PL-15-985 Inspection Worksheet
-� Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-233320 Permit Number: PL-4-15-985
Scheduled Inspection Date: October 07, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz,Osvaldo
Inspection Type: Final
Owner: ROY,WILLIAM Work Classification: Septic
Job Address:1280 NE 101 Street
Miami Shores, FL
Phone Number
Parcel Number 1132050210010
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963-0082
Building Department Comments
INSTALL NEW 1350 TANK, 500 GAL DOSING TANK AND Infractio Passed Comments
NEW 967 DRAINFIELD INSPECTOR COMMENTS False
Inspector Comments
Passed EV
Failed
l
Correction ❑
Needed
df�
Re-Inspection ❑ C1 t4,
Fee
No Additional Inspections can be scheduled until Cr C G ,
re-inspection fee is paid
October 06,2015 For Inspections please call: (305)762-4949 Page 6 of 60
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y Miami Shores Village 1
10050 N.E.2nd Avenue NE "
Miami Shores,FL 33138-0000 F ,
PIWVED
Phone: (305)795-2204 uE >>
Expiration: 10/212015
Project Address Parcel Number Applicant
1280 NE 101 Street 1132050210010
Miami Shores, FL Block: Lot: WILLIAM ROY
Owner Information Address Phone Cell
WILLIAM ROY 1280 NE 101 Street (305)793-5050
MIAMI SHORES FL 33138-
1280 NE 101 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone $ 13,800.00
STATEWIDE SEPTIC CONNECTIONS (954)963-0082 Valuation:
Total Sq Feet: 967
Type of Work:INSTALL NEW 1350 TANK,500 GAL DOSI Available Inspections:
Type of Piping:
Inspection Type:
Additional Info: HRS Approval
Bond Return: Final
Classification:Residential Scanning:1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $8.40 Invoice# PL-4-15-55322
DBPR Fee $7.25 04/24/2015 Check#:4661 $522.90 $0.00
DCA Fee $7.25
Education Surcharge $2.80
Permit Fee $483.00
Scanning Fee $3.00
Technology Fee $11.20
Total: $522.90
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 zoning. Fut rmore,I a rize the above-named contractor to do the work stated.
_7711— April 24,2015
Authorized Signature: / Applicant / Contractor / Agent Date
Building Department Copy
April 24,2015 1
Miami Shores Village
x APR E 2015 '
Building Department BY:
_
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 20
BUILDING Master Permit No.VU5
PERMIT APPLICATION Sub Permit No.
7BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
%PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
1 �q r CONTRACTOR DRAWINGS
JOB ADDRESS:_ I ® 0 � (o S c�
City: Miami Shores County: Miami Dade Zip: 3�
Folio/Parcel#: ? ®gip,2, 1 - 001 Q� Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
11 n �p�1
OWNER:Name(Fee Simple Titleholder): l 1 a hn R- (2®q a �Inc �� one#: 'J a6-M l-2,29L-
Address: 1 ND N11 Vo I
City: m wi) State: F7 zip-3-N3
(31�
Tenant/Lessee Name: Phone#:
Email: �^^ (y
CONTRACTOR:Company Name: 1 4�?e �1Z � �J C hhf CTIOrS' Phone#: 2>ZS- ' G/6 33
Address: V�o-_ N\A) 1� �e
City: �� y !C-�Cj State: ly Zip: '33-os q=
Qualifier Name: Te'e � Phone#:
State Certification or Registration#: 3 0 k26 Z Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ (3 ,90 0 Square/Linear Footage of Work: '16�
Type of Work: ❑ Addition [r Alteration ❑ NewAd❑ Repair/Replace `` ❑ Demotion t
Description of Work: Ln VN Ik g� r35&-k-an K , 900 � aA C12Srh.� TGh k
tqeAl, DCQ t n-(p.16
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ f CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond
'6�0 c*-j 1 A @ TOTAL FEE NOW DUE$
(Revised02/24/2014)
i
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
Zi p
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, PLL MBING, 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 donEl 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 BEF RE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with on estimated value exceeding$2 00, 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 b�posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. in the absence of s ch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature-0-5�5 7 Signature c
Oor A T CONTRACTOR
The foregoing instrument
w-as acknowledged before me this The foregoing instrument was acknowledge before me this
Q day of ` `r _ , l 20k' by 2-E3 day of 3 r-L, 20 13 by
T
who is personally known to SS cT` � h'
�-- `1 a"n who is pe sonally known to
me or who has produced f lft RfN U Y-94 as me or who has produced FLA" '^ C32v-g as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
-4igSign:.--1
—Print:. Print:— t 1 S
Seal: - Seal:
el, Notary Public State at Florida N:::
of
Trencelia Lewis TFlod to
Any ncellComLewssion FF 196307 M19630vaa�P�SlE * * ***********
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revsed02/24/2714)
� a
S rATZ OF FLORIDA PERMIT #: 13-SC-1589871
DEPARTMENT OF HEALTH APPLICATION #: AP 1178004
ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID:
S Y STEM
CONSTRUCTION PERMIT FEE PAID:
RECEIPT #:
�b wit
DOCUMENT #: PR96941 0
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: (Wiliam Roy&Susan Kelley)
PROPERTY ADDRESS: 1280 NE 101 St Miami, FL 33138
LOT: 1 BLOCK: 184 A SUBDIVISION: Miami Shores Sec. 8
PROPERTY ID #: 11-3205-021-0010 [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
I
T [ 1,350 ] GALLONS / GPD Septic CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ 450 ] GALLgNS DOSING TANK CAPACITY [ 97.00 ]GALLONS
@[ 6 ]DOSES PER 24 HRS #Pumps [ 1 ]
D [ 967 ] sQUARIE FEET Bed confiquration SYSTEM
R [ J SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [XJ FILLED [ ] MOUND
I CONFIGURATION: ( J
[ J TRENCH [Xl BED [ ]
N
F LOCATION OF BEN( CL NE 101 st.,6.25'NGVD
I ELEVATION OF PRO OSED SYSTEM SITE [ 4.56 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
L INCHES BELOW
E BOTTOM OF DRAINF E7LD BE [ 15.00 ] [ FT ] [ ABOVE BENCHMARK/REFERENCE POINT
D FILL REQUIRED: [ 8,00] INCHES EXCAVATION REQUIRED: ( 52.401 INCHES
O Inspector to verify the existing septic tank is properly abandoned before final approval.
T
"Invert elevation of grainfield to be no less than 5.50'NGVD.
'Bottom of drainfielelevation to be no less than 5.00'NGVD.
H 'Install 42"of slightl limited soil under the bottom of drainfield.
E
Perimeter of exc, ' tion area shall be at least 2 ft. wider and longer than the proposed absorption bed or drain trench
The system is sized!for 4 bedrooms with a maximum occupancy of 8 persons(2 per bedroom), for a total estimated flow
R of 580 gpd
(Comments Continued on Page 2.)
SPECIFICATIONS BY: Teresa J Solomon
TITLE: Master Septic Tank Contractor
APPROVED BY:
ar
TITLE. Dade
os M Icaza CHD
DATE
ISSUED: 1 03/31/2015
EXPIRATION DATE: 09/30/20 16
DH 4016, 08/09 (Obsgletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
Page 1 of 3
AP1I73009 SE955843
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Miami shores V
Building Department
es 1 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
t
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.
Signature:
caner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this `2.0 day of �Y I' ,20_�.
By AM R o who is personally known to me or has produced
0-TtvCrS L+Gef-i'Ye. as identification.
Notary.
SEAL: "A,, 11 p Duni a c, ,da Notary Public State d Florida
'I r +a s • Trencelle Lewis
,;u307 �` My Commission FF 189307
v
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1
FLORIDA DEPARTMENT OF HEALTH.
CERTIFICATE OF AUTHORIZATION FOR SEPTIC TANK CONTRAC'I'ING
HEALTH
1 he Florida Department of Health hereby certifies the business or entity named below has satisfied the reyuirernenr. nJ Part
111. ('lutpter 4134. Florida Statutes,for septic tank contracting and has been dulv authorized by the Department to provide
septic tank contracting services under the name of.-
STATEWIDE SEPTIC CONNECTIONS, INC.
Qualifying Contractor: 'rERESA J.SOLOMON
SA0021074 _ March 24, 20,1,5.. March 31, 2017
Authorization Number Date Issued Expiration Date
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