PL-15-2233 Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FIL
Phone:(305)796-2204 Fax::(305)756-8972
Inspection Number: INSP-242683 Permit Number: PL-9-1 5-2233
Scheduled inspection Date: September 13,2015 Permit Type: Plumbing - Residential
Inspector: Diaz,Osvaldo
Inspection Type: Final
Owner: BRADSHAW, ELSTON&RUBY Work Classification: Septic
Job Address:432 NW 111 Terrace
Miami Shires,FL 33168-3326 Phone Number (305)7674604
Parcel Number 1121360010510
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
Building Department Comments
REPLACE SEPTIC &DRAIN FIELD Infractio Passea Comments
INSPECTOR COMMENTS False
RENEWAL OF EXPIRED PERMIT PL13-1386
Inspector Comments
Passed HRS 1N FILE
Failed
Correction
Needed
Re-inspection
Fee
No Additional Inspections can be scheduled until
re-inspectiGn fee is paid.
September 22,2015 For Inspections please call; (306)762-4949 Page 1'5 of 35
- TL 2-2 33
' �,� ,,���►o+:. DIVISION OF
Environmental Health
Florida Health *AO� Miami-Dade County �0
eQ� OSTDS/Well Division
11805 SN'26th Street•Miami,F1,33175 O
Inspector ri �rl`� Date / J2 O �J
Address-1,11-7- �l Af p
Comments:
Signature_
i
Miami Shores VillagecF1vvED
BuildingDepartment 01 20,
p5
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20
BUILDING permit No.
PERMIT APPLICATION Master Permit No.
Permit Type: PLUMBING
JOB ADDRESS: 4- 2— NW
City: Miami Shores County: Miami Dade Zip: f b
Foho/Parcel#:
Is the Building Historically Designated:Yes NO V/ Flood Zone:
OWNER:Name(Fee Simple Titleholder): IF 1 S ®� �� rC Phone#: `�36''6 3 z- 7 B o 9
Address: p��
City: �r i �"1D rCS' State: E v Zip:
6 8-
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Co any Name: ` �� �\ 5, i " l� S Ph no e#: 3(6G(—G632
Address: Qwto Nf6,J 0i Avp, f -�
City: (Qp6 State t
Zip: "3 309
Qualifier Name: Phone#:
State Certification or Registration t 1 6 Certificate of Competency#: _
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer. Phone#:
®
Value of Work for this Permit:$��® Square/Linear Footage of Work: 22E�
Type of Work: ❑Address ❑Alteration ❑New tepair/Replace ❑Demolition
Description of Work•
v�
e
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
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 ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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.
Signature, Signature �
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this__ Z-5- The foregoing instrument was acknowledged before me this
day of ,20 1 S,by j rl 6Y-Cd&�Q,J day of ,20 S by 's. O 1.0 r-10q
who is personady known to me or who has produced FA who is personally known to me or who has produced
%) As identification and who did take an oath. 03 as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign.
Print: — I lr if e�6 e I o Print: I !2t L(
My Commission Expires: +iT a•r�N Notary Punic SNre of Florida My Commissi F c
. TrenteUe Lewis Notary Pubic Stat®of Rorie
w *mon
2 �s 1 ; Trenrelie Lewis
0 M n,, r=FF 18307
t9F3e�Fdekk3e3:YdroYkYYYYdr9nY9F aY�3nY9c3:sYYYde9cskia9eaF�3r&a4�e�r aF Y:�F?�+.S��r�9e9 eY �Y 4re43e
APPROVED BY /—/-5 Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012XRevised 07/10/07XRevised 06/10/2009)(Revised 3/15/09)
4 i !!Ii
Y
Miami Shores Village iial
3� 1 �
10050 N.E.2nd Avenue NW
.... ,
fk Cl� l�on s�ti
Miami Shores,FL 33138-0000
e Phone: (305)795-2204
'"y
� ass '` I � � �. Expiration: 0310212016
J,,
Project Address Parcel Number Applicant
432 NW 111 Terrace 1121360010510
Miami Shores, FL 33168-3326 Block: Lot: ELSTON 8,RUBY BRADSHAW
Owner Information Address Phone Cell
ELSTON 8,RUBY BRADSHAW 432 NW 111 Terrace (305)757-2604
MIAMI SHORES FL 33168-3326
Contractor(s) Phone Cell Phone Valuation: $ 2,400.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082 Total Sq Feet: 225
Type of Work:REPLACE SEPTIC &DRAIN FIELD Available Inspections:
Type of Piping: Inspection Type:
Additional Info: HRS Approval
Bond Retum: Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.80
DBPR Fee Invoice# PL-9-15-56921
$2'25 09/04/2015 Check#:4880 $ 168.30 $0.00
DCA Fee $2.25
Education Surcharge $0.60
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $168.30
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: 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. Futhermor autho'ze the above-named contractor to do the work stated.
September 04,2015
6A 42L2�
w9rued Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
September 04,2015 1