PL-14-2751 VL ILI
-Z s 6
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-225354 Permit Number: PL-12-14-2751
Scheduled Inspection Date: April 07, 2015 Permit Type: Plumbing- Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: BERNSTEIN, HOWARD Work Classification: Addition/Alteration
Job Address:178 NE 111 Street
Miami Shores,FL 33161-7048 Phone Number
Project: <NONE> Parcel Number 1121360040140
Contractor: PSG PLUMBING SERVICES, INC Phone: (305)796-7304
Building Department Comments
PLUMBING FOR REPLACEMET OF KITCHEN CABINETS infractio Passed Comments
SINK AND DISHWASHER INSPECTOR COMMENTS False
Inspector Comments
Passed E9/
Failed
Correction
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
April 06,2015 For Inspections please call: (305)7624949
Page 12 of 63
Miami Shores Village ' '
Building Department DSC 17 2014
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
BUILDING Master Permit No. T�--�"l"
PERMIT APPLICATION Sub Permit No.1-1"--q-151
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
LUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
// CONTRACTOR DRAWINGS
�f/
JOB ADDRESS: ( 4 ' " 4Cl(� �ie P le
City: Miami Shores //-,, ( County: Miami Dade Zia: 3 AF
Folio/Parcel#: -,2136_ V 0 /T b// IQ Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):-4awu� B14
-es(1� ' t�.1 Phone#:��S"`3 3"
Address:
ID 0
City:�V�Nd� S)L�'Q CeA State: Zip: J J
Tenant/Lessee Name: ^ \ Phone#:
Email: Q=6n W lW� .e
CONTRACTOR:Company Name: I— ?/45Y+t��!� a L) lel e Phone#: 37`5 2 /—� %3G�
Address: -�c /V u-
City:e l�- 1— /4 State: F le�;'r- H Zip:
Qualifier Name: P<f-4V rte - C)z 1-y1 V4-^2 Phone#:
State Certification or Registration#: Fe- &.;2 .5 7 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: Square/Linear Foo ge of Work:
Type of Work: ❑ Addition ❑ Alteration j� -kNew Repair/Repla e ❑2,reolition
i
U Pel / -Description of Work: / /lt / 6 %
rD/^ .5 i
Specify color qf color thru tile:
Submittal Fee$ '`�� Permit Fee$ 50' XY CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Train!ng/Ed ucation Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
1
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.
Signature Signature
OWNER or AGENT Y!rNTR OR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 l by I day of�/c Cy ,20 X by
w� R"f.ys/ai who is personally known to —!22k, ^-D who is personally known to
me or who has produced /Q_ L as me or who has produced �� /J Q G.- as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: eM6 Sign:
r
SrPublic Stag Of
Print: o c c Print:
�lz ,, ��� X011" , Notary Publid 8tata of Ftof1/a
Seal: Seal: T Jose 1. a Pdato
_:y, MY Commission EE112102
y fid'' CxplMs 01/13/2018
APPROVED BY - -/ Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
CERTIFICATE OF LIABILITY INSURANCE DATE
12/15/14(MMIDDIYY)
PRODUCER' Excellence Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
3801 SW 107 Avenue ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Miami,FL 33165 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Phone (305)226-3900 Fax (305)226-3997 INSURERS AFFORDING COVERAGE NAIC#
INSURED PSG Plumbing Service, Inc. INSURER A: Scottsdale Insurance Company 41297
3892 NW 125 Street INSURER B. Infinity Auto Insurance Company 11738
Cipalocka, FL 33054 INSURER c: Ascendant Commercial Insurance Co. 11398
INSURER D:
INSURER E:
COVERAGES INSURER F:
THE POLICIES OF INSURANCE LISTED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD DATE(MM/DD(YY) DATE(MM/DD/YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE 3,000,000
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
CPS1854001 08/22/14 08/22/15 PREMISES(Ea occurence) 300,000
CLAIMS MADE 41 OCCUR MED EXP(Any one person) 5,000
A �� I PERSONAL&ADV INJURY 1,000,000
[_ GENERAL AGGREGATE 3,000 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 3,000,000
POLICY [41 PROJECT i_j LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
!_._.j ANY AUTO 509-55946-6827-001 07/09/14 07/09/15 (Ea accident) 1,000,000
ill ALL OWNED AUTOS
BODILY INJURY
B LI SCHEDULED AUTOS (Per person)
[VI HIRED AUTOS
BODILY INJURY
[m/] NON OWNED AUTOS (Per accident)
iyJ Comp$500.00 Ded PROPERTY DAMAGE
J Coll $500.00 Ded (Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
C [_] LJ ANY AUTO OTHER THAN EA ACC _
AUTO ONLY: AGG
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 2,000,000.00
CP51854001 08!22/14 08/22/15
;y_J OCCUR i ] CLAIMS MADE AGGREGATE 2,000,000.00
l DEDUCTIBLE
[_ RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY WC-66349-0 11/18/14 11/18/15 vl TORY LIMITWC LIMITS ER
-
C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1,000,000
OFFICER/MEMBER EXCLUDED? N E.L.DISEASE-EA EMPLOYEE 1,000,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Plumbing Contractor-CG2033 Blanket Additional Insured - Included/CG2404 Waiver of Subrogation - Blanket coverage
included per written agreement; GLS-295s Primary and Noncontributory Wording—Included as applicable to CG 20 33; CG2503
Designated Construction Project(s) General al Aggregate Limit—Included
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Miami Shores Village Building Dep 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
10050 NE 2 Ave THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY
Miami Shore, FI 33138 OF ANY KIND PON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Fax 305-756-8972 AUTHORIZ E ESENTATIVE
ACORD 25(2001/08)QF ;AtRD C RPORATION 1988
STATE OF FLORIDA CENTRAX #:-13-SG-23319
a DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID $
CONSTRi7CTION PERMIT RECEIPT
OSTDSNBR 04-4269- -R
CONSTRUCTION PERMIT FOR:
[ ]New System ( ]Existing System ( ]Holding Tank ( ] Innovative Other
[ X ] Repair [ ]Abandonment [ ] Temporary [ NA I
APPLICANT: Palacios, Ligia AGENT: SA0021074, Solomon Teresa
PROPERTY STREET ADDRESS: 161 NW 105 St Miami FL 33150
LOT: 11 BLOCK: 204 SUBDIVISION: Dunning Miami Shores
[Section/Township/Range/Parcel No.]
PROPERTY ID #: 11-2136-008-0110 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E-6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T { 900 ] Gallons SEPTIC TANK MULTI-CHAMBERED/IN SERIES: [Y ]
A [ 0 ] Gallons MULTI-CHAMBERED/IN SERIES: [Y ]
N '[ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY
K ( 0 ] GALLONS DOSING TANK CAPACITY [ 0 ] GALLONS @ [0 ] DOSES PER 24 HRS # PUMPS [ 0 ]
D [ 300 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: ( 1f ] STANDARD [ N ] FILLED [ N ]MOUND [ N ]
I CONFIGURATION: [ N ] TRENCH BED [ N ]
N 1
F LOCATION TO BENCHMARK: Existing Finished Floor Elev. : 12.90 Ft NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 2.1 ] [ FEET ] [ BELOW I BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 4.6 ] L FEET ] ( BELOW ]BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.0 ] INCHES EXCAVATION REQUIRED: [ 30.0 ] INCHES
OTHER REMARKS:
1. Install 900 gal. category-1 septic tank equipped with an approved filter.
2. The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with sec. 64E-6.013(3) (f) , FAC.
3. Install 300 sf of drainfield in bed configuration.
4. Existing 900 gal. septic tank to be inspected for an appropriate pump-out and properly
abandonned.
5. Invert elevation of drainfield to be no less than 8.80, NGVD.
6. Bottom of drainfield elevation to be no less than 8.30' NGVD.
THIS PERMIT IS NOT FOR AN ADDITION.
SPECIFICATIONS BY: Andre, Paul / , TITLE:
kPPROVED BY: Andre, Paul „rg�— TITLE: Professional Engin Dade CHD
DATE ISSUED: 12/27/04 EXPIRATION DATE: 3/27/05
r�
�Ad STATE OF FLORIDA
= ` DEPARTMENT OF HEALTH
'.�. APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
------------------- PART II - SITE PLAN-------------------
>cale: Each block represents 5 feet and 1 inch =50 feet
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Signature Title
'Ian Approved Not Approved Date
ly County Health Deparlynent
ALL CHA ESST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT'