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PL-15-1427Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-236529 Permit Number: PL -6-15-1427 Scheduled Inspection Date: June 23, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: JEAN TRACH REVOCABLE LIVING Work Classification: Septic TDI ICT KAKI TDA!`1-1 DC%1r%1-A0I C Job Address: 409 NW 111 Terrace Miami Shores, FL Phone Number (305)754-2415 Parcel Number 1121360010450 Project: <NONE> Contractor: A AMERICAN SEPTIC & PLUMBING Phone: (305)866-5600 Building Department Comments DRIANFIELD REPAIR Infractio Passed Comments INSPECTOR COMMENTS False June 22, 2015 For Inspections please call: (305)762-4949 Page 19 of 38 Inspector Comments Passed El HRS IS ON FILE Failed a �C Correction 6 Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. June 22, 2015 For Inspections please call: (305)762-4949 Page 19 of 38 Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address 409 NW 111 Terrace Miami Shores, FL Information JEAN TRACH REVOCABLE LIVING Parcel Number Applicant 1121360010450 Block: Lot: Address 402 NW 111 Terrace MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone A AMERICAN SEPTIC & PLUMBING (305)866-5600 (786)236-5599 of Work: DRIANFIELD REPAIR of Piping: onal Info: Return : ification: Residential Scanning: 1 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 $3.00 Technology Fee $2.40 Total: $662.30 JEAN TRACH REVOCABLE LIVII Cell (305)754-2415 Valuation: $ 2,450.00 Total Sq Feet: 225 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -6-15-55932 06/15/2015 Check #: 3937 $ 112.30 $ 550.00 06/10/2015 Credit Card $ 50.00 $ 500.00 06/11/2015 Credit Card $ 500.00 $ 0.00 Bond #: 2748 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 ce i th a[ thgloregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Fut re I t o izp the above-named contractor to do the work stated. June 15, 2015 Authorized Signatur*: Owner Y Applicant / Contractor / Agent Building Department Copy 1 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 g� JUN �I 0 2015 FBC 201 Master Permit No. TL 1 S_" ) Z_ Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [-]RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [-]CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: q0 q 0 V" I I & r a'Le_ City: Miami Shores ff L�,�' County: Miami Dade Zip: 3 bD Folio/Parcel#:�� 3 �l � �� - -l'� l7 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: _ BFE: — FFE: OWNER: Name (Fee Simple Titleholder): r�I^ ) F'� Phone#: Address: U L) 1 0� i(( City: r0l State: In, Zip: Tenant/Lessee Name: 1 /A- Phone#: Email: t,, N CONTRACTOR: Company Name: I �,I i -1^ J c,l� h i✓ 'f- Pt V1�J�Piou!rq-ws 'yltl�` Oti Address: City: Qualifier Name: State: i F,_ Zip: 3 J 1 fi �q 00 Phone#: 1816- 231 - �S f State Certification or Registration #:`1 S� V� � 'f 7i Certificate of Competency #: �t 0VV ��j DESIGNER: Architect/Engineer: 0/ Pf Phone#: Address: f a ` City: State: Zip: L. Value of Work for this Permit: $ �J Square/Linear Footage of Work:��U Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace ❑ Demolition Description of Work: rain e,lk a I r Specify color of color thru tile: Submittal Fee $ (5;70 -� Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Structural Reviews $ (Revised 02/24/2014) if Se), ;-e CCF $ Training/Education Fee $ DBPR $ CO/CC $ Notary Double Fee $ Bond $ r TOTAL FEE NOW DUE $ 612.30 Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address Zip 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.Ff 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 o reinspection fee will be charged. / Signature `1 1: Signatur AI OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrTO was acknowledged before me this {o day of )U %N C .20 i J by tl day of n 120/5 by. kQV'VJ(-A 74C.4% who is personally known to k�f 190 ,0i, -f a i ersanally known to me or who has produced :ICG%j.;s1 AQ 'ey-: as has produced as identification andy4u)-di�,ak n oath. NOTARY identification and who did take an oath. NOTARY Sign: I " <' I. Print: Print: ,� 1 _ r ►µ' ^,y•s, LEONARDO RAS >��R:P& J Seal: +°. NotaryPublic - Stae af f oWs Seal: NANCY ION # EE * • * MY COMMISSION # EE 880780 M, ^oTm Expires Misr IT. tCtd P EXPIRES: February 15, 2017 •+ o„, ssion # FF 102757 "r"OFFLpe-`O Bonded Thru Budget Notary Services ♦��esa��aa •tr/tt�y•�iS������t1iY+Rt��i�tM�/���R*I��A�tiMbOtMttf�a�t0lt��rf�tOfU• APPROVED BY`// -I Plans Examiner Structural Review Zoning . Clerk (Revised02/24j2014) Scanned by CamScanner e - C REVOCABLE LIVING TRUST AGREEMENT THIS TRUST AGREEMENT, made this - day of -z� o /, between JEAN TRACH, whose post office address is 409 N.W. 111th Terrace, Miami Shores, Florida 33168, as "Settlor", and JEAN TRACH, of the same address, as "Trustee", WITNESSETH: The Settlor hereby transfers to the Trustee the property listed in the attached Schedule A. The property and all investments and reinvestments thereof, and any additions thereto, are herein collectively referred to as the "Trust Estate", and shall be held upon the following terms and conditions: FIRST 1. During the lifetime of the Settlor, the Trustee shall pay the income from the Trust Estate in convenient installments to the Settlor or otherwise that she may, from time to time, direct in writing such sums from principal as she may request. If at any time or times the Settlor is unable to manage her affairs, the Successor Trustee(s), hereinafter named, may use such sums from the income and principal of the Trust Estate as the Successor Trustee(s) deems necessary or advisable for the care, support and comfort of the Settlor and any other person dependent upon her, or for any other purpose the Successor Trustee(s) considers to be in the Settlor's best interest, adding to principal any income not so used. 2. For the purposes of this Agreement, the Settlor shall be considered to be unable to manage her affairs if she is under a legal disability or, by reason of illness, mental or physical disability, and is unable to give prompt and intelligent consideration to financial matters. The determination as to the Settlor's inability at such time shall be made by the Settlor's physician and the Successor Trustee(s) may rely upon written notice of that determination. SECOND 1. Upon the death of Settlor, the Successor Trustee(s) shall pay from the principal of the Trust Estate the expenses of Settlor's last illness, funeral, burial, claims allowable against her estate, costs of administration including ancillary, estate and inheritance taxes assessed by reason of her death, except that the amount, if any, by FIFTH The Settlor appoints herself to be the Trustee of this Trust. Upon the death or disability of the Settlor, the Settlor appoints TANYA A. TRACH as her Successor Trustee. In the event that TANYA A. TRACH has either predeceased Settlor, is unable to serve or otherwise chooses not to serve, then Settlor appoints PERRY M. TRACH as her Successor Trustee. SIXTH The laws of the State of Florida shall govern the validity and interpretation of the provisions of this Agreement. SEVENTH The Settlor may, at any time or times during her lifetime, by instrument in writing delivered to the Trustee, amend or revoke this Agreement in whole or in part. The Trust property to which any revocation relates shall be conveyed to the Settlor. This power is personal to the Settlor and may not be exercised by any guardian, successor trustee or otherwise. IN WITNESS WHEREOF, I, JEAN TRACH, have signed this instrument the day and year first above written. JEAN TRACH STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair. APPLICANT: (Jean Trach TRS) PROPERTY ADDRESS: 409 NW 111 Ter Miami, FL 33168 PERMIT #: 13 -SC -1608713 APPLICATION # : AP 1190322 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT # : PR976568 LOT: 29 BLOCK: 2 SUBDIVISION: New Miami Shores Estates PROPERTY ID #: 11-2136-001-0450 [SECTIO'N, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 361.0065, 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 Y GALLONS / GPD Septic (Existing) CAPACITY A [ O ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY' [ ]GALLONS i?[ ]DOSES PER 24 HRS #Pumps [ ] D [ 225 ] SQUARE FEET Trench Confiquration SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: (x] STANDARD ( ] FILLED [ ] MOUND [ ] I CONFIGURATION: (x) TRENCH ( ] BED [ ] N F LOCATION OF BENCHMARK: FFE 13.6' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 26.40 ] ( INCHES F••t' ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 81.40][ INCHES .FT JIi'.BOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: ( 55.001 INCHES —THIS PERMIT IS NOT FOR ADDITIONS O 1. -Existing 900 gal. septic tank, certified by "A American Septic on 05120/15" to rernain. T 2. -Install 225 sf of drainfield in trench configuration. H 3. -Perimeter of excavation area shall be at feast 2 ft wider and longer than the proposed absorption bed. 4. -Invert elevation of drainfield to be no less than 7.32' NGVD. E 5. -Bottom of drainfield elevatio to be no less than 6.82' NGVD. The system is sized for 3_b roo s w#h a maximum occupancy of 6 persons (2 p: -r bedroom), for a total estimated flow R SPECIFICATIONS BY: 1 Wal jVa 4Ard _ TITLE:` APPROVED BY: DATE ISSUED: ,':.TITLE: Engineering Specialist II Dade CFD EXPIRATION DATE: 08/31/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not be ::sed) Incorporated: 64E-6.003, FAC •i 1.1,3 F.?11;90x32 Suss?2�9 Page 1 of 3