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PL-16-1409 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-259468 Permit Number: PL-5-16-1409 Scheduled Inspection Date: November 14,2016 . Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type• Final Owner: DAVIS III,GEORGE Work Classification: Drainfeld Job Address:250 NW 111 Terrace Miami Shores, FL 33168- Phone Number Parcel Number 1121360010620 Project: <NONE> Contractor: MR C'S PLUMBING&SEPTIC INC Phone: (305)651-7859 Building Department Comments DRAINFIELD INSTALLATION Infractlo Passed Comments INSPECTOR COMMENTS False TO REPLACE PERM IT#PL1 5-1583 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. L �..� DIVISION OF Environmental Health Q Florida Health ql p Miami-Da a County Q OSTDSlW Division �►. 11$05 SW 26th Strec, Miami,FL 33175 IAector G aJL"r' �"P Date j `Address OSTDS#� Comments; Signotu're r Permit o. PL-5464409 �s►�ORns i,� Miami Shores Village Perm#Type:Plumbing»=Residential 10050 N.E.2nd Avenue NW Work Classsifrcatib .Grainfield Miami Shores,FL 33138-0000 Peanut Status. P 'f } ECS Phone: (305)795-2204 f ioA Expiration: 05/06/2017 issue Date.��t712t11E� Project Address Parcel Number Applicant 250 NW 111 Terrace 1121360010620 Miami Shores, FL 33168- Block: Lot: GEORGE DAVIS III Owner Information Address Phone Cell GEORGE DAVIS III 250 NW 111 Terrace MIAMI SHORES FL 33168-3325 Contractor(s) Phone Cell Phone Valuation: $ 1,800.00 MR C'S PLUMBING S SEPTIC INC (305)651-7859 Total Sq Feet: 200 Type of Work:REPLACE 14 WINDOWS AND 3 DOORS WITH 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 $1.20 Invoice# PL-5-16-59886 DBPR Fee $2.25 11/07/2016 Credit Card $ 116.70 $50.00 DCA Fee $2.25 Education Surcharge $0.40 05/23/2016 Credit Card $50.00 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $166.70 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 contractor to do the work stated. November 07,2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy November 07,2016 1 Miami Shores Village Building Department artment 23 ZN% 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 B INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201 L4 BUILDING Master Permit N.-p kC5 ( 09 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP II�� cc CONTRACTOR DRAWINGS JOB ADDRESS: 950 MW III U_� City: Miami Shores County: Miami Dade Zip: 33 1 d r Folio/Parcel#: 1119134 061 0 601 o Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: P Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): (�20�'r?C- OLr Phone#: -165 7sS' '161, Address: TA-+y' City: l c4: State: zip: 33 16 j Tenant/Lessee Name: Phone#: Email: / fy►I., `- L C CONTRACTOR: °Company Name: 1,t5 1 W"l to Phone#: 365-6SI 1Ca Address: 0L m W a &3f- City: t _� ^ I State: E'L— Zip: 3 41 Qualifier Name: ke w.�,Le. E*1 mak.. Phone#: State Certification or Registration M L rJ-36 Certificate of Competency M DESIGNER:Architect/Engineer: Phone#: Address: 11[�_` City: State: Zip: Value of Work for this Permit:$ L j W• Square/Linear Footage of Work: Ga"4 Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition n Description of Work: x "T1 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 FFeee/$ Structural Reviews$ Bond$ f L /�' Su3 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 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 Eo Signature WNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this a�7 day of tkam 020 J by OR I day of 20 b by 66601-1—GE C DA.LfS�,who is personally known to Kyo who is personally known to me or who has produced /U yeFtd [aC.ISfilSei as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: k—� Sign: i Print: �'�£77�:+ �rGC..�PPrint: WL j65' 211%1 J-61 ���' Claudette Phillips .`4. °�' SHERYL A MENDES Seal: �{�' �j Seal: �= COMMISSION#FF222451 , �;° Notary Public-State of Florida ='' ••;My Comm.Expires Oct 23,2018 o, EXPIRES: April 20, 2019 C, opa, Commtssio �, 1114AbMMt�11Ft ®iQ111 *�xa *** ******�x**�x*** ** ew $c`��k** ** �+ `8+�* It IM " `e'�' }`rough National Notary Assn. APPROVED BY �' � Plans Examiner Zoning Structural Review Clerk (RevisedO2/24/2014) v APPLICATION #:AP1193633 STATE OF FLORIDA PERMIT #:13-SC-1613804 DEPARTMENT OF HEALTH DOCUMENT #:F11009565 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DATE PAID:06/22/2015 y CONSTRUCTION INSPECTION AND FINAL APPROVAL FEE PAID:200.00 RECEIPT #:13-PID-2698844 APPLICANT: Geo Davis AGENT: Mr C"s PROPERTY ADDRESS: 250 NW 111 Ter Miami, FL 33168 LOT: 14 BLOCK: 3 SUBDIVISION: ID#: 11-2136-001-0620 CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS I l [01] TANK SIZE [ll [21 I l [271 SURFACE WATER FT I l [021 TANK MATERIAL I 1 [281 DITCHES FT [ ] [031 OUTLET DEVICE [ ] [291 PRIVATE WELLS FT [ ] [041 MULTI-CHAMBERED [ Y / N ] [ ] [301 PUBLIC WELLS FT [ ] [051 OUTLET FILTER [ l [31] IRRIGATION WELLS FT [ l [061 LEGEND 1. 2. [ ] [32] POTABLE WATER 50 FT [ l [07] WATERTIGHT [ ] [33] BUILDING FOUNDATIONS 10.1 FT [ ] [08] LEVEL [ ] [34] PROPERTY LINES 7.9 FT [ l [09] DEPTH TO LID [ l [351 OTHER FT DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM I ] [10] AREA [ll 210 [21 SQFT [ l [36] DRAINFIELD COVER [ ] [111 DISTRIBUTION BOX HEADER X [ ] [371 SHOULDERS [ l [12] NUMBER OF DRAINLINES 1. 4.00 2. [ ] [38] SLOPES [ ] [13] DRAINLINE SEPARATION [ ] [391 STABILIZATION [ ] [14] DRAINLINE SLOPE [ l [15] DEPTH OF COVER ADDITIONAL INFORMATION [ l [16] ELEVATION [ ABOVE / BELOW ]BM 63.84 [ ] [401 UNOBSTRUCTED AREA [ ] [17] SYSTEM LOCATION [ l [411 STORMWATER RUNOFF [ 1 [18] DOSING PUMPS I l [421 ALARMS [ ] [19] AGGREGATE SIZE [ l [431 MAINTENANCE AGREEMENT I l [20] AGGREGATE EXCESSIVE FINES [ ] [441 BUILDING AREA [ ] [211 AGGREGATE DEPTH [ l [45] LOCATION CONFORMS WITH SITE PLAN FILL / EXCAVATION MATERIAL [ l [461 FINAL SITE GRADING [ l [22] FILL AMOUNT [ ] [47] CONTRACTOR (MrC"s) [ ] [23] FILL TEXTURE [ l [48] OTHER PTI MPRDS(9 pipes-2 tier) [ l [24] EXCAVATION DEPTH ABANDONMENT [ ] [251 AREA REPLACED [ 1 [491 TANK PUMPED [ ] [26] REPLACEMENT MATERIAL [ l [503 TANK CRUSHED 6 FILLED Comments: Comments are on page 2. 0 CONSTRUCTION [ APPROV&D / Dade �a OAT 7/16/2015 DISAPPROVED )' Environmental Specialist II Heber Montero(Depa ant o in •a FINAL SYSTEM I APPROVED / DISAPPROVED ): TE: 07/16/2015 Environmental pec a st 11 Heber Montero e5artment of a (Explanation of Violations on following page) DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0.1 AP1193633 EID16 804 a • APPLICATION #:,AP1193633 STATE OF FLORIDA PERMIT #:13-SC-1613804 DEPARTMENT OF HEALTH DOCUMENT #:F11009565 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:06/22/2015 .� FEE PAID:200.00 RECEIPT #:13-PID-2698844 Violation Number Comment Comments The system is sized for 2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimated flow of 300 gpd.7 pack bundles of 9 pipe each,4 drainlines,bed configuration,30 inches of sand. DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0.1 AP1193633 EID1613804 r ij PERMIT #: 13-$C-1613804 _ '--ib=AWLICATION #:AP 1193633 STATE OF FLORIDA � DATE PAID: DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID: CONSTRUCTION PERMIT RECEIPT #: DOCUMENT #:PR979041 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Geo Davis PROPERTY ADDRESS: 250 NW 111 Ter Miami, FL 33168 LOT: 14 BLOCK: 3 SUBDIVISION: PROPERTY ID #: 11-2136-001-0620 [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 [ 750 ] GALLONS / GPD existinq septic tank to remain CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 200 QUARE FEET new bed Confiq.drainfield SYSTEM R [ 0 l SQUARE FEET SYSTEM A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [xl BED [ F - N F LOCATION OF BENCHMARK: FFE 13.4'NGVD I ELEv`ATION OF PROPOSED SYSTEM SITE [ 30.0011 INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 80.00 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 62.00 ] INCHES 1.-Existing 750 gal.septic tank,certified by"Mr.C's Plumbing"on 6/20/2015 to remain. O 2.-Install 200 sf of drainfield in bed configuration. . T 3.-Install 12"of slightly limited soil at the bottom of the drainfield. H 4.-Perimeter of excavation area shall be at least 2 ft wider and loriger than the proposed absorption bed or drain trench. (Comments Continued on Page 2.) E R SPECIFICATIONS BY: 1Mi' �C's Plb Sept TITLE: APPROVED BY: TITLE: Engineering Specialist II Dade CHI) Martin DATE ISSUED: 64/2015 EXPIRATION DATE: 09/22/2015 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 AP11536 3 SE964334 6/25/2015 CCF06202015 OOOOO.jpg STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number ---------------------------PART II SITEPLAN--------------------------- Scale: Each biock represents 10 feet and 1 inch a 40 feet. WN 7 WX S• �a a 9 � 2 o 1 , S There are no pertinent features on adiacent properties and or across the street that may affect the New Septic system installation. Notes: '„x•50 N :j>w-Q.k v\r'j-e gd -6 ►-Q0jq&e-o4• �•� • 'ta �ty1�l r� Site Pian submitted by: Plan Approved Not Approved Date 28 I By County Health Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015.10196(Replaces HRS-H Form 4016 which maybe used) Page 2 of 4 (Stock Number: 5744-002-40156) httpsJ/drive.google.com/drive/u/Offolders/0B3SYVJLiZWiRfVnNyWVFnSWuaGM 1/1 a DATE(MMlDDIYYYY) ACCAR!D CERTIFICATE OF LIABILITY INSURANCE 11...r-'' 9/30/2016 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 Nikki Alexander NAME: LRA Insurance PHI E (407)838-3445 AI�No): (407)838-3460 498 S Lake Destiny Dr E-MAIL :NAlexander®lrainsurance.com ADDRESS INSURER($)AFFORDING COVERAGE NAIC t Orlando FL 32810 INSURER Brid efield Employers Ins Cc 10701 INSURED INSURERB: Mr. C's Plumbing & Septic, Inc. INSURERC: 19932 NW 2nd Ave INSURER D: INSURER E Miami FL 33169-2904 INSURER F COVERAGES CERTIFICATE NUMBER-.16/17 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. LTR TYPE OF INSURANCE POLICY NUMBER MM1DD EFF MPMOt�EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AMACLAIMS-MADE EJOCCUR PREMISES Ee oa u r TO nce $ MED EXP(Any one person) $ PERSONAL 3 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY 1:1 PE LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY Fa accident OMBINED L LI 17 $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per aoddent) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peracadent UMBRELLA LAB HOCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X SEATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y�NIA E.L.EACH ACCIDENT $ 100,000 OFFICER/MA (Mandatory In H)EXCLUDED? 0830-54817 10/1/2016 10/1/2017 (MandatorylnNH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Septic Systems Installations. License# SR061536 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE �-- Brian Tomlinson/NIKKI 071888-2014 ACORD CORPORATION- All rights reserved. ACORD 25(2014/01) The ACORD'name and logo are registered marks of ACORD INS025(201401) 004311 Local Business Tax Receipt Miami-Dade Counts, State of Florida IS NOT A BILL-00 N#)T PAY LBT 2866482 BUSHWESS MASWUMA,WU NO. EXPIRES MR CS PL IMBIMG&SWIX INC WIMMAL SEPTEMBER 30, 2017 19932 NW 2 AVE 2999176 Must be displayed at plata of busdness MUNI GARDENS FL 33169 Pursuant to County Code Chapter 8A-Art.9&10 R SES TYPE OP gueff Has PAMEWIMCOVED MRCS6WW4G&SEPTIC INC 196 PLUMBING CONTRACTOR By TAX COLLATOR SEPOWISM $45.00 07/18/2015 w0dw(s) 1 CIIECK21-16-090597 1MsLaeal Tsa a* �0odwimeal 7wL TkeBevslPis sli=me, p era m1ow beldws Notdsraim com*wM anY � Mw RECMm&&wmaMbe as 88 00m==W vehicles-W=mWk&Cab Bes ht-M Foraseas REGISTERED SEPTIC TANK C®NTRACTcmt KEMBLE G. ETTRICK 15932 NW 2 AVENUE MIAMI, FL 33169- MR. C'S PLUMBING&SEPTIC, INC. It SR0061536 Business Aut or¢afion: SA0121793 Reg'strat'on ExP On SePtmber 30,2017 g