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PL-15-1657 (2) Permit A4?L7M5-1 07 Miami Shores Village Pent'7, pe:Numbing—ResidQ`tfitl*�� 10050 N.E.2nd Avenue NE WorkClas,� Chvnj�C "'� Miami Shores,FL 33138-0000 F'errnit5tefuS: � .... • Phone: (305)795-2204 '' ' PNTt+g N 8 FL°R`°A 7l1�201'S Expiration:iration: 01/1212016 tssue:date: Project Address Parcel Number Applicant L N E 101 Street 11320501so23oJEFFREY MOWERS i Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell JEFFREY MOWERS 1175 NE 101 ST MIAMI SHORES FL 33138-2606 Contractor(s) Phone Cell Phone Valuation: � $ 11,250 00 JASON'S SEPTIC INC 305-252-1080 ; Total Sq Feet: 700 Type of Work: INSTALL NEW TANK AND 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 CCF $7.20 Invoice# PL-7-15-56200 DBPR Fee $4.50 07/16/2015 Check#:3157 $287.20 $50.00 DCA Fee $4.50 Education Surcharge $2.40 07/02/2015 Check#:3129 $50.00 $0.00 Permit Fee $300.00 Scanning Fee $9.00 Technology Fee $9.60 Total: $337.20 In consideration of the issu ce to me this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in st ct conformity ith the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this p mit I a ume respon ility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for EL C RIC FLUMBIN ,MECHANICAL,WINDOWS, DOORS,ROOFING and SWIMMING POOL work. OW RS AFF DA I edify at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating cons ruction an Fut rmore,I authorize the above-named contractor to do the work stated. July 16, 2015 Autho ze gnature. wner / Applicant / Contractor / Agent Date Buildin ent Copy July 16, 2015 1 Miami Shores Village BuildingDepartment p R _ �i'4 _T\T 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 ,Iu 2 2015 INSPECTION LINE PHONE NUMBER:(305)762-4949 BUILDING Master Permit No.--?I— PERMIT o.i I—PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING [:] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP fry CONTRACTOR DRAWINGS 0 JOB ADDRESS: �l J�J / I )'-t'C--ej2zI— City: Miami Shores County: Miami Dade Zip: iJ Folio/Parcel#: �c"Y�/C� �� _ Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: St1 C Flood Zone: BFE: FFE: — OWNER:Name(Fee Simple Titleholder): o) I��-_y // u(Aitot Phone#: Address: City: State:FL - Zip: 1�5 Tenant/Lessee Name: Phone#: --- Email: S_e 'a CONTRACTOR:Company Nam ( n C- Phone#: "J % Address: _131 City:_/22/ a441 I ' State: Zip: Qualifier Name: Phone#: ;('y,S State Certification or Registration#:,srz 00?�, Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: �-- Value of Work for this Permit:$ //.0 2—S e 0 Square/Linear Footage of Work: 700 Type of Work: ❑ Addition ElAlteration w ❑ Repair/Replace IDDemolition Description of Work:,/ )Lc6� Obi( : Specify color of color thru tile: Submittal Fee$ Permit Fee$ 31 '`�` CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ a(P--) d (Revised02/24/2014) I 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. �,..• ;,ice Signature Signatur '�' OWNER or AGENT CONTRACTOR The foregoing instrumer was a kZ d before rJpe this The foreg ' instr a was acknowledged before me this da of —/—�\�� y 20 by day of -,20 by 1. (� sonally known to personally known to �y w --�� me or whom produced ( �! �S �� s me or who has produced i )y ((e(i S as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: CO- \ Print: Com% w Notary Public State Florida Seal: ;4 : Catherine E Nylund Seal: My Commission EE 216211 tp k'b Notary Public State of Florida o,R Expires 0 711 512 0 1 6 Catherine E Nylund My Commission EE 216211 oI R Expires 07/15//220 77, �t�lAPPROVED BY S Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 1oa.Mt Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY LBT 5175567f__j BUMESS NAIME&OCAT10N RECEIPT NO. EXPIRES JASONS SEPTIC INC RENEWAL SEPTEMBER 30, 2015 13341 YN 88 AVE 5409677 Must be displayed at place of business MIAMI FL 33176 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS 1ASONS SEPTIC INC 196 SPECIALTY PLUMBING CONTRACTOR RECEMED sY TY E COU.ECTOR Worker(s) 3 SEP031444 $75.00 08/07/2014 ECHECK-14-140607 This Local Basiness Tax Receipt only confirars payment of the Local Business Tax The Receipt is ant a license, Permit.or a cerdfieatioa of the holler's gaalificatioas,to do business.Holder mast comply with any governmental or rnagoveramemal regulatory laws and requirements which apply to the basmess. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 8a-M. For more information,visit REGISTERED SEPTIC TANK CONTRACTOR JASON A. NESENMAN a, slip 334" SW 88.A'JEN+L:E MAW =- 33'-'P- J 33`.P v„ JASON'S Sr71-F, �- - NC. SAnrZ 7 SR0031 44 07/02/2015 12: 05 7862067066 STATEWIDE INSURANCE PAGE 01 DATE CERTIFICATE 4F LIABILITY INSURANCE 07/0zi15) PRODUCER Calloway Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 17354 South Dixie Highway ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami,FL 33157 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305)255-1661 Fax (786)206-7066 INSURERS AFFORDING COVERAGE NA1C# INSURED Jason's Septic, Inc. INSURERA: Scottsdale Insurance Companym 13341 SW 88th Avenue INsuReR s. Scottsdale Insurance Company Miami Florida 33176 INSURER C: INSURER D; Vendor 0 254564 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIOATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAI MS. IR A LT TYPE OF INSURANCE POLICY NUMBER POLICY BFFECTNE POLICY EXPIRATION LTR INSRO RD DATE MM1DDlYYYY DAT$ MMIDONWY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY CPS2134676 12/04/2014 12/04/2015 �RE7VIISES Es 000urronce $100,000 ❑❑ CLAMS MADE © OCCUR MED EXP(Any one person) $5,000 'A ❑ Q PD:Ded:$1,00=4airn PERSONAL 8 ADV INJURY — $1,000,000 ❑ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE UMrr APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 © POLICY ®PROJECT ❑ LOC 7AUTOMO'BILE LIABILITY ANY AUTOCOMBINED SINGLE LIMIT ALL OWNED AUTOSEa aocidorlt SCHEDULED AUTOS BODILY INJURY (Per Person) HIRen AUTOS ❑ NON OWNED AUTOS BODILY INJURY ❑ (Per eocidenn PROPSDAMAGE (F+er aor.Ndenl) GARAGE LIABIUTY AUTO ONLY•EA ACCIDENT n ❑ ANY AUTO OTHER THAN EA,ACC _ AUTO ONLY: AG® EXCESS/UMBRELLA LIABILITY XB80046153 12/04/2014 12/04/2015 EACH OCCURRENCE 1,000,000 B F1 AGGREGATE OCCUR ❑ CLAIMS MMM AGGREGATE 1 000000 ❑ DEDUCTIBLE Excess Liability Form 1,000,000 ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ❑ WC STATU- OTH- ANY r'ROraRIETOR/PARTNER/EXECUTIVE YIN TO Y LI ITS OFFICER/MEMBER EXCLUDED? CL FACH ACCIDENT (Mandatory In Ifyender E.L.DISEASE-EA EMPLOYEE SPs,describe under PROVISIONS hakwv OTHER E.L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED r3Y ENDORSEMENT 1 SPECIAL PROVISIONS Installation, Service, Repair, Excavation, Maintenance, Drain Fills, Grease Traps and Cleaning of Septic Tanks..... "Please note that any changes to this policy must be submitted to the Insurance Company for approval"*... CEK77FICATE NoWEg CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES C EL LED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURE WI L DEAVOR TO MAIL Miami Shores Village N/A DAYS WRITTEN NOTICE TO THE CERTIR T ER NAMED TO 10050 NE 2nd Avenue THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE OR LIABILITY Miami Shores, Florida 33138 OF ANY KIND UPON THE INSURER,ITS AGENTS OR TATIVES. Attn: Building DeptAUTHORIZED REPRESENTATIVE Fax*305-756-8972 Jose H Romero, Licensed Agent-A225234 ACORD 25(2009101)CIF C 1988-2009 ACORD CO TK)N.A#)rights rasery®d. The ACORD name and logo ar Istered marks of ACORD Aco® CERTIFICATE OF LIABILITY INSURANCE DATE`MMIDD"YYY' 9/11/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement (s). PRODUCER CONTACT NAME: Jacqueline Allen LRA Insurance PHONE (407)838-3445 1 FAX No):(407)838-3460 498 S Lake Destiny Rd AppgEss. INSURERS AFFORDING COVERAGE NAIC# Orlando EZ, 32810 INSURER A:Brid efield Casualty Ins Co 10335 INSURED -INSURERB: Jason's Septic, Inc INSURER 13341 SW 88th Ave INSURER D INSURER E: Miami LrL 33176 INSURER F: COVERAGES CERTIFICATE NUMBER:14/15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEADDL SLUR POLICY FF POLICY EXP LIMITS LTR POLICY NUMBER MMI P YYY MMI GENERAL LIABILITY E--H cCJRFENI_= _ $ C_'AMthC:•;L'==NE^AL_tAE L11 — F�tM M-LULF•i-,ny FLk" NAL S PLIV II LUI-i $ �,[!.I'L .�.;.Cr-r•�[ LIMI?N J1 ['I;. EI. qir I. M1...�1 ,�..,. AUTOMOBILE LIABILRY .•I ''3 -LE JIM;' If ,.n:. .b:•r:' /u:T A?Tr, E DIL r IN:UR'. (Perperson) $ AL_Ov.NELHEDULEU AI.Tn_ iT E�DIL�IN_UR +Peracc1enY $ Hi.—FF-5117-,^ $- F•=ra id<^'I $ UMBRELLA LIAB r = E-I,H :,CC JRFENCE $ EXCESS LIAR HC-AIN*S-M-OE AL-GFEGA'E $ OED I I RETEN"ON 5 $ A WORKERS COMPENSATION X :!TI,.. AND EMPLOYERS'LIABILITY YIN 75T7, k ArJPF F� Ln:�1 rLGR E El_i n4- L_ L H;�_� Lrrl $ 100,000 OF«ICE;/ME%1FER E U--�Ef NIA 30-51549 /1/2014 /1/2015 (Mandatory in NH) L_ L -L-,-E y Lr.II-L�rE� $ 100,000 If a5, r-r;—urJer LL�-h Ii.NLRi,IK-0 L—,w L V .LA-.,E A_.-YLEMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule.If more space Is required) License N: SR0031444. Work performed: Repair, Service, Excavation, Maintenance and Cleaning of Septic Tanks. CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Department 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores, L*L 33136 B Tomlinson/DCOGGO '-�CS - ACORD 25(2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. INS025;20oos,'iI The ACORD name and logo are registered marks of ACORD * STATE OF FLORIDA PERMIT NO.- "T DEPARTMENT OF HEALTH DATE PAID':✓-_ i ONSITE SEWAGE TREATMENT AND !DISPOSAL SYSTEM FEE PAID: W,. CONSTRUCTION INSPECTION AND FINAL APPROVAL RECEIPT #: _ APPLICANT: �� �c r5 -- PROPERTY ADDRESS: LOT: BLOCK: SUBDIVISIONA iq�J [ u/�[��ef PROPERTY ID fl: CHECKED (X1 ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS I ) [Oil TANK SIZE(1) �121 ( ' j - [27] SURFACE WATER FT ( 1 1021 TANK MATERIAL�d V�`1 ( J [281 DITCHES ��' FT [ 1 1031 OUTLET DEVICE [ ) 1291 PRIVATE WELLS„� FT [ 1 1041 MULTI-CHAMBERED (� ( 1 (301, PUBLIC WELLS FT ( 1 1051 OUTLET FILTER _ [ 1 [311 IRRIGATION WELLS_ FT ( 1 1061 LEGEND 1 [32) POTABLE WATER LINES FT ( 1 (071 WATERTIGHT ( 1 [331 BUILDING FOUNDATION— __ FT ( ] [081 LEVEL [ 1 - [341 PROPERTY LINES FT [ j 1091 _OEPTH TO LID [ 1 1351 OTHER_. FT //2'DORA/14JELD INSTALLATION FILLED!MOUND SYSTEM [ 1 (101 AREA 11150_(2) SOFT ( 1 (361 DRAINFIELD COVER [ ) (111 DISTRIBUTION BOX HEADER [ 1 (37] SHOULDERS [ 1 1121 NUMBER OF DRAINLINES I [ 1 (381 SLOPES ( 1 [13] DRAINLINE SEPARATION E [ ] [391 STABILIZATION [ ] (14) DRAINLINE SLOPE ( 1 (151 DEPTH OF COVER1 � ADDITIONAL INFORMATION ( j [16) ELEVATION[ABOVE/BELOW)BM_ L -i ( ] [401 UNOBSTRUCTED AREA ( ) [171 SYSTEM LOCATION I /P- [ 1 [41) STORMWATER RUNOFF [ 1 [181 DOSING PUMPS �.Cl� ( ] [42) ALARMS [ j (19] AGGREGATE SIZE M`�'�— / ( ) (431 MAINTENANCE AGREEMENT ( ) [20) AGGREGATE EXCESSIVE FINES �/A ' [ J (44] BUILDING AREA ( ] 1211 AGGREGATE DEPTH 4^/g+ [ ] [45) LOCATION CONFORMS WITH SITE PLAN ( ] (461 FINAL SITE GRADING FILL/EXCAVATION MATERIAL [ ] (471 CONTRACTOR _ [ 1 (221 FILL AMOUNTIlk- 1 1/ ( ] (481 OTHER ( 1 [23) FILL TEXTURE k ( 1 (241 EXCAVATION DEPTH 7Z-- ABANDONMENT [ 1 [25) AREA REPLACED� q ( 1 (49) TANK PUMPED [ 1 (261 REPLACEMENT MATERIAL.9°y ] [501 TANK CRUSHED& FILLED EXPLANATION OF VIOLATIONS/REMARKS: I 1 [ 1 - [ 1 C,ONSTRUCTIOIAPPROVED/ APPROVEDJ: CHO DATE: FINAL SYSTEM APPROVED/DI PPROVED]: , 'z - CHD DATE: DH 4016(Page 2), 10/97(Previous Editions May Be Used) �'� Page 2 of 3 Stock Number:5744.0024016.4 PT t: Applicant PT 2: Inslaller/Contractor PT 3: Building Depanmen: PT 4: Health Department