy April 22, 2015 1 BUILDING PERMIT APPLICATION Miami Shores Village��a�'®_� Building Department APP 0 201 j BY: _.. 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 -�- iT��i�� V� 7 INSPECTION LINE PHONE NUMBER: (305) 762-4949 /l 83 / 6 4 FBC 20 b Master Permit No. Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [:]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 69 $ f?� I✓� t �'( i�x f �I' City: Miami Shores County t/tide Miami Dade Zia 13cp Folio/Parcel#: I I - .3 a G b Is the Building Historically Designated: Yes N Occupancy Type: _ Load: Construction Type: Flood Zone: BFE: FFE:114? OWNER: Name (Fee Simple Titleholder): iL�W'So 0) Phone#: Address: Z a) C f 0 City: Or -mss State: 1— (vv--, 1A zip: -331 3 1;- Tenant/Lessee Na e: �� Phone#: Email: CONTRACTOR: Company Name: Lpa6�2 � � ��, ,,,� , Phone# -30-t `3 Aa -ok'3 Address: �7�T w 1��5i° 04{�j.Q City: f Isr-� d Zip: ®/"f Qualifier Name: '�(f.4 ,,(� �,1 7% Phone#: 902 -3f t 3 State Certification or Registration M94- d (oo SJS G 67A91,d 0 Certificate of Competency % DESIGNER: Ar hit ngineer: Phone#: Address: City: _State: Zip: ' Value of Work for this Permit: $ /.;2, Q 0 0. `� Square/Linear Footag ork: 3 Aid S 6G; -r Type of Work: ❑ Addition ❑ Alteration El Repair/Replace ❑ Demotion Description of Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Educatlon Fee $ Structural Reviews $. (Rev1sed02/24/2014) �L CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ C:mC.�� TOTAL FEE NOW DUE $ 11 • 3 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 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 inspecti will not be approvedca ret 777 sp ion fee will be charged. 7 OWNER or AGENT The foregoing )nstrumen efore me this day of �- , "/ 20 /J— . by . _ &v,y Pct -f-, , who is personally known to me or who has produced f- /? (- identification identification and who did take an oath. NOTARY PUBU5: Noiafr Public State. of F arida Seal: n FE 993335 �., '1,2u 16 as The foregoing me this / r day of Pr , 20 9 , by 14 hdfcl,� ✓K ZP_ f -O . who is personally known to me or who has produced ISL -Q 7 60-013-3f--OIT-0 as identification and who did take an oath. NOTARY PUBLIC: Sign:. Print: fff t(.- Seal: 101;-;;&P,07 My Commission Expires 08/29/2017 OF F1.O Commission No FF 49828 i##ffiffi##ffi#####iffi#ffiiffii######ffiffiiffiffi#####iii###ffiffiffiiffiiiffi#ffiiffi#ffiiiffiiffii#i######iiiffiffi##iffiiffiffiffiffiii#ffii###ffi#i##ffi##ffi#i##iii APPROVED BY Plans Examiner Zoning Structural Review Clerk iRevised02/24/2014) REGISTERED SEPTIC TANK CONTRACTOR ANDREW M. ZERO 7701 W. 18TH LANE Ems` HIALEAH, FL 330`14- A 3014A SUPER SEPTIC TANK, INC. Business Authorization: SA0960829 SR0890722 Registration Expires on September 30. 2015 ANDREW M. ZERO A SUPER SEPTIC TANK, INC. 7701 W. 18TH LANE HIALEAH, FL 33014 - FLORIDA DEPARTMENT OF HEALTH CERTIFICATE OF AUTHORIZATION FOR SEPTIC TANK CONTRACTING The Florida Department of Health hereby certifies the business or entity named below has satisfied the requirements of Part Ill, Chapter 489, Florida Statutes, for septic tank contracting and has been duly authorized by the Department to provide septic tank contracting services under the name of A SUPER SEPTIC TANK, INC. Qualifymg Contractor: ANDREW M. ZERO SA0960829 April 6, 2015 March 31, 2017 Authorization Number Date Issued Expiration Date 602376 Local Business Tax Receipt Miami—Dade County, State of Florida` THIS IS NOT A BILL 00 NOT PAY 3820314 LBT BUSINESS NAME/LOCATION RECEIPT NO., EXPIRES Pi SUPER SEPTIC TANK INC RFEIVIR NAL SEPTEMSE R 6, .2015 7701 W 18 LA 1 3988779 Must be displayed at place of business HIALEAH R 33014 Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS OWNER PAYMENT RECEIVED ASUPER SEPTIC TANK INC 196 SPECIALTY PLUMBING CONTRACTOR ' BY TAX COLLECTOR SEP M122 i 890722 $45.00 09/15/2014 CREDITCARD-14--037365 This Local Business Tax Receipt only confirms psymant of the Local Business Tax. The Receipt is not a 11cen", permit, or a certiRMtiun of the holler-s _ ualficadons, to do business. Holder must comply with any governmental ornonoovermnentolrsfouietoryiagvsa nmdreelern-Wbicitapplytothebuei►nls�s The RECEIPT NO. above must•ba displayed on all ou�l vehiolus - iVliami-11ado Code Sec so-M. For more infornuaion,Visit vn w,niomidad AWARxowl Report Viewer r 9 100°k JEFF AIMTEA CHM FMAMCML QFRCM t �r srs� a ems` STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS' COMPENSATION • `CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKEIM COMPENSATION LAW' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual Usted below has elected to be exempt from FkMa Workers' Compensation law. EFFECTIVE DATE: 6/411014 EXPIRATION DATE: 8/3/2018 PERSON: ZERO ANDREW M FEIN: 650455404 BUSINESS NAME AND ADDRESS: A SUPER SEPTIC TANK INC 7701 WEST 18 LANE HIALEAH FL 33014 SCOPES OF BUSINESS OR TRADE: IRRIGATION OR DRAINAGE SYSTEM ono OFs-F24NJC-262 CERMCATEOF ELECTON TO BE EXEM r FnSED 0712 QUEST=Mt 1a-109 Page 1 of 1 htt-ne-//P.mcR fldA r nm/nrrpnnrtviPwPr/rnnnrtViPurpr acnx9tiata=ktitmuinr91770311H6TP,R6e___ 6/4/2014 A SUPER SEPTIC TANK INC. 7701 WEST 18 LANE HIALEAH, FLORIDA 33014 LICENSED AND INSURED STATE REGISTERED SEPTIC TANK CONTRACTOR CC#SEP890722 PHONE: 30S-364-0113 FAX: 305-364-0349 WWW.ASU PERSEPTICTAN K.COM ASSTI@BELLSOUTH.NET April 20, 2015 State of: Florida County of: Dade Before m n thi 20th day, ersonally appeared .e ev o -who being Sworn deposes and says: That he/she will be the only person working on the project located at: 289 NE 102 Street Miami, Florida Sworn to: (Or affirmed) and subscribed before me this 20th day of April, 2015, by: Personally known: Or Produced Identification: Type Of Identification Produced: PRINT, STAMP, OR STAMP NAME OF NOTARY lelvv SAVE-, WMWASvda date of Ftp # FF OW •DOW41119820117 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 -rime 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 . f 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, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW U ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. /"1 Signature_ Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this -.Q0 day of �� , 20 IG . By P�1 1) %150N who is personally known to me or has produced e T5 as identification. Notary: SEAL: pity public State of Florida Sindfa Alvarez rA �< My Commission FF 156760 3) ' }� Y PERMIT #:13 -SC -1597668 ,gyp xcATIoN #:AP1183163 STATE OF FLORIDA �8 , v:9 -I ::'t' ; d.?_. { �irt�.�R �� DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTT-24 CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Alfeed Dawson PROPERTY ADDRESS: 289 NE 102 St Miami, FL 33138 LOT:. 22 BLOCK; 36 SUBDIVISION: Miami Shores FEE PAID: RECEIPT #: DOCUMENT #: PR970194 PROPERTY ID #: * 11-3206-013-4970 [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 [ 1,050 ] GALLONS / GPD existinq septiolank to remain CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ALL 3�SOSING TANK CAPACITY [ ]GALLONS �[ ]DOSES PER 24 HRS #Pumps [ l r 300 SQ FEET • new trench confiq. drainfie SYSTEM 0 ARE FEET SYSTEM YP STEM: [x] STANDARD [ ].FILLED [ ] MOUND I ] I CONFIGURATION: [x] TRENCH [ ] BED N F LOCATION OF BENCHMARK: FFE 11.8' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 22.80][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 66.80 1 [FINCEMsl FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: f 56.003 INCHES 1. -Existing 1050 gal. septic tank, certified by "Drain Master" on 3/10/2015 to remain. 2. -Install 300 sf of drainfield in trench configuration. T 3. -Install 12" of slightly limited soil at the bottom of tfie drainfield: H 4. -Perimeter of excavation area shall be at least i ft" de -f and long6t than the proposed absorption bed or drain trench. (Comments Continued on Page 2.) ` R n SPECIFICATIONS BY: TITLE: APPROVED BY: \MAX V \ TITLE: Engineering Specialist II Dade CHD Yudeisg� r n DATE ISSUED: 04/06/2015 EXPIRATION DATE: 07/05/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not: be used) ' Incorporated: 64E= ►•� DIVISION' OF Environmental Health 01Florida Health 'Mi 0 ami -Dade County �D QQIP '. OSTDSlWell Division ► 11805 SW 26th Street • Miami,..FL 33175 InspectorC- Q l� n' O Date rJ I I L'„cj Address �q 1 S'•r OSTDS # AP 1183�b p Signature