PL-15-666 Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-230962 Permit Number: PL-3-15-666
Scheduled Inspection Date: September 24, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: ORTEGA,JUAN Work Classification: Drainfield
Job Address:173 NE 106 Street
Miami Shores, FL 33138- Phone Number
Project: <NONE> Parcel Number 1121360060390
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
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Building Department Comments
INSTALL NEW TANK(900 GALLONS) Infractio Passed Comments
INSTALL NEW DRAIN FIELD(150) INSPECTOR COMMENTS False
Inspector Comments
Passed 9/a L�f
1
Failed
Correction
Needed
Re-inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee Is paid.
September 23,2015 For Inspections please call: (305)762-4949 Page 7 of 34
DIVISION OF
Environmental Health
• �� `Q Mama Health
01� Miami-Dade County �O
118OSTDS/WeR Division
05Mir-)
treet•Miami,FL 33175 O
Inspector Date
Address l�3 n e" 10 Y0 S7 OSTDS# /70" f l +v UT5
Comments:
Signature
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Miami Shores Village Et11t �tlljq
tt��Ii+ ' It
10050 N.E.2nd Avenue NE 3 }�
Miami Shores,FL 3313&0000 -Row wi
Ap
Phone: (305)795-2204
t1e,C�ate � Expiration: 11/1612015
Project Address Parcel Number Applicant
173 NE 106 Street 1121360060390
Miami Shores, FL 33138- Block: Lot: JUAN ORTEGA
i
Owner Information Address Phone Celt
JUAN ORTEGA 173 NE 106 Street
MIAMI SHORES FL 33138-
173 NE 106 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 6,000.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082
Total Sq Feet: 150
Type of Work:INSTALL NEW TANK(900 GALLONS) 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 $3.80
DBPR Fee Invoke# PL-3-15-54926
$4.50 05/20/2015 Check*4733 $277.60 $50.00
DCA Fee $4.50
Education Surcharge $1.20 03/25/2015 Check#:235 $50.00 $0.00
Permit Fee $300.00
Scanning Fee $9.00
Technology Fee $4.80
Total: $327.60
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. Futhermore,Iau orize the above-n ed contractor to do the work stated.
11 May 20, 2015
Authorized Signature:Ow r / Applicant / Contractor / Agent Date
Building Department Copy
May 20,2016 1
Miami Shores VillagecE .,
Building Department I AMAR52015
10050 N.E.2nd Avenue, Miami Shores,Florida 33138B�
Tel:(305)795-2204 Fax:(305)756-8972 -.-._.
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 l0
BUILDING Master PermitNo.
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION []RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: F (0 -0
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1 1l 16-oO0 6-020'® Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: `Flood Zone: �BFE: FFE:
OWNER: Name(Fee Simple Titleholder): ��( eoC.�l D PhdnJs#:
Address: .1 zr�z�. Ie /06-11
-
City: ��*"o S4&-,L State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: 4t u)° oLk, 1 C. C111+0-C )V) Phone#: � ® f 6
Address: �,,--''�Go
(�'�/� V IS
��
City: �� GoC Qom; gg State: '"� _ Zip:
Qualifier Name: 14J rnPhone#:
State Certification or Registration#: m Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ (0®®®� Square/Linear Footage of Work: 50
Type of Work: ❑ Addition ❑ Alteration ❑ New 0 Repair/Replace ` Demolition
Description of Work: �' Q t >j 112 tQvq F-
p
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ 36U` CCF$ .. co/Cc$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$_RT 145-
TOTAL FEE NOW DUE$ �
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
�Signat a Signature
WNER or AGENT CONTRACTOR
The foregoing instrumAe�nt was acknowledged before me this The foregoing instrument was acknowledged before+me this
A day of 1v�CAJ Gh .20 `� by day of �—ACa°_C�W . .20 1 .by
UA 9AO QVkekc- ,who is personally known to tIA Q'r«uce, --r- ,who is personally known to
e—` ��
me or who has produced 7?1. 'T-'L+®6324350513SQas me or who has produced � ' Jas
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print: 1
,•�o� 'eL� LEONARDO RAMIREZ &JOpubk Stm of Edda
Seal: �� Notary Public-State of Florida Seal: TranwIla Levis
My Comm.Expires Mar 17,2018 ro
My Commission FF 198307
y'4;;orn�..•` Commission N FF 102781 E 02/05/2019
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�k�k�k�k�le�te�yi�7k�k�k�le�k�k�k*7k�k9t�itrk�k�k�kilt7k7k7ktkffiBtM��k�k �k �k�k 7k 7kffi�k�k*7kffi�k�ltik�k7k�k�k�k�h�k�k�k�k*$MND**&�k&��k�kN�N��k*�k�k**$�k�k*�kffi+k�k*�k**�k*�k*�kffi**�k�k7k�k
APPROVED BY 46 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
r73�vE 106 sr
Miami shores V
Building Department
�tpR�A 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-rime employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signatur .
/I � I&
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this 'Z6 day of rt� ,20 IS
By Vg�1 P� �c� Q r'-rea a who is personally known to me or has produced
C"�by1ye's, (.I Qna< as identification.
Notary: IA14 e, TERESA J SOLOMON
SEAL: MY COMMISSION#EE131935
� „••. EXPIRES November 08.2015
7j 398 0153 Flcs�eFbtery3erv�e.�m
I
k �
PERMIT #: 13-SC-1592371
r APPLICATION #:AP1179699
DE ARTMENST kTE OF TLOFIDA HEALTHf� � OE�ggy�� E PX�=D:
ON ITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIP #:
DOCUMEN #: PR967417
CONSTRUCTION PERMI FOR: OSTDS Repair
APPLICANT: Juan Ortega
PROPERTY ADDRESS: 173 NE 106 St Miami, FL 33138
LOT: 15 BLOCK: 208 SUBDIVISION:
PROPERTY ID #: 11-2136-006-0390 [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 SYSTEMI DOES NOT GUARANTEE
SATISFACTORY PERIORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE SIN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLIIANT TO MODIFY THE
PERMIT APPLICATIO . 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 GN AND PECIFICATIONS
T [ 9 GAL NS / GPD new septic tank CAPACITY
A ( 0 J GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ J GALLONS DOSING TANK CAPACITY [ ]GALLONS [ ]DOSES PER 24 HRS #Pumps [ ]
I
I
D [ 015�OSQU FEET new trench COnfq.drainfie SYSTEM
R [ SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ J
I CONFIGURATION: [x] TRENCH [ J BED [ ]
N
F LOCATION OF BENC FFE 12.2' NGVD
I ELEVATION OF PRO SED SYSTEM SITE [ 19.20 ] [ INcxEs FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINF ELD TO BE [ 59.16 ] [ INCHES FT ] [ABOVE BELOW BENCHMA2IC/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 40.00 ] INCHES
1.-Install a 900 gal rnin.septic tank with an approved filter.
0 2.-The licensed cont actor installing the system is responsible for installing the minimum category of tank in accordance
T with s. 64E-6.013(3)if), FAC.
H 3.-Install 1500 sf of c rainfield in trench configuration.
4.-Perimeter of exca ation area shall be at least 2 ft wider and longer than the proposed absorption bed or dr)�in trench.
E 5.-Invert elevation of drainfield to be no less than 7.77'NGVD.
6.-Bottom of drainfie d elevation to be no less than 7.27'NGVD.
R
SPECIFICATIONS BY: Temon Solomon TITLE: I
Master Septic Tank Coltractor
APPROVED BY: �tt � TITLE: Engineering Specialist II Dade CHD
tin
DATE ISSUED: 03/1 015 EXPIRATION DATE: 06/11/2015
DH 4016, 08/09 (Obs letes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 ,.-AP1179699- -'S',E5�6Q31
I .
DOCUMENT #: R967417
-------------------- ----_-------
7.-This permit includes the abandonment of the existing septic tank.
The system is sized for2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimaQad flow of
300 gpd.
THIS PERMIT IS NOT FOR ANY ADDITIONS.
i
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
•�� APP ICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTI iN PERMT�WE
1 �, f
Permit Application Number
J hg
-------- 7--------- PART II ' SITE PLAN--------.--
Scale:
LAN-----Scale: Each block represents 5 feet and 1 inch=50 feet. f
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Notes: S -3?,1
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Site Plan kvbmitted by: —.` a6 I
Signature Title
Aopro�ve"d \J Not Approved
Date
By A,
�ounty Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPA TMENT
)H4015.10/96(Replaces HRS-H Form 4015which may be used)
Stock Number:5744.002-4015.6) I Page 2 of 3