PL-15-1205 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-235095 Permit Number: PL-5-15-1205
Scheduled Inspection Date: July 08, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: FABRICANT, RACHEL Work Classification: Drainfield
Job Address:406 NE 103 Street
Miami Shores, FL 33138- Phone Number (305)759-9949
Parcel Number 1132060170760
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
Building Department Comments
REPLACE DRAINFIELD Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS IN FILE
Wv)-L�
Failed
Correction
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
July 07,2015 For Inspections please call: (305)762-4949 Page 18 of 52
• ;� Miami Shores Village
' P \J� Building Department M Y 0 2015
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
BY:
Tel:(305)795-2204 Fax: (305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2010
BUILDING Master Permit No.�
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
Z]PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
I JOB ADDRESS: �(i�' N I �� � � �(J—
r
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1/ -3 ztl V Is the Building Historically Designated:Yes NO j/
Occupancy Type: Load: r��Construction Type: # Flood Zone: BFE: FFE:q�/
OWNER: Name(Fee Simple Titleholder): Fmj',ie I t�r1 CGU ( Phone#: �S 75 GI GJf T f
Address: oG /V C /u-3 �n''e e t
City:_�ICUhi (,dy' 1 State: ice-" Zip: 3
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: SiA+eW"1je, C. Corn-eC-k JnS I,-%c Phone#: 3 6
Address: ('�iG40 NW q Aw` Ads
City: Ova Lo a<0, State: ?+ Zip: 3 3a 4
Qualifier Name: TG MCA �0 o Mon Phone#:
State Certification or Registration#: SMt m 7 6Z Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ J, 10e): Square/Linear Footage of Work: 2Z5
Type of Work: ❑ Addition ❑ Alteration ElNew (CC Repair/Replace ❑ Demolition
Description of Work: StpUce, D rA In 'lf 1G�
Specify color of color thru tile:
Submittal Fee$�\J Permit Fee$ j 1507- CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ V' 0 00
TOTAL FEE NOW DUE$ ':�!
(Revised02/24/2014) ( q b
Bonding Company's Name(if applicable) ' t
Bonding Company's Address
City State Zip
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 be approved and a reinspection fee will be charged.
Signature Signature
•.',
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was-acknowledged before me this
day of 20 bye day of f� �' 20 I by
&C elt �O)«l� who is personally known to �aca� J ��O'�-��T��� who is personally known to
1.Te or who has produced as me or who has produced 1-L � � lJ� �C as
identification and who take an oath. identification and ytho did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC
Sign: s �.• t
Sign:
Print: Print:
Seal: KAREN IiERNANDQ � Notary Public State of Florida
MY COMMISSION#EE 081170 Sea I
Sindia Alvarez
EXPIRES:May 20,2015 MY Commission FF 156750
7pf �' Bonded Thor Notary Public underwriters
�ci�� E,.;;..res nsros�aols
APPROVED BY �s,2c Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
c
Statewide Septic Connections Inc
Date: (2,0 /2JJ 15
State of 'FU '-1 DA
County of M 1A M l- 1�f\TA-
Before me this day personally appeared��(< � �-b1J who, being duly sworn, deposes and
says:
That he or she will be the only person working on the project located at: �0 S7
Sworn to(or affirmed) and subscribed before me this 9-0 day of 20L�,, by
Personally know
OR Produced Identification�4�t�
Type of Identification Produced FL-L" �S
I I'
Print,Type or Stamp Name of Notary
o+O Notary Public State of Florida
: Sindla Alvarez
p� My Commission FF 156750
NOF Expires 0910312018
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Miami shores Village
Building Department
�ORiDp' 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,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 YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
OvIner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of rl\ 20__LC
By CIAChe I alXt Cit4At who is personally known to me or has produced
as identification.
Notary:
KAREN HERNMDEZ
XRgu
MY COMMISSION 0 EE 081170
SEAL: EXPIRES:May 20,2015
;oF 11P Bonded Thru Notary Public UndermiteM
PERMIT #: 13-SC-1602813
, a APPLICATION #:AP1186415
STATE OF FLORI115)1;` 1�
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYST:M FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
DOCUMENT #: PR974833
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Loretta Fabricant
PROPERTY ADDRESS: 406 NE 103 St Miami, FL 33138
LOT: 1112 BLOCK: 92 SUBDIVSS16N:
PROPERTY ID #: 11-3206-017-0760 [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 TH_S 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 PROPEP�TY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ] GALLONS / GPD exlstlnq s2ptic tank to remain CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS C[ ]DOSES PER 24 HRS #Pumps [ ]
D ( 225 SQUARE FEET new trench confiq.drainfie SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ], FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] 'BED [ ';']
N Y i,o..,
F LOCATION OF BENCHMARK: FFE 13.3' NGVD-•'
I ELEVATION OF PROPOSED SYSTEM SITE [ 21.60 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 79.60 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 58.00 ] INCHES
1.-Existing 900 gal. septic tank, certified by"Statewide Septic"on 4/27/2015 to rer:ain.
O 2.-Install 225 sf of drainfield in trench configuration.
T 3.-Perimeter Of excavation area shall be at least 2 ft wider and longer than the prclosed absorption bed or drain trench.
4.-Invert elevation of drainfield to be no less than y 17'NGVD. '
H 5.-Bottom of drainfield elevation to be no less than'V.67'NGVD.' n" '
E The system is sized for 3 bedrooms with a ma'ximiam'occupancy of 6 persons(2 F_r bedroom),for a total estimated flow
of 400 gpd.
R _
SPECIFICATIONS BY: re a J Solomon =- TITLE: Mister Septic Tank Contractor
APPROVED BY: TITLE: Engineering Specialist II Dade CHD
n
Martin
DATE ISSUED: 5 EXPIRATION DATE: 08/13/2015
DH 4016, 08/09 (Onsoletes all previous editions which may not be used)
Incorporated: 64E--6.003, FAC Page 1 of 3
v 1.1.4 AP.1i8'c4a.5. S «6G720
STATE OF FLORIDA
DEPARTMENT OF HEALTH
a�WS
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERM'JT
Permit Application Number
----------------- PART II -SITE PLAN---------------- -----
.
Scale: Each block represents 5 feet and 1 inch=50 feet.
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Notes:
'Site Plan submitted by:
Signature Title
Plan Approved "'" Not Approved Date
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015,10!96(Replaces HRS-H Form 4015 which may be used)
(Stock Number:5744-o02-4015-6) Page 2 of 3
3
�swO1t S y,� Miami Shores Village lT!?"t 8 j cif ( �llf@ilt('s1
10050 N.E.2nd Avenue NE
� atc Gtessfidr� �itlfield
Miami Shores,FL 33138-0000OVED
AMP
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Phone: (305)795-2204 P@
F<oR1oA
�y1 Expiration: 12/23/201
Project Address Parcel Number Applicant
406 NE 103 Street 1132060170760
Miami Shores, FL 33138- Block: Lot: RACHEL FABRICANT
Owner Information Address Phone Cell
RACHEL FABRICANT 406 NE 103 Street (305)759-9949
MIAMI SHORES FL 33138-
406 NE 103 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 3,300.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082 Total Sq Feet: 225
Type of Work:REPLACE DRAINFIELD Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
HRS Approval
Bond Return: Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Owners Bond $500.00
Invoice# PL-5-15-55644
CCF $2.40 05/20/2015 Check#:4733 $50.00 $619.90
DBPR Fee $2.25
DCA Fee $2.25 06/26/2015 Check#:2699 $619.90 $0.00
Education Surcharge $0.80 Bond#:2766
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $3.20
Total: $669.90
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 information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futher ?ore authori the above-named contractor to do the work stated.
June 26, 2015
A rized Signature:Owner / Applicant / Contractor / Agent Date
v
Building Department Copy
June 26, 2015 1