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PL-16-1472 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-259835 Permit Number: PL-5-16-1472 Scheduled Inspection Date: July 07,2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: , Work Classification: Drainfield Job Address:444 NE 102 Street Miami Shores, FL Phone Number Parcel Number 1132060170580 Project: <NONE> Contractor: MIAMI DADE ENVIROMENTAL Phone: 786-251-4099 Building Department Comments DRAINFIELD REPAIR Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed HRS APPROVAL IN FILE Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until reinspection fee is paid July 06,2016 For Inspections please call: (305)762-4949 Page 9 of 30 �►�.� DIVISION OF •� Environmental Heatth Florida Health lbo Miami-Dade County OSTDS/Well Division at 40, / 1105 SW 26th Street-/Miami,FL33175 Inspector � bt �' /, T`�'/@ Date 7 ,49; Address / 'y t P-_0 AS1 OSTDS# Comments: Signature Miami Shores Village fi 'itil€ bin 10050 N.E.2nd Avenue NE Miami Shores,FL 3313&0000 yv � Phone: (305)795-2204 P Expiration: 11/28/2016 Project Address Parcel Number Applicant 444 NE 102 Street 1132060170580 ROBERT STEPHEN MAHONEY 8 Miami Shores, FL Block: Lot: Owner Information Address Phone Cell ROBERT STEPHEN MAHONEY&W S 444 NE 102 ST -- -- ---- MIAMI SHORE FL 33138-2453 Contractor(s) Phone Cell Phone Valuation: $ 5,000.00 MIAMI DADE ENVIROMENTAL 786-251-4099 ------- _,...� . m___ Total Sq Feet: 300 Type of Work:DRAINFIELD REPAIR Available Inspections: Type of Piping: Inspection Type: Additional Info: HRS Approval Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 Invoice# PL-5-16-59954 CCF $3.00 06/01/2016 Credit Card $621.50 $50.00 DBPR Fee $2.25 DCA Fee $2.25 05/26/2016 Credit Card $50.00 $0.00 Education Surcharge $1.00 Bond*3100 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $4.00 Total: $671.50 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 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. Futhermore,I authorize the above-named ntractor to do the work stated. June 01,2016 Authorized Signature:Owner / Appli Con ctor / Agent Date Building Department opy June 01,2016 1 Miami Shores Village =Qf�� Building Department 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 12-0 —1 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: ��%/�[/� IA V L' 10,-) ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11—?�) 4)(0 — (9 f m Is the Building Historically Designated:Yes NO _ Occupancy Type: Load: ((�� Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Ro use A t ado lloo)e`t Phone#: Address: ����� N E- 10 0. ;T• City: #11 ya "I n rl P C State: F1 Zip: �s Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: M i4 4.(lIU(�lI<d ti�-fc�AI�69� Phone#: 786-25-1-qO'9!7 Address: S 2 90 1 in k P 0 A S/4 33V. City 81 In k i State: Cj14 Zip: 16 Qualifier Name:Ac�" c� IA S Phone#: State Certification or Registration#:C-,k .QC4 r71 2 7G Certificate of Competency#: lT— DESIGNER:Architect/Engineer: N 1n. Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: 3 Type of Work: 1:1 Addition ❑ Alteration ❑ NewRepair/Replace ❑;Demolition Description of Work: R l 11 I r1 t, 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$ TOTAL FEE NOW DUE$v1 (Revised02/24/2014) �� P 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 - whoseproperty-issubject to attachment.Also,-a-certified copy of Me-recarded7ratite of cammerrcemsent-rnust-b-e-pu tewa Th-e—job-rit�---- 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 �57Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged befoa me this The f egoing instru nt was acknowledged before me this _ I[a day of 20 J by ®I day of 20 ( �O by �►_i�19A�!®t.� _,who is personally known to S who is personally known to me or who has produced as me or who has produced U)kj��L4 identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY P IC: II W COAUSSM#FF 150202 EXPIRES:October 8,2018 Sign: BawedTin ik" Sign: Prin , Print: i �AO-C-775 Seal: Seal: ZAvP p Y"Ve4 NotaryPubfin State 0'Fftihda a Sindia Alvarez jog AAY 155 n APPROVED BY 31 � Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AMID DISPOSAL SYSTEM FEE PAID: CONSTRUCTION PERMIT * + RECEIPT #: V° DOCUMENT #:PRI 019412 CONSTRUCTION PERMIT FOR: OSTDS Repair 'y APPLICANT: Robert Mohoneg PROPERTY ADDRESS: 444 NE 102 St Miami,FL-33138 LOT: 7 BLOCK: 91 SUBDIVISION: PROPERTY ID #: 11-3206-117-0580 [SECTION, TOWNSHIP, RANGE, PARCEL NMWERI [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, RSQUntE 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 FRCM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic(Existing) CAPACITY A [ 0 l GALLONS ! GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY DOLNUd4M CAPACITY SINGLE TANK:1250 GALLONS] K [ I GALLONS DOSING TANK CAPACITY [ IGALZAM lI[ IDOSES PER 24 HRS #Pumps [ ] D [ 300 ] SQUARZ FEET Bed Drainfleld SYSTEM R [ 0 I SQUARE FEET SYSTEM A TYPE SYSTEM: Ix] STANDARD t ] FILLED E MDU14D t I I CONFIGURATION: [ ] TRENCH IX) BED [ I N F LOCATION OF BENCHMARK: FFE10.8 I ELEVATION OF PROPOSED SYSTEM SITE [ 8.40 1 tF=_cEm__sj FT I[ABOVE BELOW BENCHM&Px/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 32.401 zriCHES FT I[ABOVE BELS BENCHMMRK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 24.00] INCHES "THIS PERMIT IS NOT FOR ADDITIONS" O *Perimeter of excavation area shall be at least 2 ft ander and longer than the proposed absorption bed. T 'Invert elevation of drainfield to be no less than 8.60'NGVD. *Bottom of drainfield elevation to be no less than 8.19 NGVD. H 'Water line within 10 ft of septic system to be Sch 40 PVC or-sleeved in accordance with FAC Ch 64E-6.005(2)(b). E The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow of 400 gpd. R SPECIFICATIONS BY: pR a TITLE: APPROVED BY: TITLE: Engineering Specialist II Dade CHD 1® - DATE ISSUED OU24r2016 EXPIRATION DATE: 08/22/2016 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 AP1240398 SE996709 . ra a• a - 1 - • 9� _- MEN No No frAtm No MENNEN oMFAM M!!!!RlO !!!EM! !!!!■ E MEN !!!!! !E\.5'FAM1�!!!!!M! !! IMMEMMEM ON ONES im ! MOEN M MEMO �!�!!l!!�!!!��l�!!�!lr�x�l�!!!!■ NN _MR ME mom mrimm"T. ...1frWWWO RUN RIM P17�� T77 mom m mom MEMO No NEON- - --- ME !!EN SEPTIC TANK CONTR REGISTERED ACTOR JOSE BOLANOS 8290 LME DRIVE,SUITE 3— DORAL, s, FL 33166- MjAI DADE ENVIRONMENTAL SERVICE,'NC' Business Authorization. SA�p91617 SR0971276 ' ires on September 30,2016 Registration Exp /e Local Business Tax Receipt Miami.-Dade County,State of Florida THIS Is NOT a eel-no Not PAY LBT-If 4882578' BUSINESS NAM&FLO"TION RECEIPT NO. EXPIRES MIAMI DADE ENVIRONMENTAL RENEWAL SEPTEMBER 30, 2016 SERVICE INC 5096144 Must b 8M LAKE DR 334 edisplayedto at place of business DORAL,FL 331 Pu rptant to County code Chapter 8A—Art 9&TO OWNER SEC.TYPE OF BUSINESS MIAMI DADE ENVIRONMENTAL SVS 196 SPECIALTY PLUMBING er TAAX BYMENT INC CONTRACTOR -- 45.00 09/01/2015 Workers) 1 SEP021077 0222-154004199 Ibis Local Easiness Tax Receipt only cam payateat tithe Local MidnessTax.The Receipt is we Rte. permit era cpm olthe hobbit's�i .m do b .xobler aa�at coalpty with nay regulatory laws anti requfteatmonblab apply to the boabress The 111MOPT NO.above most bedaldeyed man commercials — Corot Sec ea-EL HIAMD m ® yorme visit � A From: 05/26/2016 14:40 4#137 P.001/001 CERTIFICATE OF LIABILITY INSURANCE 15/26/2016DATE(MWDD1YYYY) 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 poilcy(Ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the cerUftcate holder in Ileo of such endorsement(s), PRODUCER CONTACT ADVANTAGE INSURANCE OF AMERICA PHONE WC.No Ext: (305) 649-5566 1 FAX I Svc Nor(305) 649-5559 4520 NW 7th StE-MAIL ( Miami:, FL 33126 !4DR£Ss. �acklebatista 749@hotmai�l.com INSURER(S) AFFORDING COVERAGE NMc# I INSURER A GRANADA INSURANCE INSURED MIAMI DARE ENVIRONMENTAL SERVICES,INC INSURER 8:PROGRESSIVE AMERICAN INS CO INSURER C: 8290 LAKE DRIVE STE 334 INSURER D. MIAMI, FL 33166 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. �LrR TYPE OF INSURANCE , VNa POLICY NUMBER MMlOp/YYYY MMlDD/YYYY LIMITS �GENERAL LIABILITY EACH OCCURRENCE !$ 1'.000,000 COMMERCIAL GENERAL LIABILITY I I , PREMISES £a occurrence $ 100,000 j 1 I CLAIMS-MADE F i OCCUR r —' -- I MED EXP(Any one Person) s 5_11 00 0_ PERSONAL&ADV INJURY $ 1,000,000 i I !j 0185FL00037668 .08/03/15108/03/16 GENERAL AGGREGATE g 2,000,000 GEN'L AGGREGATE LIMrr APPLIES PRODUCTS-COMP/OP AGG $ i POLICY PRO — LOC ! AUTOMOBILE LIABILITY COMBINED SIM LIMIT is $ 500 .000 ANY AUTO I I Ea accident �I ALL OWNED SCHEDULED 80DILY INJURY(Per person) $ AUTOS 1- I ( 108/26/14 :08/26/15 . ., $ B INJURY �� e`")NOT 1022J7915-7 O HIRED AUTOS i Prdat $ 1I$ F— UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ �_ EXCESS LIAR - CLAIMS-MADE i AGGREGATE $ OED RETENTION$ WORKERS COMPENSATION $ 'AND EMPLOYERS'LIABILITY YIN ! I ' T RY GAITS R ANY PROF"ETOfWARTNEMEXECUTIVE ( $ --- --- OFFICERIMEMSER EXCLUDE09 �I INIA I E.L.EACH ACCIDENT (Mandatory In e u 'E.L.DISEASE-EA EMPLOYE $ 1/ s,describe under € € DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule.it more space is required) Septic Tank Systems Cleaning/Installation/ Servicing or Repair 2000 FORD RANGER 1FTYR14C9YTA89368 1996 FREIGHTLINER TANK TRUCK 1FUPDSEB8TH623682 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores, FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE 1.4I 01988-201 RD CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD -(A AGENTMAR A AWS STATE OF FLORIDA --------�`-------- DEPARTMENT OF FINANCIAL SERVICES I IMPORTANT' Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation DIVISION OF WORKERS'COMPENSATION who s exon from this chapter by a ate of CONSTRUCTION INDUSTRY I election under this section may rrecover �EMPTION � °� I F compensation under this chapter.. benefits or CERTaICATE of MECTronr To BE WMWrr O wowcE)M COMN u►ar MOM R°�°^ f L Pursuant to Chapter 440.05(12),F.S..Certificates of election toEFFECTrvE DATE: 10425a014 E7(PIRATr01y PATE: M2412016 D exempt..apply only within the scope of the business or trade �oN.- eouwos JOSE I listed on the notice of election to he exempt. FEIN: eanss-Wl BUSINESS NAME AND ADDRESS: H Pursuant to Chapter 440.05{13),F.S.,Notices of election to be MIAMI DADE ENVIRONMENTAL SERVICE INC IR subject;E exempt and certificates election S be exempt shalt be to revocation if,at any thne after the flung of the notice E or the issuance of the certificate.,the person named on the 8290 LAKE DR 334 I notice or certificate no longer meets the requirements of this DORAL section for issuance of a certificate.The department shag revoke f FL 33166 I a certificafe at any time for failure of the person named on the SCOPES OF BUSINESS OR TRA I ©amficate to meet the requirements of this section. f � PLUMBING NOC qNp l DRIVERS J Miami-Dade Environmental Services, INC. 8290 Lake Drive Suite 334 Miami, Florida 33166 Phone: (786) 251-4099 / Fax: (305) 513-9200 Miami DadeEnvi ronmental @ msn.com May 31, 2016 State of f10 fu Q r%_ County of 0 #Q(by- Before me this day personally appearedAOS Q_�o�Wk2PJ who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: Llu % t*-JF-, IOct S( A(%4m(S 06ftes F/16 Sworn to (or affirmed) and subscribed before me this day of 20 by SCZ aS Personally know OR Produced Identification Type of Identification Pro ced �N1e m�1UN��i �� G N,N11SS%p'••;c'Qy°°i hatch 6.p Print, Type or Stamp Name9AbtaVYZ47W .... ..�.. Miami shores Village Building Department 'p Rte' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to Owner — Workers' Compensation Insurance Exemption 1 z; 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. r Signature: �9 _4 J wne - % State of Florida County of Miami-Dade The foregoing was acknowledge before me this ��1---day of ,204- 9�0 . By �obey i( 14 610A znJ� who is rsonatly me or has produced as identification. Notary: SE '`Fka .,; - ,,