PL-15-1114 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-245776 Permit Number: PL-5-15-1114
Scheduled Inspection Date: October 20,2016 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: CENOZ,EFREN Work Classification: Septic
Job Address:51 NW 110 Street
Miami Shores, FL 33168-4318 Phone Number 3051751-5274
Parcel Number 1121360030600
Project: <NONE>
Contractor: A AMERICAN SEPTIC&PLUMBING Phone: (305)866-5600
Building Department Comments
NEW SEPTIC AND DRAIN FIELD REPAIR Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-245562. need permit on site
HRS IN FILE
Failed
Correction v- !S
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
October 19,2015 For Inspections please call: (305)762-4949 Page 30 of 42
t
�- _ ` � ,
T c lip p
,9e°mss i, Miami Shores Village r5 P�lf#Tl[ } Pl� �
10050 N.E.2nd Avenue NW �
Miami Shores,FL 33138-0000 �� ' +
'��oniop Phone: (305)795-2204
Expiration: 11/1112015
Project Address Parcel Number Applicant
51 NW 110 Street 1121360030600
EFREN CENOZ
Miami Shores, FL 33168-4318 Block: Lot:
Owner Information AddressPhone .... Cell
.. . _ ............
EFREN CENOZ 51 NW 110 Street 305/751-5274
MIAMI SHORES FL 33168-4318
51 NW 110 Street
MIAMI SHORES FL 33168-4318
Contractor(s) Phone Cell Phone Valuation: $ 2,450.00
A AMERICAN SEPTIC&PLUMBING (305)866-5600 (786)236-5599 i
Total Scl Feet: 225
Type of Work:NEW SEPTIC AND DRAIN FIELD REPAIR Available Inspections:
Type of Piping:
Inspection Type:
Additional Info:
HRS Approval
Bond Return: Final
Classification:Residential Scanning:3 Review Plumbing
3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Owners Bond $500.00 (nVOICe# PL-5-15-55514
CCF $1.80
DBPR Fee $4.50 05/15/2015 Check#: 1638 $ 500.00 $322.80
DCA Fee $4.50 05/12/2015 Credit Card $50.00 $272.80
Education Surcharge $0.60 05/15/2015 Credit Card $272.80 $0.00
Permit Fee $300.00 Bond#:2716
Scanning Fee $9.00
Technology Fee $2.40
Total: $822.80
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compli ince with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the prol er 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 wor<.
OWNERS AFFIDAVIT: I ertify that all the foregoing information is accurate and that all work will be done in comAiance with all applicable laws regulating
construction and zoni aut`orize the above-named contractor to do the work stated.
May 15, 2015
Authorized Signathre.WvYner / Applicant / Contractor / Agent -)ate
Building Department Copy
May 15, 2015 1
R Miami Shores Village
RE EIVED
MAY 12 2015
Building Department
x.
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 20 /y
BUILDING Master Permit No.P_/_
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION ❑RENEWAL
(PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP
77�� rr CONTRACTOR DRAWINGS
JOB ADDRESS: I N I JT
City Miami Shores County: Miami Dade Zig:
3 to8
Folio/Parcel#: w �3 000 Is the Building Historically Designated:Yes NO x
Occupancy Type: Load: Construction Type:"" Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): Lcf'le /lJ `/�fo 1- Phone#: 7,66 </- n 23 - 7<10_�l
Address:_ S/ /%/k/
City: /yl A M J State: �— zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: lk �tyJY�fP(Tt T 6 d S p�lnUp
36 St o Slow
Address: ns 1 is YAC 160-01 13 O
City: 1_, State: Zip: t,,
Qualifier Name: i ll1w (• W1� � Phone#: -100 26s6iq
State Certification or Registration#: 5E M i AZ Certificate of Competency#:_s"A 600
DESIGNER:Architect/Engineer: N Pf Phone#:
Address: City: State: r Zip:
Value of Work for this Permit:$_W6-0, W Square/Linear Footage of Work: 2a7 4a R
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work:
fid+ p �h titsr
Specify color of color thru tile:
Submittal Fee$!tdg:Permit Fee$�• CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$
Bond$ -Psoox>'] 1�
TOTAL FEE NOW DUE$ ��• ��
(Revised02/24/2014)
' t
Bonding Company's Name(if applicable) N
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 inspectictC occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will no a and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT /CONTRACTOR
The foregoin ' strument was acknowledged before me this The f egoing instru nt was acknowledged beforL�this
day of 20 1 by day of 20 "J by
1F who is ersonally known { it W who is personally known to
me or who has produced as me or who has produced as
identificati J1th_o did 4AVAEfsb LVGO identification and who did take an oath.
NOTARY P '' MY GOMMMION 8 EE212865 NOTARY PUBLIC:
-LWMSJ*02.2018
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Si Sign: —A
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rint: Print:
Seal: Seal:
••; MY M MBSSIOM 1EEMIN
' * EXPIRES:Fobnaq 15,2017
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s****s*******s+*�************�*s**�.***********s************ss*sr��************■*seer****:**s***.**�**s******
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
FLORIDA DEPARTMENT OF HEALTH
oFir
r .a CERTIFICATE OF AUTHORIZATION FOR SEPTIC TANK CONTRACTING
HEALTH
The Florida Department of Health hereby certifies the business or entity named below has satisfied the requirements of Part
III, Chapter 489, Florida Statutes,for septic tank contracting and has been duly authorized by the Department to provide
septic tank contracting services under the name of.-
A AMERICAN SEPTIC & PLUMBING, INC.
Qualifying Contractor: WILLIAM M. WOODARD
SA0000947 April 10, 2015 March 31, 2017
Authorization Number Date Issued Expiration Date
ACCOR& CERTIFICATE OF LIABILITY INSURANCE `MM'°°"YYY'
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 policyges)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 Hou of such endo s.
PRODUCER 954318-2469 954-318-2474 . INFINITY INSURANCE SOLUTIONS
INFINITY INSURANCE SOLUTIONS M&N 954-318-2469 Ne:954-318-2474
6412 N UNIVERSITY DRIVE ADDIUIL •BERNADETTEK IISFL.COM
SUITE 132 INSU AFFORDING COVERAGE NA1Ce
TAMARAC. FL 33321 INSURER A:ASCENDANT INS. CO.
INSURED 305-866-5600 305-891-6905 wsuRERe:SOUTHERN INS_
AAMERICAN SEPTIC&PLUMBING, INC INSURERC:
12555 BISCAYNE BLVD INSURER O:
SUITE 970 INSURERE:
-NORTH MIAMI, FL 33181 INSUM F
COVERAGES CERTIFICATE NUMBER: 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.UMMS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY MBER — POLICxY MONY LIMITS
GENERAL LIABILITY IEACH OCCURRENCE S1,00,00
OAARGETO
A ✓ COMMERCIAL GENERAL LIABILITYP n S 1
CWMS-MADE 7 OCCUR GL-37126-01 11/21/2014 11/21/2015 MED EXP(Anyone ) S5,000
PERSONALS ADV INJURY $ 1,000.00
GENERALAGGREGATE s2.000.000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-compmP AGG 31,000,000
1/7 POLICY PRO.r=CT Loc COMBINS
AUTOMOBILE LIABILITY *Wdent)IN LE LIMIT
ANY AUTO BODILY INJURY(Per person) S
AAILL�MED SCHEDULED BODILY INJURY(Per eWdent) S
HIRED AUTOS NON- D PRperOPTYPEERDAMAGE S
5
UMBRELLA LIABHCLAIMS-MADE
OCCUR EACH OCCURRENCE S
EXCESSLIAB AGGREGATE S
DED I I RETENTION S
WORKERS COMPENSATION rF-LtC0)rSEASE
ATU- OTH-
AND EMPLOYERS•LL40IUTY BAF�FI�Et�PAR�E�ECUTIVE❑ NIA PWC002043-12 02/03/2015 02/03/2016CIDENT S10 O(Mandatory In NN) -EA EMPLOYE S100,000
If yit,desaibe under
DESCRIPTION OF OPERATIONS bdaw EL DISEASE-POLICY LIMIT S500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Adwh ACORD 191,AddWwal Ramaft SchedulR B mon►space Is requlmd)
98482 PLUMBING COMMERCIAL& INDUSTRIAL
98483 PLUMBING RESIDENTIAL & DOMESTIC
98805 SEPTIC TANK SYSTEMS CLEANING
(WC) 5183 AIR CONDITIONING SYSTMERS NON PORTABLE PLUMBING & DRIVERS
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF MIAMI SHORES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2 AVE AUTxoRIZEDRV IEWffAWE
MANII SHORES,FL 33138
®1868-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(21"01M The ACORD now and logy are rtegistSrlsd mwft of ACORD
PERMIT #: 13-SC-1603668
STATE OF FLORIDA APPLICATION #: AP1187054
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
SYSTEM
FEE PAID:
CONSTRUCTION PERMIT
RECEIPT #:
41 DOCUMENT #: PR973812
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Efren Cenoz
PROPERTY ADDRESS: 51 NW 110 St Miami, FL 33168
LOT: 28 BLOCK: 220 SUBDIVISION: Miami Shores Ext
PROPERTY ID #: 11-2136-003-0600 [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 l GALLONS / GPD new septic tank CAPACITY
A [ 0 1 GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY I ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 225 1 SQUARE FEET Trench confquration drain SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD I ] FILLED I MOUND [ ]
I CONFIGURATION: [xl TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE: 13.0'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 24.001 [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 79.00 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 55.00 ] INCHES
0 1.-Install a 900 gal min.septic tank with an approved filter.
2.-The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
T with s.64E-6.013(3)(f), FAC.
H 3.-Install 225 sf of drainfield in bed configuration.
4.-Invert elevation of drainfield to be no less than 6.91'NGVD.
E 5.-Bottom of drainfield elevation to be no less than 6.41 NGVD.
R 6.-This permit includes the abandonment of the existing septic tank. THIS PERMIT IS NOT FOR ANY
ADDITIONS.
SPECIFICATIONS BY: A American TITLE:
APPRWD 1t: TITLE: Engineering IW :ailist II Dade CHD
BetsyLange- nano
DATE ISSUED: 05/07/2015 EXPIRATION DATE: 08/05/2015
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1187054 SE959608
• I
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one (21) days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN #A02, Tallahassee, Florida 32399-1703. The
Agency Clerk's facsimile number is 850-410-1448.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order
will constitute a waiver of your right to an administrative hearing, and this order shall become
a 'final order.
Should this order become a final order, a party who is adversely affected by it is
entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings
are governed by the Florida Rules of Appellate Procedure. Such proceedings may be
commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the
Department of Health and a second copy, accompanied by the filing fees required by law,
with the Court of Appeal in the appropriate District Court. The notice must be filed within 30
days of rendition of the final order.