PL-15-1206 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-237517 Permit Number: PL-5-15-1206
Scheduled Inspection Date:July 28, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: MILVERTON, DAMIAN & SYLVIE Work Classification: Drainfield
Job Address:30 NE 104 Street
Miami Shores, FL 33138-2027
Phone Number
Parcel Number 1121360130900
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
Building Department Comments
Infractio Passed Comments
DRAIN FIELD REPLACEMENT:
INSPECTOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-235100. SIDEWALK
EZIREQUIRES REPAIR
HRS OK
SOD O
Failed
Correction
Needed ❑ %��
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
July 27,2015 For Inspections please call: (305)762-4949 Page 17 of 44
�L . S
DIVISION OF
Environmental Health
O Florida Health
Miami-Dade County
QQ� OSTDS/Well Division MAI
Q11805 SW 26"Street-Miami,FL 33175
Inspectors - 1i q-� Lr..„ .gin Date
Address .3c) 'l Gam^ tog Cr OSTDS# '
Comments 'S' rl.4. -C-4-6-ts P, I
K
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Signature .� h�
Pett off '
�s�O1S y� Miami Shores Village Pem?It7"rpe0itial
10050 N.E.2nd Avenue NE
W,o&Cta,�sfcatir3ra Dill t nl l .
- Miami Shores,FL 33138-0000 '
P8►ritNZtittLtSF
60` Phone: (305)795-2204
FC01ttDp'
'61271266, Expiration: 11/23/2015
Project Address Parcel Number Applicant
30 NE 104 Street � 12 36013090
�
DAMIAN 8SYLVIE MILVERTON
Miami Shores, FL 33138-2027 Block: Lot.
Owner Information Address Phone Cell
DAMIAN &SYLVIE MILVERTON 30 NE 104 Street (443)570-0304
MIAMI SHORES FL 33138-
30 NE 104 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 3,800.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082
Total Scl Feet: 375
Type of Work:DRAIN FIELD REPLACEMENT. 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-Contractors Bond $500.00 Invoice# PL-5-15-55645
CCF $2.40
DBPR Fee $2.25 05/20/2015 Check#:4733 $50.00 $619.90
DCA Fee $2.25 05/27/2015 Check#:4744 $619.90 $0.00
Education Surcharge $0.80 Bond#:2730
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. +more, I autho the ove-named contractor to do the work stated.
May 27, 2015
Authorized Sig atur Owner / Applicant / Contractor / Agent Date
Building Department Copy
May 27, 2015 1
1
Bonding Company's Name(if applicable)
Bonding Company's Address _
i 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 611
applicable laws regulating construction and zoning.
"WARN INOr OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR
'PROPEIZTY-.., IF.Y.O41 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 e9ceeding$2500 the applicant must
promise in go*faith;kat a copy of the notice of commencement and cgnstruction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recdrded notice of commenoen+nrr9iust be 0o3t6id'dt`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.
rr(
;
Signature_ ' Sijnature77.
(� r
NtRAC'FOR
bWNER or AGENT CO '
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before hie this
L5 day of K'°e„,t20 tl by 15e day of `M -1 a"!20 t by
SK�V�i wu f who is personally known to �- �f + ' �1.'b^��,who is personally known to
me or who has produced ft 1 h as me or who has produced t as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
-�-�-7
Sign:_ Sign`:
Print: _S Print:
Seal: r Seal:
Latrpt&
Notary Public State a Florida
4Notary Public State of Fbrida My Co m Lewis
TrenCelle Lewis My Commission FF 196307
My Commission FF 196307 Expires 02105/2019
n Expires 02/05/2019
*********** * ****************************************************************
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
c�= � 1
Building Department MAY �O 2015
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305)756-8972
INSPECTION LINE PHONE NUMBER: (305)762-4949
FBC 20(0
BUILDING Master Permit No—R--�E - 1 2Oxfb
PERMIT APPLICATION Sub Permit No.
-(BUILDING ELECTRIC D ROOFING F-] REVISION F-] EXTENSION (RENEWAL
�jPLUMBING MECHANICAL PUBLIC WORKS F-] CHANGEOF D CANCELLATION ❑ SHOP
`7 j CONTRACTOR DRAWINGS
JOB ADDRESS: 0 µv—_���v
Miami Shores _ Counhi: _ Miami Dade _ Zip: � v _
Folio/Parcel#:_ ISG • b s— 0100 __--Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: _
OWNER: Name(Fee Simple Titleholder): �y(Vie M`�V�n Phone#: L•{-4 3"5 7o w 3cLF-
Address: ---3c-- {, �.o L+—J` 1 --
MtAr�t State: -------Zip — 3 e-----
Tenant/Lessee Name:
---------- �+ ��
CONTRACTOR: Company Name, Ge.�l dtL Ci x.11^ _+1C'Phone#
* State:----- - p
State: —_
r ,ir-e' �a Phone#:
:ate ��(,rtjficdtior) or Registration#: S�n 4v1 X2.,'62 Certificate of Competency #:
DESIGNER:Arch itect/Enginger: Phone#: -
Address: City: State:
Zip:_ —
value of Work for this Permit:$ 6 O Square/Linear Footage of Work:
Type of Work: [-J Addition t—I Alteration ❑ New K Repair/Replace Dernoi,tion
Dosr.ription of Work: —
Specify color of color thru tile: -----
Submittal Fee $ Permit Fee$ _— �jU• �Y CCF$.- _ CO/CC$____-________
Scanning Fee$ Radon Fee$ DBPR$ -_Notary
Technology Fee $_.__ Training/Education Fee$ Double Fee$
Structural Reviews 5 _ _ — _ Bond $
TOTAL FEE NOW DUE$
F,ev .ed0�/24iZCla)
e
Statewide Septic Connections Inc
Date: 01
Ls
State of FlO'F-1 v
County of
Before me this day personally appeared who, being duly sworn, deposes and
says:
That he or she will be the only person working on the project located at: ' J CJ�
Sworn to(or affirmed) and subscribed before me this day of 20�by
Personally know
OR Produced Identification
Type of Identification Produced
Print,Type or Stamp Name of Notary
M
Notary Public State of FloridaSindia AlvarezMy Commission FF 158750
Expires 09/03/2018
`SNoRfs
rill Niggle" Miami,,,, shores Village
".r.. I'-��a
Building Department
�LORIDP` 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
I lorida L.aM 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 I
employees, including the owner, must obtain workers' compensation coverage. Corporate olliccr.�
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if: I
I. 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.
I
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
\�orkcr�' c(,nn cnsation insurance coycraLe from the contactors company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDLRS"I AND ITS
('O\l F_.N'I S.
�I
I
� I
Signature:
Owner
State of Florida
County of Miami-Dade
1-he foregoing was acknowledge before me this t 3 day of N1 A 204-5 .
M11 ii who is personally known to me or has produced
i
R (�✓V �-' ft as identification.
Notary:
-
Y .---
, ' Notary Public State of Florida
SEAL: ;F+ Trenoetla Lewis
MI/
My commisltlon FF 196307
MI/ Expires 02M5/201 9 �
CFN:20150279843 BOOK 29599 PAGE 2798
DATE:05/01/2015 11:49:37 AM
DEED DOC 5,100.00
HARVEY RUVIN,CLERK OF COURT, MIA-DADE CTY
Return to:
Clear Title Services,Inc.
1111 Kane Concourse, Suite 209
Bay Harbor Islands,FL 33154
Instrument Prepared By:
Christopher P. Kelley, Esquire
11098 Biscayne Boulevard, Suite 205
Miami, FL 33161
Folio No. 11-2136-013-0900
WARRANTY DEED
THIS INDENTURE, Made this 2 q'k day of ni: , 2015,
Between, MICHAEL HOULE and DIEGO R. MANTILLA, now married, each to the other,
under the laws of the State of Florida, as GRANTORS, and DAMIAN S. MILVERTON and
SYLVIE F. MILVERTON, husband and wife, whose post office address is 30 NE 104 Street.
Miami Shores, FL 33138, GRANTEES,
WITNESSETH,That said GRANTORS,for and inconsideration of the sum of Ten and 00/100
Dollars, and other good and valuable considerations to said GRANTORS in hand paid by said
GRANTEES, the receipt whereof is hereby acknowledged, have granted, bargained and sold to the
said GRANTEES, and GRANTEES' heirs and assigns forever,the following described land, situate,
lying and being in Miami-Dade County, Florida to-wit:
The West 1/2 of Lot 7 and Lots 8 and 9,Block 123, of Amended Plat of Miami Shores
Section No. 5,according to the plat thereof as recorded in Plat Book 10,Page 47,Public
Records of Miami-Dade County, Florida
SUBJECT TO: Applicable zoning and/or restrictions and prohibitions imposed by
governmental authority; Conditions,Restrictions limitations,reservations, easements,
and other matters appearing on records, if any; Utility easements of record, taxes for
the year 2015 and subsequent years.
CFN: 20150279843 BOOK 29599 PAGE 2798
DATE:05/01/2015 11:49:37 AM
DEED DOC 5,100.00
HARVEY RUVIN,CLERK OF COURT, MIA-DADE CTY
Return to:
Clear Title Services,Inc.
1111 Kane Concourse, Suite 209
Bay Harbor Islands,FL 33154
Instrument Prepared By:
Christopher P. Kelley, Esquire
11098 Biscayne Boulevard, Suite 205
Miami, FL 33161
Folio No. 11-2136-013-0900
WARRANTY DEED
THIS INDENTURE, Made this 2 q k day of nr 2015,
Between, MICHAEL HOULE and DIEGO R. MANTILLA, now married, each to the other,
under the laws of the State of Florida, as GRANTORS, and DAMIAN S. MILVERTON and
SYLVIE F. MILVERTON, husband and wife, whose post office address is 30 NE 104 Street.
Miami Shores, FL 33138, GRANTEES,
WITNESSETH,That said GRANTORS,for and in consideration of the sum of Ten and 00/100
Dollars, and other good and valuable considerations to said GRANTORS in hand paid by said
GRANTEES, the receipt whereof is hereby acknowledged, have granted, bargained and sold to the
said GRANTEES, and GRANTEES' heirs and assigns forever,the following described land, situate,
lying and being in Miami-Dade County, Florida to-wit:
The West 1/2 of Lot 7 and Lots 8 and 9,Block 123, of Amended Plat of Miami Shores
Section No.5,according to the plat thereof as recorded in Plat Book 10,Page 47,Public
Records of Miami-Dade County, Florida
SUBJECT TO: Applicable zoning and/or restrictions and prohibitions imposed by
governmental authority; Conditions,Restrictions limitations,reservations, easements,
and other matters appearing on records, if any; Utility easements of record, taxes for
the year 2015 and subsequent years.
�yy PERMIT #: 13-SC-1606116
E71 N
APPLICATION #:
AP1188708
iv Arc.)E 4{?IJ14T1' NR #i�s a;r�'�}a.'';
STATE OF FLORIDA ` ,, ,
DEPARTMENT OF HEALTH ,!.'� DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT i RECEIPT #:
40 DOCUMENT #: PR975088
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Michael Houle
PROPERTY ADDRESS: 30 NE 104 St Miami, FL 33138
LOT: 7 9 BLOCK: 123 SUBDIVISION;`,
PROPERTY ID #: 11-2136-013-0900 ` [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 septic tank to remain CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS SE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GAL S DOSING TANK CAPACITY [ ]GALLONS P.[ ]DOSES PER 24 HRS #Pumps [
D [ 375 SQUARE FEET new trench confiq.drainfie SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ j FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] BED [ ] "
N .,
F LOCATION OF BENCHMARK: FIFE 14.0'NGVD--
I ELEVATION OF PROPOSED SYSTEM SITE t. 30.00 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE �[ 78.00 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 48.00 ] INCHES
1.-Existing 1050 gal.septic tank,certified by"Statewide Septic"on 5/11/2015 to remain.
O 2.-Install 375 sf of drainfield in trench configuration.
T 3.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench.
4.-Invert elevation of drainfield to be no less than 8.00'NGVD.
H 5.-Bottom of drainfield elevation to be no less than 7.50'NGVD.
E The system is sized for 5 bedrooms with a maximum occupancy of 10&?sons(2.per bedroom),for a total estimated flow
of 460 gpd.THIS PERMIT IS NOT FOR ANY ADDITIONS
R
SPECIFICATIONS BY: &e;rsa
JSolomon TITLE: Master Septic Tank Contractor
APPROVED BY: TITLE: Engineering Specialist II Dade CHD
d 'sy Martin
DATE ISSUED: 0 /19 015 EXPIRATION DATE: 08/17/2015
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 - F.P1188708 &E960945
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