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PL-15-2701 PermitNo PL-1,0-1.5-2701 Miami Shores Village Permit T"m Plumbit -,"I ential 10050 N.E.2nd Avenue NE W+�rtcCiaslfict3ctx Otsilt� iel+d Miami Shores,FL 33138-0000 �' � � Phone: (305)795-2204 Peanit Status'APPROVED �CORIDA , l201s Expiration: 26/201 Project Address Parcel Number Applicant 10651 NE 11 Court 1122320280220 NINA BIRNBACH Miami Shores, FL 33138-2122 Block: Lot: Owner Information Address Phone Cell NINA BIRNBACH 10651 NE 11 Court MIAMI SHORES FL 33138-2122 Contractor(s) Phone Cell Phone Valuation: $ 2,300.00 A AMERICAN SEPTIC 8,PLUMBING (305)866-5600 (786)236-5599 . .._ Total Sq Feet: 150 Type of Work: INSTALL NEW DRAINFIELD&DOSING TA Available Inspections: Type of Piping: Inspection Type: Additional Info: HRS Approval Bond Return Final Classification:Residential Scanning:3 Review Plumbing Fees Due Amount �Date Pay Type Amt Paid Amt Due CCF $1.80 DBPR Fee Invoice# PL-10-15-57527 $2.63 10/29/2015 Credit Card $ 194.06 $0.00 DCA Fee $2.63 Education Surcharge $0.60 Permit Fee $175.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $194.06 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 AFFID T: 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 ZMore,I authorize the above-named contractor to do the work stated. October 29, 2015 Authorize Si ature:bwner / Applicant / Contractor / Agent Date Building Department Copy October 29,2015 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-246358 Permit Number: PL-10-15-2701 Inspection Date: November 02, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: BIRNBACH, NINA Work Classification: Drainfield Job Address: 10651 NE 11 Court Miami Shores, FL 33138-2122 Phone Number Parcel Number 1122320280220 Project: <NONE> Contractor: A AMERICAN SEPTIC & PLUMBING Phone: (305)866-5600 Building Department Comments INSTALL NEW DRAINFIELD & DOSING TANK Infractio Passed Comments INSPECTOR COMMENTS False TO CLOSE PERMIT#PL06-1860 nspector Comments Passed 12r FailedEl �� Correction ❑ ' Z' l Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 October 30,2015 Page 1 of 1 STATE OF FLORIDA PERMIT NO. DEPARTMENT OF HEALTH DATE PAID: ._._ ........._ ONSITE SEWAGE T EAT NT AND DISPOSAL SYSTEM FEE PAID: CONSTRUCTION IN PEC ION AND FINAL APPROVAL RECEIPT IL: �. = ,b y_ APPLICANT: _ ✓' �_�r� T - AGENT: ',+A+M PROPERTY ADDRESS: LOT: 4P BLOCK: Z SUBDIVISION: "�'��i 5_Q_I �.i� 5 kRdPERTY ID 1!: IIS' Ld2SO2A CHECKED (X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS [ ] 1011 TANK SIZE(11 7;-'0 121 ( 1 [27] SURFACE WATER� FT [ [ 1021 TANK MATERIAL C ( J 1281 DITCHES FT 1 1 1031 OUTLET DEVICE ( ] [29] PRIVATE WELLS filFT ( 1 1041 MULTI-CHAMBERED [Y 162 ( 1 [301 PUBLIC WELLS FT [ 1 [051 OUTLET FILTER_ 1 1 [31] IRRIGATION WELL Al � FT ( 1 [061 LEGEND [ 1 [32) POTABLE WATER LINES- FT [ 1 (071 WATERTIGHT [ 1 [33] BUILDING FOUNDATION 5' FT I 1 [081 LEVEL ( 1 [34] PROPERTY LINES r FT [ 1 1091 DEPTH TO UD [ 1 [35] OTHER FT DRAINFIELD INSTALLATION FILLED/MOUND SY [ ] 1101 AREA[1]-�s) (2) SQFT [ 1 [361 1 RAINFIE COVER ( J III] DISTRIBUTION BOX—HEADER ( 1 [37] S/HOURS ( ] [12] NUMBER OF DRAINUNES_.��____ [ ] [38) SL'O S ( 1 (13) DRAINUNE SEPARATION Z 1 ( ] [39] S ILIZATION 1 1 [14] DRAINUNE SLOPE /Q w e.104 ( 1 [15] DEPTH OF COVER. ADDITIONAL INFORMATION [ ] 1161 ELEVATION[ABOV p BMD [ 1 [40) UNOBSTRUCTED AREA ( ] [171 SYSTEM LOCATION [ ] I41] STORMWATER$tINOFF ( ] [111] DOSING PUMPS [ 1 [42] ALARMS �/ 1 ] 1191 AGGREGATE SIZE [ 1 [43) MAINTENANCE AGREEMENT 1 ] [20] AGGREGATE EXCESSIVE ES [ 1 1441 BUILDING AREA ( 1 [211 AGGREGATE DEPTH 1 1 (45] LOCATION CONFORMS WITH SITE [ 1 [461 FINAL SITE GRADING FILL J EXCAVATION MATERIAL [ ] [47] CONTRACTOR ( 1 1221 FILL AMOUNT ( ] [48] OTHER [ 1 1231 FILL TEXTURE I 1 [24] EXCAVATION DEPTH ABANDONMENT [ ] [25] AREA REPLACED 1 1 [491 TANK PU [ ] (26) REPLACEMENT MATERIAL. I 1 1501 TAN USHED&FILLED—/ —/— EXPLANATION OF VIOLATIONS/REMARKS: l I [ 1 [ 1 [ I CONSTRUCTION PPR ISAPPROVED]: CHO DATE: s FINAL SYSTEM 6CROWCHD DATE:.r DH 4019(Page 2),1(1197(PmWue Editw May Be Used) Pam 2 of 3 StoCk NWr4W.5744-002.40194 PT 1: App4ictM PT x PT& mfiv Dops vmd Scanned, by amScanner Miami Shores Village g Buildin Department Cw 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 'C I } FBC 20 ISI a BUILDING Master Permit NOT L-( S—2 3 o I PERMIT APPLICATION Sub Permit No. []BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL r-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 1 1 CONTRACTOR DRAWINGS `a JOB ADDRESS: 6` Of. it CT City: Miami Shores County: Miami Dade Zip: 3138 Folio/Parcel#: 11 —' ?,7;57, 07s— `�M�(�y Is the Building Historically esignated:Yes NO X Occupancy Type: 0% Load: fYA-"Construction Type: a�Of Flood Zone: t3/'4r- BFE: O/P�- FFE:N/>A' OWNER:Name(Fee Simple Titleholder): ,�Fre {- `i" o fid` y it�6� Phone#: ��D' Ao— 940 Z Address: 10&S k tic C f �1 City: rA- J►`�9 State: N Zip: 3313 D Tenant/Lessee Name: a/Pr Phone#: Email: CONTRACTOR:Company Name: ri�i"n t(�'h c G r 10 V 1'i one#: 3t)5 S�01V V Address: j tlfql�_ 51uill''�� 8 City: State: Zip: 37 Qualifier Name: 011tio-M M' 00441-t' Phone#: ��gopywo ooa State Certification or Registration#: SO-'0013' 2 Certificate of Competency#: J40000gq j l SE 1 0co DESIGNER:Architect/Engineer: a Phone#: Address: A /er City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: 0 Type of Work: ❑ Addition ❑ Alteration l❑ New 9 Repair/Replace ❑ Demolition Description of Work: of W(% Log Ii 06W�` twt prop ` r`4 1t, 00(o • PSS Or S-4%c,L 0(0• 0 i dere . c J, sem I �_ Specify color of color thru tile: Submittal Fee$ Permit Fee$ K" CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ P(_0(0 I TOTAL FEE NOW DUE$ 194- 0(o (Revised02/24/2014) Bonding C;e npany's Name(if applicable) dlh Bonding Company's Address City State Zip lortgage 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 �� � � Signatures 6 OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 40G� w 20 IS , by ; day of �' 2Q" J... bya IN >rV-V I �UL&�- personally rN 7 who is personally known to � who' ersonall known to me or who has produced as or who has produced ry3Jj4 as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLI NOTARY Plj IC: Sign: Sign: Print: Print: me`tn No1af 6s C NAND ,0LDRIPUG Seal: y Public-State o1 FlwWa Seal: s PAY COMMISSION#EE 660780 sw� Aly Comm.Expires Nov 16,2018 "` •,, �o, Cwnmission#�EE 838595 <? EXPIRES:February 95,2017 NONi1 NOIU W1 A Aov r�oa`O Bonded Thru Budge!Notary Services APPROVED BY L-iS Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) a v REGISTERED SEPTIC TANK CONTRACTOR WILLIAM M.WOODARD 12555 BISCAYNE BLVD,#970 NORTH MIAMI, FL 33181- A AMERICAN SEPTIC&PLUMBING, INC. ' Business Authorization: SA0000947 SR0001342 Registration Expires on September 30. 2016 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 4231718 [L::B T, BUSINESS NAME/LOCATION RECEIPT NO. P UM NG INCERICAN RENEWAL& EXPIRES RENEWAL SEPTEMBER 30 2016 1990 NE 163 ST 104 4418836 Must be displayed at place of business NORTH MIAMI BEACH, FL Pursuant to County Code 33160 Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS A AMERICAN SEPTIC&PLUMBING 196 SPECIALTY PLUMBING PAYMENT RECEIVED INC WICONTRACTOR BY TAX COLLECTOR rin I I IAM M WnnnARn PRFR 45.00 10/07/2015 Worker(s) 1 SEP000947 0226-16-000120 This Local Business Tan Receipt only confirms payment of the Local Business Tax.ThReceipt is not a license, permit or a certification of the holdere s qualificatlons,to do business.Holder mus[comply with any governmental or nongovernmental retory gulalaws and requirements which apply to the business, The RECEIPT NO.above most be displayed OR all commercial vehicles-Miami-Dade Code Sec Be-276. �I For more information,visit www.miamidade gov&MII ft0Q 9 A� CERTIFICATE OF LIABILITY INSURANCE DAT1YYY1f) 10/126/2026/2015 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 r certificate holder In lieu of such endorsement(s). PRODUCER CNAMONTAE:CT Sheena Hastings Wise Insurance Agency LLC PHONE , (863)5343431 tFjaNo): (863)533-6485 E-MAI1410 East Georgia Street ADDRESS, jamiewisel986@gmail.com Bartow,FL 33830 INSURER(S) AFFORDING COVERAGE NAIC 0 Phone (863)5343431 Fax (863)533-6485 INSURER A: Catlin 15989 INSURED INSURER B: A American Septic and Plumbing INSURER C 12555 Riscayre Blvd#970 INSURER D: INSURER E: Miami FL 33181 INSURER 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD UBR POLICY EFF POLICY EXP LIMITS LTR INR POLICY NUMBER MM/DD MIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 © COMMERCIAL GENERAL LIABILITY PREMISES Ea oNccurrence $ 100,000.00 A F—] F—] CLAIMS-MADE ❑ 0900104202 08/07/2015 08!07/2016 OCCUR MED EXP(Any one person) $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000.00 ❑ POLICY ❑ PRO- ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ❑ AUTOS ❑ AUTOS NON-OWNED PROPERTY DAMAGE $ ❑ ❑ AUTOS Per HIRED AUTOS accident ❑ ❑ 1 $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑PTAT TE ❑OTH- AND EMPLOYERS'LIABILITY Y I N ER ANY PROPRIETORIPARTNER/EXEC E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? �� N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space is required) Septic tank contractor/SR0001342 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami shores THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E.2nd Avenue, AUTHORIZED REPRESENTATIVE Miami Shores,FL 33138- 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01)OF The ACORD name and logo are registered marks of ACORD