PL-15-1268 0 Miami Shores Village
Building Department Mir ,
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 2 7 2 15
Tei:(305)795-2204 Fax:(305)756-8972 b r
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2010
BUILDING Master Permit No.R—15'— I G
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
LUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
� L CONTRACTOR DRAWINGS
JOB ADDRESS: �y Al, • q,5 � Skee_J
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1I - 32®1ff - 37cc Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name /d`(Fee Simple
E,Simple Titleholder): i� 9 ¢ "e— ie�L�" Phone#: .3,95.3,9563.2 -53,57
Address: A* /q,5 sI -
City: /�/F�rnt` Sh�'E� Stater Zip: 3313o""
Tenant/Lessee Name: Phone#:
Email: /5ellerC_L'df'alol A07-7
CONTRACTOR:Company Name: 9JA+tw;dt, 1 C: G4y7-f I"7 C Phone#: 3 ��
Address: 1340 1'Lv iy9 IS
City:- 6D pe, LoCgA State 33oSt+
pp �. Zip:
Qualifier Name: � ,�� �1� Phone#:
State Certification or Registration#: �F�s3®111 Z 6 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ �� ®� Square/Linear Footage of Work: 22 S'
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: Ck C'e� 1 tkel
Specify color of cqjqr thru tile:
Submittal Fee$ Permit Fee$ 0 ty CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 3
(Reviwd02/24/2014) G ro- Cj O
}
0
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.
CIL&Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of tJlnL L4 2015 ,by ci day of GG 20 iS , by
L.tSaHe Rei'A ,who is personallyknown t0 Tis ispersonally known to
me or-who-lza.&W4d4eed as me or who has produced "� 11� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sig
Print: C, archS vvl Print �I
Seal: : Seal:
o� :�s4 ,par Pq,, Notary fublic State of Florida
a ° 9AllY N' ) r° o Jacquatin Rodriguez
* * MY COMMISSION#FF 042471
EXPIRES: ,62017
August Au My Commission EE115407
,q 9 �9� ~oQe Expires 07/25/2015
APPROVED BYZ�i Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami shores Village
Building Department
rim 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-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this )5tk day of �
,20 .
By L1 se Eta Re iC� who is personally known tom or has produced
as identification.
Notary: �W(Poo, 01Y AL ROW11"
SEAL: * * W OOI4lMMION#FF 042471
EXPIRES:August 6,2017
k*dTfn1u tNWySmic"
PERMIT #: 13-SC-1602815
4 ; STATE OF FLORIDA. APPLICATION #:AP 1186417
DEPARTMENT OF HEALTH M 'I-DADE C011N`_r°I-,7A,!_ w r'ry An4.s„_.�DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT
Ei RECEIPT #
DOCUMENT #:PR974963
CONSTRUCTION PERMIT FOR: OSTDS Repair .
APPLICANT: Lisette Gonzalez
PROPERTY ADDRESS: 290 NE 95 St Miami, FL 33138
LOT: 56 BLOCK: 28 SUBDIVISION:
PROPERTY ID #: 11-3206-013-3700 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN A�TCORpANCE. FTTTH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S. , AND CHAPTER 64E-6, DEPARTMENT• 'APpg
SATISFACTORY PERFORMANCE FOR OVAL OF SYSTEM DOES NOT GUARANTEE
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 [ 855 ] GALLONS / GPD existing septic tank to remain CAPACITY
A [ 0 1 GALLONS / GPD CAPACITY
N [ 0 ] GALLORr GREASE INTERCEPTOR CAPACITY ' [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] ONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 225 ] SQUARE FEET new trench confiq:deainfle SYSTEM
R [ 0 l SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED I l MOUND
I CONFIGURATION: [ ]
Cx] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE 10.5'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE Y.C,.8.40 ] CINCHES, FT ] [ABOVE EL
BOW BENCHMARK/REFERENCE ppm
E BOTTOM OF DRAINEIELD TO BE ,;[;:56.40•] [ INCHES FT ] [ABOVE BELOW BENCHMARK
L � /RE
FERENCE POINT
D FILL REQUIRED: [ 0.001 INCHES ] ''
•: "EXCAVAfiIO1T U�`1#ED: [ 48.00 ] INCHES
[4.-Invert
.-Existing 855 gal.septic tank,certified by"State i�fe.Se tic"cn /17/2 `
o .,�°',,., p. ,l... . _..,.2Q15 to,remain.
.-Install 225 sf of drainfield in trench configuratiop. "
T .-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench.
H elevation of drainfield to be no less than 6.3'NGVD.
.-Bottom of drainfield elevation to be no less than 5.8'NGVD.
E The system is sized for 3 b rooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow
of 400 gpd.
R '
SPECIFICATIONS BY: J Solomon
iT"TLE: Master Septic Tank Contractor
APPROVED BY:
U TITLE: Eri05 ie6-tI ,g S13ecialist II
U i Martin Dade CHD
DATE ISSUED: 18/2015 '
EXPIRATION DATE: 08/16/2015
DH 4016, 08/09 (Obsoletes all previgus ed,tion w i li m� not
used]
Incorporated: 64E-6.003, FAC l h cor:craCr,:,r�,:,r cl?c;ry,
v 1.'1:�'r - a ;rtC;'r'i�W fi� i].8trdih'i ,. ,. • _ Page 1 of 3,
sE960627
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER.
�W"s
Permit Application Number d•
------ PART II -SITEPLAi. ------
Scale: Each block represents 5 feet and 1 Inch=50 feet.
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>ite'Plan submitted by: -
�`, Signature
Tide
'Ian- �pfpve�i Not Approved
Date
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
14015,10/96(Replaces HRS-H Form 4015 which may 6e used)
ock Number:5744-002-4015-6i Page 2 of 3
° y4 Miami Shores Village it ow Phil blr�g �e It elrttla
10050 N.E.2nd Avenue NE
Miami Shores,FL 33138-0000 to
Phone: (305)795-2204 _ i Ic'@iYt�1� tQJR 4"
i Expiration: 04/2612016
Project Address Parcel Number Applicant
290 NE 95 Street 1132060133700
LISETTE REID
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
LISETTE REID 290 NE 95 Street (305)632-5357
MIAMI SHORES FL 33138-2712
Contractor(s) Phone Cell Phone Valuation: $ 3,200.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082
Total Sq Feet: 225
Type of Work:REPLACE DRAINFIELD Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
HRS Approval
Bond Return: Final
Classification:Residential Scanning:1 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Contractors Bond $500.00 Invoice# PL-5-15-55726
CCF $2.40 10/29/2015 Credit Card $663.90 $0.00
DBPR Fee $2.25
DCA Fee $2.25 Bond#:2898
Education Surcharge $0.80
Permit Fee $150.00
Scanning Fee $3.00
Technology Fee $3.20
Total: $663.90
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 ELE RIC L,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFID VIT• certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and i uthermore,I authorize the above-named contractor to do the work stated.
October 29, 2015
Authorized Signa re:Owner / Applicant / Contractor / Agent Date
Building Department Copy
October 29,2015 1