PL-16-1570 Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-260412 Permit Number: PL4-16-1570
Inspection Date: July 06,2016 Permit Type: Plumbing- Residential
Inspector: Hernandez,Rafael
Inspection Type: Final
Owner: SANCHEZ,VIVIANE Work Classification: Septic
Job Address:41 NW 109 Street
Miami Shores,FL 33168-4314 Phone Number
Parcel Number 1121360030290
Project: <NONE>
Contractor: PULLES PLUMBING COMPANY Phone: (786)251-1234
Building Department Comments
INSTALL ASEPTIC TANK AND DRAINFIELD SYSTEM " o Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed ® HRS APPROVAL IN FILE
Failed
Correction
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
e-_...e�.___ae_�_ �e____ __u_ .wwwe�ww •w•w
DIVISION OF
Environmental Health
Florida Health A
Miami-Dade County 44
QSTDS/Well Division
11803 SW 26th Street•MIsmI,FL33173 O
Inspector Date
Address �� 4,f"7� OSTDS#
Comments:
Signature
Plerryvtwo. PL-6-16-16,7
RE
Miami Shores vmItsa� ti
'Permit Type:Plumbin Resilential
/ouoow�s�zn��venuowvv
�iamia�ues. ��aa1no*000
tatu
it's s:APPROVED
Phone: (305)785-2204
ORWDato:'6/14/2016 x�iration: 1211112J61
Project
41 NW 109 Street
1121360030290
Miami Shores, FL 33168-4314 Block: Lot:
Phone Cell
VIVIANE SANCHEZ 41 NW 109 Street
MIAMI SHORES FL 33168-
Contractor(s) Phone Cell Phone
PULLES PLUMBING COMPANY (786)251-1234
Total Sq Feet: 0
Type of Work: INSTALL ASEPTIC TANK AND DRAINFIELD Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
Bond Return HRS Approval
Final
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Annt Due
Bond Type-Owners Bond $500M Invoice# PL-6-16-60084
CCF $4.80
DBPR Fee $4.50 06/14/2016 Check#:8075 $285.80 $ 550.00
DCA Fee $4.50 06/06/2016 Check#:8039 $ 50.00 $500.00
Education Surcharge $1.60 06/10/2016 Check#: 171 $500.00 $0.00
Notary Fee $5.00 Bond#:3106
Permit Fee $300.00
Scanning Fee $9.00
Technology Fee $6.40
Total: $835.80
In consideration of the issuance to mo of this pennn. | agree to perform the work covered hereunder in compliance with on ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit | assume responsibility for all work done uyeither myself, my aoent, servants, or employes. | understand that separate permits are
required for ELECTRICAL,PLUMBING, MECHANICAL,WINDOWS, DOORS,ROOFING and SWIMMING POOL work.
°....=Ra°,,.unv// / certify regulating
construction and zoning. author e the above-named contractor to do the work stated.
June 14, 2016
Auth,drized sibnatL66—Owner / Applicant / Contractor / Agent Date
Building Department Copy
Miami Shores Village JUN 06 2016
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201y
BUILDING Master Permit No.P L-,l (0
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: "O -eJ /'z S/ ;,—
City: Miami Shores County: Miami Dade zip:,--T
Folio/Parcel#: /� r-� ��" y y Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
C" OWNER:Name(Fee Simple Titleholder): 01 C11�i�C G � �nlU« "Phone#: ,S
Address: `7 / / y c�
City: fvLI nyy- " State: Zip: 3'3
Tenant/Lessee Name: Phone#:
Email: ,
CONTRACTOR:Company Name: / �C�PS /`"�� � �'� `y �� Phone#:
Address: J ��� �G� r✓�� �
City: State: Zip. -3-�
Qualifier Name: Phone#: 7y�
State Certification or Registration#: C 46 F-3Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
c
Value of Work for this Permit:$ 7 7 O U• Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile: n
Submittal Fee$ SO •OiI3 Permit Fee$ ��rr--G--�/ ✓ CCF$_ f
- CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$157• ('1:)
Technology Fee$ 44 Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ S OO - OG
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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 issu nce of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the no c of commencement and construction lien law brochure will be delivered to the person
whose property-is subject to attachment. A o a certified copy of the recorded notice of commencemerttmust be posted at the job site
for the first inspection w . occ s ( ) days after the building permit is issued. In the absence of such posted notice, the
inspection will not p ov da d ei s e tion fee will be charged.
Signature Signature l
OWN R or AG_. � CONTRACTOR
The foregoing instrum nt w acknowledged before(me this The foregoing instrument was acknowledged before me this
1 day of f 20 by /_���y�,. day of 20 �� , by
t o is pers nally known to C � 5 L O-3Qv6o is personally known to
aVf ��1v�. > 11'cEq
me or who has produced >Sda �h }I c(jt/ y as me or who has produced I�c, IvF - as
identification and who did take an oath. identification and who did take an oath.
�eeee►tullr�yhe
NOTARY PUBLIC,'+ ,,! NOTARY PUBLIC:
`tee �.•�v.•Outi1/ 'ss/`i
O=,�• arch `Si'lG
Sign: — �; �1.� e_Y��--Z� Sign: - <• - k:n=
Print: )'Z,��1 1 C�C,3 � � 19
Print:
,,, '
nt: S S a
Seal: �= Seal: `y�,dj• ers .:K\\\Sz�
1L0 Peon\\\`
APPROVED BY 4 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
PULLES PLUMBING CO.
8541 S.W. 133 PL.
MIAMI, FLORIDA 33183
305-558-0410 305-382-8914 FAX
LISCENCE CFC056693
June 2, 2016
STATE OF FLORIDA
COUNTY OF DADE
BEFORE ME THIS DAY PERSONALLY APPEARED CARLOS PULLES WHO, BEING DULY SWORN, DESPOSE AND
SAYS:THAT HE OR SHE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED AT: 41 N.W. 109
STMIAMI SHORES, FLORIDA 33168
SWORN TO (AFFIRMED) AND SUSCRIBED BEFORE MEQ_ DAY OF� .20ABY
PERSONALLY KNOWPRODUCE IDENTIFICATIONTW � � "1b5lTYPE OF
IDENTIFICATION_ ('" l��—
PRINT, TYP OR STAMP NAME OF NOTARY.
YR18V8 Iem"tn
F
almy Public-SM of Florida
Cowailselos 0 FF904426
Comm.Etpim:Jul 29.2019
0—&
RES
♦ ANCO.19 Miami shores Village
logo Of 1111orm
Building Department
ES 10050 N.E.2nd Avenue
0 Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
?W
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 subcor,,actors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on y project. In these circumstances,Miami Shores Village does not require verification of
workers' compensation insur ce cover e from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELO Y A WLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature*,
wVer J
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of 20
\J
By who is personally known to me or has produced
5k 5
as identification.
Notary:
SEAL: zf?
PERMIT #: 13-SC-1 684638
APPLICATION #:AP 1241242
STATE OF FLORIDA
1- DATE PAID:
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
W L, DOCUMENT #: PRI 019976
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Viyiane Sanchez
PROPERTY ADDRESS: 41 NW 109 St Miami, FL 33168
LOT: 29 BLOCK: 219 SUBDIVISION:
PROPERTY ID #: 11-2136-003-0290 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[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, 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 [ 1,050 l GALLONS / GPD Septic CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 I GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 400 ] SQUARE FEET SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ 1.56 ] [ INCHES FT I ABOVE BELOW]BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 46.44 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00 ] INCHES EXCAVATION REQUIRED: [ 60.003 INCHES
1.- Install a 1050 gal. septic tank with and approved filter
O 2.-The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
T with s.64E-6.013(3)(f) FAC.
H 3.-Install 400 sf. of drainfield in bed configuration.
4.-Install 12"of slightly limited soil at the bottom of the drainfield.
E 5.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or trench.
(Comments continued on Page 2
R
SPECIFICATIONS yar�L �za3�.re .., TITLE: Engineering Specialist II
APPROVED BY: ional Engineer I Dade CHD
Richard M Roja
DATE ISSUED: 05/27/2016 EXPIRATION DATE: 08/25/2016
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.A AP1241242 SE997160
f
APPLICATION # AP1241242 00
STATE OF FLORIDA t+>PERMIT # 13-SC-1684638 C.0
DEPARTMENT OF HEALTH00
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOC # RE374491
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION (j
Oi co
l
APPLICANT: Viviane Sanchez
CONTRACTOR / AGENT: Pulles Plumbing
LOT: 29 BLOCK: 219 SUBDIVISION: ID#: 11-2136-003-0290
TO BE COMPLETED BY A FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR OTHEF
CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS. COMPLETE TANF
CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
EXISTING TANK INFORMATION
[ 1060 ] GALLONS Septic Tank LEGEND: MATERIAL:Concrete BAFFLED: ( Y
[ ] GALLONS LEGEND: MATERIAL: BAFFLED: [ Y / N ]
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL:
[ ] GALLONS DOSING TANK LEGEND: MATERIAL: # PUMPS: [ ]
I CERTIFY THAT THE ABOVE NOTED TANKS WERE PUMPED ON 05/17/2016 BY Pulles Plumbing Company HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY DIMENSIONS FILLING / LEGEND ], ARE FREE OF OBSERVABLE
DEFECTS OR LEAKS AND HAVE A [ gOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ] INSTALLED.
Carlos H Pulles(Pulles Plumbing Company) 05/23/2016
SIGNATURE OF LICENSED CONTRACTOR BUSINESS NAME DATE
EXISTING DRAINFIELD INFORMATION
[ 300 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: 15.00 Y 20.00
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [X] BED ( ]
DESIGN: [X] HEADER [ ] D-BOX [X] GRAVITY SYSTEM [ ] DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE 45,00 INCHES [ ABOVE
SYSTEM FAILURE AND REPAIR INFORMATION
[ 01/01/1946 ] SYSTEM INSTALLATION DATE TYPE OF WASTE [X] DOMESTIC [ ] COMMERCIAL
[ 140 7 GPD ESTIMATED SEWAGE FLOW BASED ON [ X] METERED WATER [ ] TABLE 1, 64E-6, FAC
SITE [X] DRAINAGE STRUCTURES (X j POOL [ ] PATIO / DECK [ ] PARKING
CONDITIONS: [ ] SLOPING PROPERTY [ ]
NATURE OF [ ] HYDRAULIC OVERLOAD [ ] SOILS [ ] MAINTENANCE [X] SYSTEM DAMAGE
FAILURE: [ ] DRAINAGE / RUN OFF [ ] ROOTS [ ] WATER TABLE [ ]
FAILURE [ ] SEWAGE ON GROUND [X ] TANK [ ] D-BOX / HEADER [X] DRAINFIELD
SYMPTOM: [X ] PLUMBING BACKUP [ ]
SUBMITTED BY: TITLE/LICENSE DATE:05/25/2016
Carlos H Pulles(Pulles Plumbing Com
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 4 of 4
V 1.0.0 AP1241242 EID1684638
V
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR CONSTRUCTION PERMIT
Permit Application Number
--------------------------- PART II-SITEPLAN ---------------------------
Scale: Each block re resents 10 feet and 1 inch =40 feet.
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Notes: J I v,-I 4,t'4. �� �,r`C f /e !moi
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��C st-�l .�.F�f/�t'T7N-�fJ i�1L�^P4�jj/�'�'S o v r�ei�,�9GPt� � /'T�t�•'i<Tif'G �Q+y4,C�0%2 ��c-l"oss sL
Site Plan submitted by:
Plan Approved Not Approved Date
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015,06109(Obsotetes previous editions which may not be used) incorporated: 64E-6.001,FAC Page 2 of 4
(Stock Number. 5744-002-4015-6)