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PL-15-2180 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-242249 Permit Number: PL-8-15-2180 Scheduled Inspection Date: September 01, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: LEE, GEOFFREY Work Classification: Septic Job Address:30 NW 100 Terrace Miami Shores, FL 33138- Phone Number Parcel Number 1131010180340 Project: <NONE> Contractor: NU BLACK SEPTIC & DRAINFIELD COMPANY Phone: (954)410-2589 Building Department Comments REPLACE OLD SEPTIC TANK AND DRAIN FIELD NO Infractio Passed Comments SIDEWALKS ON THE STREET OR BLOCK HRS PERMIT INSPECTOR COMMENTS False PULLED Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. August 31, 2015 For Inspections please call: (305)762-4949 Page 27 of 37 4>4xg> •►�� DIVISION OF •• Environmental Health Florida Health Ge�0 Miami-Dade County �0 OSTDS/Well Division Q► 11805/S{�W 26th Street•Miami,FL 33175 �= Inspector ����� / 01 f?/1Y 1,C., Date � 7// S Address `O o OSTDS# �� y ✓S Comments: Signature 1 � ttww Miami Shores Village 10050 N.E.2nd Avenue NW ue - 'f►#k3s1f{C8ti�3t1 �t�lC 77" 77 Miami Shores, FL 33138-0000 gg, t '— Pr A 'P Phone: (305)795-2204 ' , Expiration: 02122/2016 Project Address Parcel Number Applicant 30 NW 100 Terrace 1131010180340 GEOFFREY LEE Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell GI EOFFREY LEE 30 NW 100 TERR MIAMI SHORES FL 33150-1208 Contractor(s) Phone Cell Phone Valuation: � �$ 5,500.00 -�� NU BLACK SEPTIC& DRAINFIELD CC (954)410-2589 Total Sq Feet: 400 Type of Work: REPLACE OLD SEPTIC TANK AND DRAIN F 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-8-15-56859 CCF $3.60 08/26/2015 Check#: 13627 $777.60 $ 50.00 DBPR Fee $4.50 DCA Fee $4.50 08/25/2015 Check#: 13624 $50.00 $0.00 Education Surcharge $1.20 Bond#:2822 Permit Fee $300.00 Scanning Fee $9.00 Technology Fee $4.80 Total: $827.60 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. Futh ore I authorize the above-named contractor to do the work stated. / I August 26, 2015 Authorized Signature:Owner / Applicant / Contr ctor / Agent Date Building Department Copy August 26,2015 1 Miami Shores Village 45 47 Iq Building Department Au 5 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 20tH ti BUILDING Master Permit NoTLIL— " 21 PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ROOFING ❑ REVISION EXTENSION ❑RENEWAL 05-LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP ___CONTRACTOR DRAWINGS JOB ADDRESS: City: /Miami Shores County: Miami Dade Zip: Folio/Parcel#: 6 / (/ I �` od 6s the Building Historically Designated:Yes NO Occupancy Type: r Load: ConstructionType: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): e U � r i �>Z O, Phone#: -3o,5 O (� Addressr:Y�3 b �° Vj City: 1 l a State: Zip: 7 c� Tenant/Lessee Name: Phone#: Email: �y CONTRACTOR:Comp ny Name: 1) n V 1-1) �U 8 /�- Phone#: 40 I /`-�' 1 Address: A U), �- if ' CyQMC %AC ( State: t Zip: �fff V Qualifier Name: U1 JJ Phone#: `i A State Certification or Registration#: ::5 �(.'� L Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: Stater Zip: Value of Work for this Permit:$ G Square/Linea;Repai,ota of Work: �Z r Type of Work: ❑ Addition Alteration 8 [] Ne , /Replace ❑ Demolitio Description of Work: �o ti- t� P-'pit ti fi t - L l'l� 1 d/" n v I� fie Specify color of color thru tile: Submittal Fee$ Permit Fee$ 360' CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ h TOTAL FEE NOW DUE$ 2�� 6 (Revised02/24/2014) P 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 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. l Signature Signature - ` 0 R or AGENT CONTRACTOR The foreggir�g instrument was acknowledged before me this The foregoing instrument was acknowledged before me this a; qday of /�+ ^;� 1' 20 , by day of (( 20 by (,�(q� Q"P." who is personally known to (/t (� ��who is personally known to me or who has produced as `e or who has produced as identification and pho did take an oath. identification and who did take an oath. 1 i NOTARY PUBLIC- yy NOTAJPUBLIC �k > r Sig �Gv � Sign: n�1 111�. Print: dPrint:l► l6 a,x Q S Seal: Seal: •:�►�' MICHAEL AUBREY(iA1NE3 .till MICHAEL AUBREY GAINES ********* � �'s�� �ll � ����� ***************sssss�s': ••'4N��#�li�l�IQM�k�1.4�lr+R��4� ******s* ,,� ,•• EXPIRES AprN 19,2016 I EXPIRES AprN 19,2016 4407130"163 OOrD 407�396A/6I FW04sN .can APPRO Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 24/08/2015 15:28 954-583-2045 Dawn Hyde Page 1/1 A CERTIFICATE OF LIABILITY INSURANCE DATE 08/24/15 YY) PRODUCER JW Insurance Services THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' 100 North State Road 7,#106 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Margate,FL 33063 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (954)583-7213 Fax (954)583-2045 INSURERS AFFORDING COVERAGE NAIC# INSUREDINSURER A: Axis Surplus Nu-Black Septic&Drainfield Company, Inc 401 SW 12th Avenue INSURER B: Dania Beach, FL INSURER C:33004 INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR NERD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD DATE(MWDDlYY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 100,000 Q COMMERCIAL GENERAL LIABILITY FLGLN01601 AX 05/28/15 05/28/16 PREMISES Ea occurence 50,000 A ❑❑ CLAIMS MADE © OCCUR MED EXP(Any one person) 5,000 ❑ ❑ PERSONAL&ADV INJURY 100,000 ❑ GENERAL AGGREGATE 200,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG 100,000 © POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS F-1El BODILY INJURY SCHEDULED AUTOS F-1HIRED AUTOS (Per person) ❑ NON OWNED AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCI D ENT ❑ ❑ ANY AUTO ❑ OTHER THAN EAACC AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ❑TORY LIMITS ❑ ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ****SEPTIC TANK - INSTALL/SERVICE/REPAIR **** Registration #SR093118 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Miami Shores 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2nd Avenue THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY Miami Shores, FL 33138 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)QF ©ACORD CORPORATION 1988