PL-15-1436 Miami Shores Village RF,ci�;1VE�
Building Department Ju 112015
i
10050 N.E.2nd Avenue,Miami Shores, Florida 33138Y;
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20�jD /
BUILDING Master Permit No.T
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
5]PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: SSS ay--- ('01 S-r
City: Miami Shores County: Miami Dade Zip: 3313e,
Folio/Parcel#: y)3 C Z80 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): e Sw S+�1►�-1� Phone#:
Address: 1f I0 S
City: MS re's State: Zip: 3?5(3s
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: "���%� �-!�1 iG lJ� �nC Phone#:
Address: ^r is V-) r e ( S
City: nc L-0 C ' A State: it Zip: 33 o S(4-
Qualifier Name: IS6 (C) Phone#:
State Certification or Registration#: Mocl,( 2-ro - Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: / City: State: Zip:
Value of Work for this Permit:$ ICS 12 w Square/Linear Footage of Work: •M
Type of Work: K Addition ❑ Alteration New *—Repair/Replace ❑ Demolition
Description of Work: Y1 stqkl C
Specify color of color thru tile:
Submittal Fee$ _Permit Fee$ 0'300_ :;ZkCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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 nZapprod 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
4-t' day of 201' S by day of i �- 20 , by
a<-0It_M who is personally known to �� ?'+- �(> �i��iti ►litho i personally known b
me or who has produced FL1:� as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
l
Sign - Sign:
Print: Print: '' i i Q C;, �'►
Seal: Seal: Notary Public Stab of Nondis
=PubhcStata
i?t F1orOsTrencella Lewis
F 196307 My Commission FF 166x07
9 Expires 02/05/2019
************************ * * * ***********
APPROVED BY �/�!S Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
♦SHoR�s
�t
sell ,,,,,f" Miami shores Village
17 Building Building Department
�LORtDp'
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
% Y
..., n;. ': ..
,,< <- ,sell: r .lass.::. 5. ,-i_ •F,
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat § 440.05
allows corporate officers in the
rp 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:
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:
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.
Signatur : ' ` '
wn
State of Florida
County of Miami-Dade /
The foregoing was acknowledge before me this _day of 20 l
By S O-<!)+4- Sm i-4-t - who is personally known to me or has produced
!" LL -fl _as identification.
Notary:
SEAL:
STATE OF FLORIDA PERMIT #: 13-SC-1599238
DEPARTMENT OF HEALTH APPLICATION #: AP1184183
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
SYSTEM FEE PAID:
CONSTRUCTION PERMIT
RECEIPT #:
DOCUMENT #: PR972393
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Gillespie Smith
PROPERTY ADDRESS: 358 NE 101 St Miami, FL 33138
LOT: 5 BLOCK: 39 SUBDIVISION:
PROPERTY ID #: 11-3206-013-5280 [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 [ 900 J GALLONS / GPD Septic CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ J GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 375 ] SQUARE FEET Trench confiquration drain SYSTEM
R [ 1 SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: (x] TRENCH [ ] BED ( ]
N
F LOCATION OF BENCHMARK: CL NE 101 st., 9.10'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 6.00 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 36.00 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00J INCHES EXCAVATION REQUIRED: [ 72.00 ] INCHES
O Inspector to verify the existing septic tank is properly abandoned before final approval.
'Invert elevation of drainfield to be no less than 6.70' NGVD.
T 'Bottom of drainfield elevation to be no less than 6.10' NGVD.
H *Install 42"of slightly limited soil under the bottom of drainfield.
Perimeter of excavation area shall be at least 2 ft. wider and longer than the proposed absorption bed or drain trench.
E The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a7total d flow
R of 300 gpd. �'��
J
The licensed contractor installing the system is responsible for installing the minimum category of to in acc Q'C,O�
SPECIFICATIONS BY: Teresa J Solomon TITLE: Master Septic ankacctXh
r
•�a
APPROVED BY: TITLE: _, a CHD
Carlos caza - 2
DATE ISSUED: 04/24/2015 a��Q•
EXPI ATE: 10/24/2016
DH 4016, 08/09 (Obsoletes all previous editions which may not be used) V
Incorporated: 64E-6.003, FAC Page 1 of 3
........41 AP11041.i3.;
TR ¢,
6= $ k e 1tal4jealt6Aiz f i
i
as �F "All IRWIc
XT
INR
VA
Mim
" 1 lot � O TD.S# �` n Y ¢
C AM-
"CAT,OWN
�r
-WORSE
v
x
T # s
74
a a "�
eft eaniL IVs'
#
�sKO1tEs y Miami Shores Villagef f !#�7yp4 11 KI
r �
10050 N.E.2nd Avenue NE
Miami Shores,FL 33138-0000
MOVED
Phone: (305)795-2204
FCORiDp' � --
Issue,' fate 't /Zt115 Expiration: 12!12!2015
Project Address Parcel Number Applicant
358 NE 101 Street 1132060135280
Miami Shores, FL 33138- Block: Lot: PATRICE AND SCOTT SMITH
Owner Information Address PhoneCell
PATRICE AND SCOTT SMITH 358 101 Street
MIAMI SHORES FL 33138-
358 101 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 6,200.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082
Total Sq Feet: 375
Type of Work:INSTALL NEW SEPTIC TANK AND DRAINFI 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-6-15-55941
CCF $4.20
DBPR Fee $3.26 06/15/2015 Check#:4772 $693.72 $50.00
DCA Fee $3.26 06/11/2015 Check#:4766 $50.00 $0.00
Education Surcharge $1.40 Bond#:2751
Permit Fee $217.00
Scanning Fee $9.00
Technology Fee $5.60
Total: $743.72
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 mo , I authorize the ve-nary*contractor to do the work stated.
June 15, 2015
Authorized Signat ner / Applicant / Contractor / Agent Date
Building Department Copy
June 15, 2015 1