PL-15-1905 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-240172 Permit Number: PL-7-15-1905
Scheduled Inspection Date: August 20, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz,Osvaldo
Inspection Type: Final
Owner: , Work Classification: Drainfield
Job Address:1151 NE 99 Street
Miami Shores, FL 33138- Phone Number (786)253-2869
Parcel Number 1132050180070
Project: <NONE>
Contractor: A SUPER SEPTIC TANK, INC. Phone: (05)364-0113
Building Department Comments
DRAIN FIELD REPAIR Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS IN FILE
Failed
Correction -X-
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
August 19,2015 For Inspections please call: (305)7624949 Page 17 of 41
DIVISION OF
•°' Environmental Health
Florida Health
Miami-Dade County
QQQ OSTDS/Well Division 0�
► /11805 SW 2,6tthJ Street•Miami,FL 33175
Inspector_ (®/j of / (c l� P/ Dater rL -fs
t
Address //f/' ''y 9� 37/ OSTDS#_
Comments: _
Signature
\\
�s�°R��c.� Miami Shores Village y' � 3 � i�f7!'!1r<' ,�3��,P)[ibi� ,
10050 N.E.2nd Avenue NE
1A/o -C ��
Miami Shores,FL 33138 0000 C #°
'a,
� a3 r-Crit�w ` i A
F r „ � Phone: (305)795-2204 ' E
oRinA
� � C11t Expiration: 02/02/2016
Project Address Parcel Number Applicant
1151 NE 99 Street 1132050180070
Miami Shores, FL 33138- Block: Lot: Shima VII LLC
Owner Information Address Phone Cell
Shima VII LLC 1235 NE 100 Street (786)253-2869 (305)796-4922
Miami Shores FL
1235 NE 100 Street
Miami Shores FL
Contractor(s) Phone Cell Phone Valuation: $ 3,000.00
A SUPER SEPTIC TANK, INC. (05)364-0113
Total Sq Feet: 00
Type of Work:DRAIN FIELD REPAIR 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-7-15-56514
CCF $1.80 08/06/2015 Credit Card $623.30 $ 50.00
DBPR Fee $2.25
DCA Fee $2.25 07/29/2015 Check#: 1014 $50.00 $0.00
Education Surcharge $0.60 Bond#:2804
Notary Fee $5.00
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $2A0
Total: $673.30
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: II the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zonin Futhe or , I authorize the above-named contractor to do the work stated.
- August 06, 2015
Authorized SignaturOwner / Applicant / Contractor / Agent ate
Building Depa ment Copy
August 06,2015 1
Miami Shores Village YZEC ,��,F�
Building Department JUL 29 2015
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20A/
-1
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. �
w
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
[APLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: pj�jP_ Miami Dade Zip:_'33/'3 fr
Folio/Parcel#: O )�U I fl 66 !Zj Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): S j M a V},1,o , Phone#:
Address: 1 I!! /
City: r m L State: j, Zip:.
Tenant/Lessee Name: Phone#: kZ4k.,
Email:
CONTRACTOR:Company Name: _. S uo�w =� �ri1 Sn�, Phone#:,3 05 D)i 3
Address: =Z)1 ku Ar+h 0__
City: (-� I4.� State: Zip: ,3-3 d/ 5/
Qualifier Name: n r✓ e ✓ y`n . e r-O , v�as� Phone#:30rj-- 0 /i 3
State Certification or Registration#:S R U ',,?a. Certificate of Competency#:
s�
DESIGNER:Architect/Engineer: qb (0,9.)yPhone#:
Address: City: State: Zip:
Value of Work for this Permit:$ `3,11/Q6 Square/Linear Footage of Work:
Type of Work: ❑ Additi ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
l�
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ ]0()
0() 0 col
�Q S� -C��vv u/r�jtpJi TOTAL FEE NOW DUE$ V
(Revised02/24/2014) H
Bonding Company's Name(if applicable)
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 pro erty is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the firs inspection which occurs seven (7) da after the building permit is issued. In the absence of such posted notice, the
inspection w 11,Jbeproved and are' spec ' n fe will be charged. z2 e�
Signatur Signature
I
�WNER or AGENT CON TOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
y�day of 20 C by �_day of v 20 IS by
i who is personally known to A-r& e1A) ZZ10 who is personally known to
me or who has produced E�/c C as me or who has produced F14-V to as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: ria r"
G J -IJ2
. NOWY U of Ron a Print:
joanna MpF 082753
Seal: My (enol/Commission02 Seal: '}ice, TERESA J SOLUNION
' a» Exp��esO1N212018 x'131935
:+I'� f)f4iv111OM#Ec
cn 8 2015
%�i EkF`CtI hlcusr�'Uer Q
oFf G �I� NotaryserviQe.CC"
APPROVED BY 3 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
A SUPER SEPTIC TANK INC.
7701 WEST 18 LANE
HIALEAH, FLORIDA 33014
PHONE: 305-364-0113 FAX: 305-364-0349 E-MAIL: ASSTI@BELLSOUTH.NET
STATE OF FLORIDA— LICENSED AND INSURED—
REGISTERED SEPTIC TANK CONTRACTOR-CC#SEP890722
www.asuperseptictank.com
July 24, 2015
State of: Florida
County of: Dade
Dore me this day perso ally ape red
o, being duly sworn, deposes and
say
That he, or she, will be the only person working on the project located
at:
1151 NE 99 Street, Miami Shores, Florida 33138.
Name: Shima V LLC
Sworn to (or affirmed) and subscribed before me this day of
2015, by d <10 2P-
Personally known OR Produced Identification f� A- f b
Type of Identification Produced In
( ��f�' r Print, Type or Stamp Name of
Nota
TE� �(�'; SOLOMON ttEE135
EXPIRES No,:froe:08,2015
F OF f4 '
07)398-0153 Fta:ySernce.com
SNoRE1JTAC-1932
s pr
,,, Miami shores Village
_� 11.11.
Building Department
rag it'
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 SIG G BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTEN 5.
Signature:
Owner
State of Florida
County of Miami-Dade 2C''
The foregoing was acknowledge before me this day of 201)J_- .
By fi�2&221 14ZLe .S/J')/ - who is personally known to me or has produced
as identification.
Notary' oar rw� NoZn
ate of Flow
: JocianoMY FF 082753SEAL: � �€ Exot8
`>a'.�.
STATE OF FLORIDA
PERMIT 13-SC-1612427
i
DEPARTMENT OF HEALTH APPLICATION : AP1192740
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
SYSTEM FEE Pte:
CONSTRUCTION PERMIT
RECEIPT #:
DOCUMENT #: PR980492
CONSTRUCTION PERMIT FOR: OSTDS Existing Modification
APPLICANT: (Shima-V LLC)
PROPERTY ADDRESS: 1151 NE 99 St Miami,FL 33138
LOT: 18 BLOCK: 178 SUBDIVISION: Miami Shores Sec,8
PROPERTY ID #: 11-3205-018-0070 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER)
(OR TAX ID NUMBER)
SYSTEM !LUST 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 [ 750 ] GALLONS / GPD ExiStinq Septic tank t0 remain CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N ( j GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMOM CAPACITY SINGLE TANK:1250 GALLONS)
K [ J GALLONS DOSING TANK CAPACITY ( IGALLONS Q( ]DOSES PER 24 HRS #Pumps I ]
D I 500 ) SQUARE FEET bed configuration drainfie[ SYSTEM
R ( J SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: (xj STANDARD [ ] FILLED [ ] MOUND [ l
I CONFIGURATION: [ j TRENCH [x) BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E.,9.89'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE ( 27.40 ] [ INCHES FT )[ ABOVE ffiLOW BENCHMARK/REFERENCE POINT
E SOTTCM OF DRAINFIELD TO BE [ 6252 )(F&cHEsT FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: ( 0,00) INCHES EXCAVATION REQUIRED: [ 77.007 INCHES
O 'Invert elevation of drainfield to be no Mess than 5.18'NGVD.
'Bottom of drain€field elevation to be no less than 4.68'NGVD_
T "install 42"of slightly limited soil under the bottom of drainfield.
H -Perimeter of excavation area shall be at least 2 ft.wider and longer than the proposed absorption bed or drain trench.
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedr ), r a total estimated flow
E of 300 gpd.
R �l
GO
SPECIFICATIONS BY: David A Prendergast TITLE:
APPROVED BY: TITLE: I I np_z� �f\�eCFiD
C4wrloe H Icaza
DATE ISSUED: 07/0912015 00 > DATE:, 01/09/2017
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
. ..c .0.(1'.92'4{ SE9e5r59
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