PL-15-1071 r
Miami Shores Village IrMAY ® � 2815,
Building Department BY:
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
r Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 16
BUILDING Master Permit No.��
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
0 PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 9105 NE 5 AVE
City: Miami Shores County Miami Dade zip:
Folio/Parcel#:11-3206-014-1210 Is the Building Historically Designated:Yes NO X
Occupancy Type: SFR Load: Construction T pe: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Alejandro Pin Phone#:(305)397-8590
Address:4985 DAVIS RD.
City. MIAMI State: 170 1 Zip: 33143
Tenant/Lessee Name: r Phone#:
Email:
CONTRACTOR:Company Name: A. SEPTICS L Phone#: (305)218-8097
Address: 15870 SW 250 ST
City. MIAMI St.te: FL Zip; 33031
Qualifier Name: RAUL MIRANDAPhone#: (305)218-5698
State Certification or Registration#: SR0141736 Certificate of Competency#:
DESIGNER:Architect/Engineer: NSA Phone#:
Address: City: State Zip:
Value of Work for this Permit:$ 1,000.00 Square/Linear Footage of Work: 3 -75 .
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: ONE SEPTIC SYSTEM NEW INSTALLATION OF
900 GALLON SEPTIC TANK WITH 375 SQ FEET OF DRAIN FIELD IN TRENCH CONFIGURATION.
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ��') •�� CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ '500-okc=-�
TOTAL FEE NOW DUE$ C�` _
(Revised02/24/2014) g� C�
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 re" spection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
5 day of MARCH 20 15 by 5 day of MARCH 20 15 by
GILLERMO PING who is personally known to RAUL V'MIRANDA who is personally known to
me or who has produced YAREXIS MIRANDA as me or who has produced --134 •I S-tka—Cas
identification and who did take an oath. identification and who did to oa
NOTARY PLILIC: NOTARY PUBLIC:
a
Sign: Sign•
Print: ` Print: °��'"°. X I MIRAN
r
Seal:
MY COMMISSION i0FF182633 : .. o;
�.., a�` Seal: EXPIRES December 10,2018
EXPIRES December 10,2018
(407)388-0153 FloridallotaryService.com (4d7) -01 Floridallotat Service.com
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Y
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REGISTERED SEPTIC TANK CONTRACTOR.
RAUL R. V'MIRANDA
0=�= 15870 S.W.250 STREET
{
MIAMI, FL 33031- , .
A.B.T. SEPTIC SERVICE.LLC
Business Authorization: SA0041185
SR0141736
Registration Expires on September 30, 2015
CDL CidiS3` 4
r V505-736-71- -a . u
RAM RMAM'
-7311
SEC
*EST «
C`GF�2I,r-t'w "soFt«ce.'NC�6 ffit MfoftfISR r.vvj*-,o#tic%awTP0 by 4-
m,
FLORIDA DEPARTMENT OF HEALTH
CERTIFICATE OF AUTHORIZATION FOR SEPTIC TANK CONTRACTING
HEALTH
The Florida Department of Health hereby certifies the basins or entity mored below has satisfied the requirements of Part
,W, Chapter 489,Florida Statutes,for septic tank contracting and has been duly aw&rized by the Department to provide
septic tank contracting services under the name of
A.E.T. SEPTIC SERVICE LLC
Qualifying Contcaall r: RAUL V'MMAMA
SA0041185 February 25,2015 March 31, 2017
Authorization Number Date Issued Expiration Date
Local Business Tax Receipt
'Miami-Dade County, State of Ronda
THIS IS NOT A BIL - DO NOT PAY
5326319 k�LB .
T .,/
BUSINESS INAMEILO"mom sEc wT NO: EXPIRES
A v.same sstvia uc WARM SEPTEMBER 30, 2015
15870 SW 250 ST 3�58$fB Must be arwoayed at place of business
MW I-ft13031 Pursuant to County Code
Chapter 8A-Art 9&10
OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED
A.B.T.SEPTIC SERVICE LLC 196 SPECIALTY PLUMBING CONTRACTOR SY TAX COLLECTOR
V!lorker(s) 1 SEP0141736 $75.00 08/08/2014
CREDITCARD-14-031944
This tomw a sTme Bso pap�ofuie Local Ba Tax The neceigis note lime,
pemdLara oa*moftlre to do bushom Hower amateaaplyw&bany gavenwooW
oraosgovaraamatal tmry base which apptlr m ibel
The RC�IP7'NB.ahoue mm3t 6e d�taged wlfif#moma3rslal rehiel�- -9itis ;
Fornnre iodon.vt� .
CERTIFICATE OF LIABILITY INSURANCE DATE04/22D/YYYY)
04/22/15
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
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME: JOSE HERNANDEZ
J.L.Hernandez&Associates, Inc. PH(AICNN : (305)238-7676 FAX No): (305)378-9056
18839 S.W. 117th Ave.
E-MAIL jihemandezinsurance@yahoo.com
Miami,FL 33177 INSURER(S)AFFORDING COVERAGE NAIC#
Phone (305)238-7676 Fax (305)378-9056 INSURER A: SCOTTSDALE INSURANCE COMPANY
INSURED INSURER B:
ABT SEPTIC SERVICE LLC INSURER C:
15870 SW 250 ST INSURER D:
HOMESTEAD,FL 33031 305 INSURER E:
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
LTR R I WVD POLICY NUMBER MM/DD MM/DD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000.00
PREMISES Ea occurrence $
A ❑ ❑ CLAIMS-MADE 0 OCCUR Y CPS19690000 MED EXP(Any one person) $ 5,000.00
❑ 04/19/2015 04/19/2016 PERSONAL&ADV INJURY $ 1,000,000.00
❑ GENERAL AGGREGATE $ 2,000,000.00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00
LJ POLICY ❑ PRO ❑ LOC _ $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $
❑ ANY AUTO BODILY INJURY(Per person) $
ALL❑
AUTOS ❑ AUTOS BODILY BODILY INJURY(Per accident $
NON-OWNED PROPERTY❑ DAMAGE $HIRED AUTOS ❑ AUTOS Per accident
❑ ❑ $
❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $
❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $
❑ DED ❑ RETENTION$ $
WORKERS COMPENSATION ❑WC STATU- ❑ ERH-
AND EMPLOYERS'LIABILITY Y/NORY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N I A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
Ifyes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
SEPTIC TANK INSTALLATION AND REPAIR
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE ACCORDANCE WITH THE POLICY P O .
MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTA E
I
1988-2010 A D CORPORATION. All rights reserved.
ACORD 26(2010/05)QF he ACORD n e and logo are registered marks of ACORD
z
's
3 .t
JEFF ATWATER -h"�•��'r�
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
"CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW'•
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 5/5/2014 EXPIRATION DATE: 5/4/2016
PERSON: VMIRANDA RAUL R
FEIN: 465267149
BUSINESS NAME AND ADDRESS:
A B T SEPTIC SERVICE LLC
15870 SW 250 ST V .
HOMESTEAD FL 33031
SCOPES OF BUSINESS OR TRADE:
IRRIGATION OR SEWER CONSTRUCTION
DRAINAGE SYSTEM ALL OPERATI
Pursuant fo CAapbr 440.05(14,F.8.,en oEker o/a eoryon0on wno sleds szemptlon from this cAapptler by faint'y s ceitilfale of ehetlon uMer Nk aadbn met'
not nc-1 W-n or canpemetbn under thls dupter.Pursuant to CMpdr 440.05(12),F.B.Csrtdketes or eledion to fro ez
of Ns DuslnHe or Inde IWsd on the notice of ekdWn to M ezempt Punuenl to Chapter 440.b 73,F.8.,Notkea of ekctbn M�zempl M cerb'(�Iptes of
eeAfAeate nbo bn�ere lie requlriti�unb olAlM eifecbon(cr bs an a oofni oMRxatls Ae dep y�e oke i artitints e1 a�iiy lino hip�re of tl�ie�w
person named on Ne certiflnte to tnssl the requhemente of this sedlon
a
DFS•F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12
QUESTIONS?(850)4111B0g
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Scanned by Cam canner
.... .� Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to Owner— Workers' Compensation Insurance Exem tion
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 contrac_toLhas pro ' i��ee
beVw-only-perstfii allo�ved_t_o-wa on . these circumstanc 1Vliami Shores Village does not require verification of
workers'compensation' ce verage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELOW OU ACKNOWI:EDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:— ,///V
er
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this 6 day of ,20 1t) .
By -'Y M-0 ,�. I �� who is personally known to me or has produced
ulcrr-e x�5 lit J c.ct as identification.
Notary:
°I►�"PB�:; YAREXIS MIRANDA
S
_. MY COMMISSION#FF1 018
°•,.y �crs tuber 10.
!Foo °r; EXPIRES Dere
to Service•com
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A.B.T SEPTIC SERVICE
15870 SW 250 ST
Homestead,FL 33031
Office 305-218-8097 Office Cell 305-218-5698
abtsenti0i,2mail.com
Date:
State of ; ®A
County of �a �_�
Before me this day personally appeared \� � ®� c,��C who, being duly
sworn,deposes and says:
That he or she will be the only person working on the project located
at:
Sworn to (affirmed)and subscribed before me thisday of CAr\ 2015,
by
Personally know
Dp►
YAa is o ap 182633 R Produced Identification " j(Q
MY COMM1Sembet 10,2018
.;; p�FtES $eNlce f Identification Produced
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Print, Type or Stamp Name or Notary