PL-16-1895 (2) Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-262729 PermitNumber: PL-7-16-1895
Scheduled Inspection Date:August 01,2016 Permit Type: Plumbing - Residential
Inspector: Hernandez, Rafael Inspection Type: Final
Owner: CAJIAS, ERNESTO J Work Classification: Drainfield
Job Address:78 NW 99 Street
Miami Shores,FL 33150- Phone Number
Parcel Number 1131010330070
Project: <NONE>
Contractor: A SUPER SEPTIC&DRAIN FIELD INC
Building Department Comments
150 SQUARE FEET 2 F TRENCH DRAIN FIELD. Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed HRS APPROVAL IN FILE
Failed
Correction a
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
For Insnections nleeass calf 13(151762&qAq
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s �y Miami Shores Village i �� F'a= NC TYi Iulblgq-Rosi[ ntlat ,
10050 N.E.2nd Avenue NW
n r� r rains ld,,.
Miami Shores,FL 33138-0000
Phone: (305)795-2204 PtrttttS: �/
7x12fl1 ,;. Expiration: 01/09/2017
Project Address Parcel Number Applicant
78 NW 99 Street 1131010330070
Miami Shores, FL 33150- Block: Lot: ERNESTO J CAJIAS
Owner Information Address Phone Cell
ERNESTO J CAJIAS 78 NW 99 Street (954)305-6685
MIAMI SHORES FL 33150-1741
78 NW 99 Street
MIAMI SHORES FL 33150-1741
Contractor(s) Phone Cell Phone Valuation: $ 4,000.00
A SUPER SEPTIC&DRAIN FIELD INC
._..,.... __ .,._... .... 1 ......... ...._,., _,..,_......, Total Sq Feet: 300
Type of Work:150 SQUARE FEET 2 F TRENCH DRAIN FI 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
CCF $2.40
Invoice# PL-7-16-60482
DBPR Fee $2.25 07/07/2016 Credit Card $50.00 $124.90
DCA Fee $2.25
Education Surcharge $0.80 07/13/2016 Credit Card $ 124.90 $0.00
Notary Fee $5.00
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $3.20
Total: $174.90
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 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 zoAing. FutherTof I authorize the above-named contractor to do the work stated.
July 13, 2016
Authorized Signature:Ow .n` / (Applicant / Contractor / Agent pate
BuildingDepartment Copy
P
July 13,2016 G` 1
(D Miami Shores Village pmcm
Building Department ju 07 2116
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 201 �
BUILDING Master Permit Nom
PERMIT APPLICATION Sub Permit No.
BUILDING F] ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION RENEWAL
(PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
M n q CONTRACTOR DRAWINGS
JOB ADDRESS: / �(� 1y_Fk.�T(
City: Miami Shores County: /J rte, Miami Dade Zia:
Folio/Parcel#: I I —J 1, 03 3 -00 VD Is the Building Historically Designated:Yes Q::N:O�L:�
Occupancy Type: Load:��Construction Type: Flood Zone:BFE:,— FFE: /
OWNER:Name(Fee Simple Titleholder): -7-r) ci /,4 /'S Phone
Address:
City: ffii'ra m �on�� State: T r ' Zip: /vim 0
Tenant/Lessee Name: Phone#:
Email:
Ike.
CONTRACTOR:Company Name: ti 12e r, S, P—c-e �, r,n red T-i e d Phone#:
Address: 1Z,41 16" kn h e�,
City: 14 r,4-1•e a-l, State: r-1 Zip:
Qualifier Name: Phon _90S-3b y- 0//_3
sA o � as 1 3G,s-
State Certification or Regi ration#: S Certificate�f Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address
City: � State: Zip:
Value of Work for this Permit:$ Square/LinearFootag Work: __-5z) U
Type of Work: EJ Addition ❑ Alteration w Repair/Repla ❑ Demolition
Description of Work:
Specify color of color thru tile: g
Submittal Fee$ J Cjiz�' Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPPjR$ Notary$
aoTechnology Fee$ Training/Education Fee$ ` ('_i Double Fee$
Structural Reviews$ Bond$ I 1 6 W CQ
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 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 ccurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved nd a reinspection fee will be charged.
Signature Signature
OWNI R or AGENT GaTRACTOR
The foregoing instrument wi s acknowledged before me this The foregoing instrument was acknowledged before me this
day of V 20 (fo by ®� day of 20�C, .by
ag-CL ,who is personally known to �{Z�Art1 i:::JPrJIVT1 6o is personally known to
me or who has produced JM\RP- wa-mg� as me or who has prod ucedT AWC� L1 0,�-NOV-as
identification and who did take an oath. identification apq who did take an oath.
NOTARY PUB NOTARY PUBLI
Sign Sign:
Print: �� Print: t\\Jj ona
Seal: Seal:
s.Y'a.-t'may,d.+�r"''u�':1n•.^�e"q,'°_ ��'a�°�e+�i°rl`°•�°'-�°�b
a onpg"op® Notary Public State of Florida s oslg vP& Notary Public state of Florida
i Sindia Alvarez y Sindia A.Ivarez
g: r oa My commission FF 156750 �+ Qc PIyCommissionFF 156750
�*****>k**sax*r�►>k�*xar*���Cw,�"�,s�*>�exe�E(D�3e>2�1�#*s�r*a�x �sx� a��R *x�> �stQ�46b' il��*s*��*� >Ks*�ax*+r�ssxx�*x�
;a�/��tL°'��+°°a`°`,orb4t. � ;saw.;Pta'�'v'ems'°•w"'e���',b9�sc,'�.,��'"t'•
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(RevisedO2/24/2014)
REGISTERED SEPTIC TANK CONTRACTOR
x.V
BRYAN K. ZERO
7701 WEST 18TH LANE
HIALEAH, FL 33014-
A SUPER SEPTIC&DRAIN FIELD
INC
Business Authorization: SA0161922
SR0161772
Registration Expires on September 30, 2016
Local Business Tax Receipt
Miami—Dade County, State of Florida
—THIS IS NOT ABILL—DO NOT PAY � LBTJ
3820314
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
A SUPER SEPTIC&DRAIN RENEWAL SEPTEMBER 30, 2016
FIELD INC 3988772
7701 W 18 LA Must be displayed at place of business
HIALEAH, FL 33014 Pursuant to County Code
Chapter 8A—Art.9&10
OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED
A SUPER SEPTIC&DRAIN FIELD INC 196 SPECIALTY PLUMBING BY TAX COLLECTOR
C/O BRYAN ZERO PRES CONTRACTOR 49.50 06/27/2016
Worker(s) 1 SEP0161772 CREDITCARD-16-036273
This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license,
permit,or a certification of the holders qualifications,to do business.Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276.
Mi"ItI DE, For more information,visit www.miamidede.gov/toxcollecter
ACID E! DATE(MMMDNYYY)
� CERTIFICATE OF LIABILITY INSURANCE 071006
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(les)must be endorsed. if SUBROGATION IS WANED,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:
Blaiae&Tyson Insurances PHCN-IAIN , (954)980,9324 No. (954)989-5998
5955 SW 21 st Street E-MAIL anny@blaizeandtyson.COm
Hollywood,FL 33023 INSU 3 AFFORDING VERAGE NAIC It
Phone (954)989-9324 Fax (954)989-5998 INSURER A: ENDURANCE AMERICAN SPECIALTY INS CO
INSURED INSURER 8:
A SUPER SEPTIC&DRAIN FIELD,INC INSURER C:
7701 W 18 LANE INSURER D:
HIALEAH,FL 33014 954 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.
ILTRR TYPE OF INSURANCE INSRADDI vivo UBR POLICY NUMBER MMMIDDY EFF POLIMMIDDD EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
Q COMMERCIAL GENERAL LIABILITY PRE SES(EAMAGE TO a Dan,) $ 100,000.00
❑ ❑ CLAIMS-MADE RI OCCUR CBC20000169601 1124/2015 11/24/2016 MED EXP(Any one person) $ 5,000.00
A F] PERSONAL&ADV INJURY $ 1,000,000.00
❑ GENERAL AGGREGATE $ 2,000,000.00
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00
R1 POLICY ❑ SPENT ❑ LOC $
AUTOMOBILE LIABILITYOM$INED SINGLE LIMIT
a a cident
❑ ANY AUTO BODILY INJURY(Per person) $
ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $
❑ AUTOS AUTOS
F-1 HIRED AUTOS ❑ ANON-OWNED PROPERTY
ociderdDAMAGE $
❑ ❑ $
❑ UMBREL.LA LIAR OCCUR EACH OCCURRENCE $
❑ EXCESS UAB ❑CLAIMS-MADE AGGREGATE $
❑ DED ❑ RETENTION s $
WORKERS COMPENSATION WC STATU ElOTH-
AND EMPLOYERS LIABILITY Y I N TORY
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? E-1N I A
(Mandatory In NH) E.L DISEASE-EA EMPLOYE $
If yyes describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarim Schedule,If more space is required)
SEPTIC AND DRAINFIELD INSTALLATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF MIAMI SHORE VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI SHORE VILLAGE,FL 33138 AUTHORIZED REPRESENTATIVE
FAX 305-756-8972
CORD 25(2010105)QF The ACORD name CORPORATION. All rights reserved.
A
logo registered marks of ACORD
Image
JEFF ATWATER
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: 5/9/2016 EXPIRATION DATE: 5/9/2018
PERSON: ZERO BRYAN K
FEIN: 811781785
BUSINESS NAME AND ADDRESS:
A SUPER SEPTIC&DRAIN FIELD INC.
7701 WEST 18 LANE
HIALEAH FL 33014
SCOPES OF BUSINESS OR TRADE:
IRRIGATION OR
DRAINAGE SYSTEM
i&MME-2,
440.0504).dsmrrrof on the notxe a oeNhcale rro brl9er meets the requlromerrB of this secllon for tssuarx;e of a a The depmhrrerd shall revoke a
DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1809
A SUPER SEPTIC TANK INC.
CC: SEP890722 7701 WEST 18 LANE
HIALEAH, FLORIDA 33014
Licensed and Insured
PHONE: 305-364-0113 E-MAIL: ASUPERSEPTIC@GMAIL.COM FAX: 305-364-0349
WWW.ASUPERSEPTICTANK.COM
DATE: 7-7-16
State of Florida
County of Miami Dade
Before me this day personally appeared,4 �,FAQ/C. who,being duly sworn,
deposes and says:
That he or she will be the on y person working on the project located
at 7:0 A,Al 7 f 5 6D
Sworn to(or affirmed)and subscribed before me this day of1/1v .2016,by
Personally know
Or Produced Identification
Type of Identification ProducedF� 1�Mgt
I
Print,Type or Stamp Name of Notarty
m10"7 Pt"e� Nlotary' olic State of Florida
Sindia A,Ivarez
` R¢ AAY Com!riss;n_n FF 156750
h OF PLO Expires 09/03;2018
,SNORES
s�
Miami shores Village
NINE p ""'1" Building Department
10050 N.E.2nd Avenue
�LORIUp' 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 fpr 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,for 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 Y ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Ovi)ner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me thisy---A day of U ,20 60 .
Byj N,LL Tl N AS who is personally known to me or has produced
l I� X as identification.
Notary:
SEAL: ot�Y pLB R O;apy Public 3t8tr>if Flnrf is
5in6ia AIVF rr z
as My 'or FF 56750
Ex Irsstl9t73(_u18
STATS OF FLORIDA PST ti: 13-SC-1692435
DEPARTM811T OF HFALTH APPLICATION #:API 246387
ONSITE SEIM= TREATMENT AND DISPOSAL
! SYSTEM DATE PAID:
�r 7 CONSTRUCTION PERMIT FEE PAM:
`�}r,�qt S�►"�i• RECEIPT #:
Docum=T f#: PR1024484
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Ernesto ( 4ias
PROPERTY ADDREss: 78 NW 99 St Miami,FL 33150
LOT: 10,11 BLOCK: 128 SUBDIVISION: Miami Shores Sec 6
PROPERTY M #: 11-31014033-0070 [SECTION, TOWNSHIP, RANGE, PARCEL NUMHRRj
[OR TAX ID NQMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH AND CffisPECIFICATION3 AND STANDARDS OF SECTION
381.0065, F.S., �TER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARRITTRE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANCE 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 NOLL AND VOM.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM CONWLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTn;G REgun= FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T I 900 I GALLONS / GPD wasting septic tank CAPACITY
A I l GALLONS / GPD CAPACITY
N [ I GALLONS GREASE INTERCEPTOR CAPACITY DgLMMUCAPACITY SINGLE TANK:1250 GALLONS]
R [ ] GALLONS DOSING TANS CAPACITY I IGALLONS @[ ]DOSES PER 24 HRS t#Pumps [ ]
D I 150 I SQUARE FEET trench confi-quretion drainf SYSTEM
R I I SQUARE FEET SYSTEM
A TYPE SYSTEM: [$I STANDARD [ ] FILLED [ ] HOUND I ]
I CONFIGURATION: [XI TRENCH I I BED [ ]
N
F LOCATION of BENCHMARK: FFE 13.3'NGVD
I ELEVATION OF PROPOSED SYSTEM SITS 1 27.60 1 INCHES FT ] [ABOVE A Pmowji BxxcsMxw=FzR=cE POINT
E BOTTOM OF DRAINFIBLD TO BE [ 67.60]IfiNCHEST FT I [ABOVE) MWcHMARR/g MMMgCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 40.001 INCHES'.
0 1-'E)dsting 900 gal-septic tank,certified by A Super Septic Tank Inc on 06/29/2016,to remain.
2Anstall 150 sf of drainfield in trend configuration.
T 3.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption ted or drain trend.
H 4:Invert elevation of drainfield no less than 8.1 T NGVD. 5:Bottom of drainfiekl elevation no less than 7.6T NGVD.
E The system is sized for 2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimated flow
Of 200 gpd. "THIS REPAIR PERMIT IS NOT FOR ANY ADDITIONS"
R
SPECIFICATIONS BY: Andrew M Zero TITLE: Registered Sep 'c Tank Contractor
APPROVED BY: eea TIS; Engineering Specialist II Dade COD
DATE ISSUED: 07101/2016 EXPIRATION DATE: 09/29/2016
DH 40161 08/09 (Obsoletes all Previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
__- ---ue0-