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PL-14-2104
Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 ec, O J Inspection Number: INSP-220416 Permit Number: PL -9-14-2104 Scheduled Inspection Date: April 18, 2016 Inspector Hernandez, Rafael Owner: ALAN CORONADO, USA AYUSO Job Address: 461 NE 101 Street Miami Shores, FL 33138-2448 Project <NONE> Contractor. A SUPER SEPTIC TANK, INC. Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1132060170670 Phone: (05)364-0113 Building Department Comments SEPTIC TANK AND DRAIN FIELD 0 ass. INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional inspections can be scheduled until re -inspection fee is paid Inspector Comments HRS APPROVAL IN FILE. i 1:t5 , 00iPt( BUILDING PERMIT APPLICATION Miami Shores Village 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 REC -F-D SEP 26 2014 BY: FBC 20»® Master Permit No.P‘ /y -c„2/0 Sub Permit No. ❑BUIL ING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING _MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS D ESS: Com: Miami Shores Folio/Parcel#: County—� Miami Dade Zip: e)/ f a‘7V Is the Building Historically Designated Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): /.S/<p 1 '�G� fZ Phone#: Address: City:Ill 44/ Tenant/Lessee Nam . Email: // // /7 State: Zip: ..�� _'� y Phone#: t�- CONTRACTOR: Company Name: Address: °. Phone#1 4e/ha City: Sta� Zip: (%ly Qualifier Nam y w/- ; State Certification or Registration # /J2 �J%ilc' 5 Certificate of Competency DESIGNER: Architect/Engineer: Phone#: Address: City: State: Value of Work for this Permit: $. `zh d' Square/Linear Footage of Work: Type of Work: 0 Addi ' • 0 Alteration ❑ Ne Repair/Replace Description of Work•. r ,° Zip: 0 Demolition V,C1// Specify color of color thru tile: Submittal Fee $ (dP Fee $ Scanning Fee $ -(J) Radon Fee $ Technology Fee $ J CCF $ dam- 41 0co/CC $ `-�l DBPR $ • IJV Notary $ c Training/Education Fee $ ' Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ �` 9 • 40 (Revised02/24/2014) t 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 d and a reinspection fee will be charged. Signature\ OWNER d The foregoing instrument was day of aro acknowledged before a this , 20 / by r , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ********* v -- ?y4 Notary Public State of Florida Joanna M Feliciano My Commission FF 082753 oFor Expires 01/12/2018 APPROVED BY The foregoing instru ent was ac nowledged before me this XI day of , 20 1 , by %44-tJ Zekti- 0 , oo is personally nown to I� as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Print: Seal: YHAUTL-PEREZ Notary Public - State of Florida ;y My Comm. Expires Nov 4, 2015 '-.;,„ Fro O Commission # EE 119518 ***************************************************************** Plans Examiner Structural Review (Revised02/24/2014) Zoning Clerk a iami Shores Village Building Department 10050 N.E.2nd Avenue - 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 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. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation iniuries of any person allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Print Name: Signatur er Contractor Print Name: Signature: State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me thi day of 5 �;/ , 20 / By Z." (SEAL) T 1• of State of Florida ) County of Miami -Dade Sworn day of By • 'I d Su•:• ri•'-.•be R PRAD • : Notary Public • „ nu as j (SEAL) T 4.e ofl Report Viewer /1 100% Page 1 of 1 JEFF A WATER 1OF FINANCIAL OPPICER 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 Florkat Workers' Compensation taw. EFFECTIVE DATE: 8/4/2014 EXPIRATION DATE: 6/3/2016 PERSON: ZERO ANDREW M FEN: 650455404 BUSINESS NAME AND ADDRESS: A SUPER SEPTIC TANK INC 7701 WEST 18 LANE HIALEAH FL 33014 SCOPES OF BUSINESS OR TRADE: IRRIGATION OR DRAINAGE SYSTEM PmmmrttoMager 44BAB(14). F.B., an Otero/ a sag %who eleds coaaption from ffib M� a det hic =dertmg =treeaatrtamtorean under this . PmmemteChapter44D.05(12). ES,oIe!l mtalmesempL epptyat8ra thesoope cif the os lade ested =Its =Use eleteoffiotobe=rapt Pursuant 40�� toamplergq..tt33 F.8.tiotiseeet tolme een�d m>�esal oeeflRnto haer�pt the,* to laved= at fano Oaths dbaotmealb* �dee t%the pass= named mtBmm et =emtnamed cotamer meta the reqthrerarael to ls dais seams dil� .da Ito depmhemntshe9 wake a keine slam tordote ca OPS*2-0W0.252 CERTIFICATE OF ELECTION TO BE EXERT REVISED 07-12 QUESTIONS? (8BOj413.1609 httasJ/anns8.fldfs.com/crrenortviewer/reportViewer.aspx?data-kdvpginc9D?Q3gH6TER6e... 6/4/2014 002376 Local Business Tax Receipt Miami --Dade County, State of Florida THIS IS NOTA BILL - DO NOT PAY 3820314 BUSINESS NAME/LOCATION A SUPER SEPTIC TANK INC 7701 W 18 LA HIALEAH FL 33014 nwmar: A SUPER SEPTIC TANK INC Worker(s) 1 RECEIPT NO. RENEWAL 3988772 LBT EXPIRES SEPTEMBER 30, 2015 Must be displayed at place of business Pursuant to County Code Chapter 6A- Art. 9 8110 SEC. TYPP tie ao �ewrn� 196 SPECIALTY PLUMBING CONTRACTOR PAYMENT RECEIVED SEP890722 BY TAX COt 6CTOR $45.00 09/15/2014 CREDITCARD-14-037365 pmt. orla cenifi�ation sTax of the holders gralificanline dons,to do the Local Holder mess ast Thecomply with any not or nongovernmental ragsiatory lows and requirements whish apply to the basbtoas, The RECEIPT 1110. ahem most he displayed an all cornmeroleI vchiciaa - MMami-Dada Cede Sec ea-vB. For mere lalottnethtn, Via 32530/4112151 1411311511262 BL L.:170 60 60 ANN jue} of}des Jedns e 6i'£0179£90£ May01 01 04:16a a super septic tank REGISTERED SEPTIC TANK CONTRACTOR ANDREW M. ZERO 7701 W. 18TH LANE HIALEAH, FL 33014- A 3014A SUPER SEPTIC TANK, INC. i X t- Business Authorization: SA0960829 SR0890722 Registration Expires on September 30. 2015 3053640349 p.2 `' '�RIar CERTIFICATE OF LIABILITY INSURANCE DATE01110/14 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 POUCIES 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 policyges) must be endorsed. If SUBROGATION 18 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 endorsemengs). PRODUCER Maize & Tyson Insurances 5955 SW 21st Street Hollywood, FL 33023 Phone (954) 989-9324 Fax (954) 989-5998 ACI Ego. ; (954) 989-9324 Da Nox (954) 989-5998 ADDRESS: anrry@btakeandtyson.com INSURERts) AFFORDING COVERAGE NAIL 0 INSURER A : ACCIDENT INSURANCE COMPANY GENERAL LIABILITY nCOMMERCIAL GENERAL LABILITY ❑ ❑ CLAIMS -MADE n OCCUR ❑ INSURED A SUPER SEPTIC TANK, INC 7701 W 18 LANE HIALEAH, FL 33014 954 INSURER B MED EXP (Any one person INSURER C : PERSONAL a acv INJURY INSURER D : ❑ INSURER E : $ 300,000.00 INSURER F : PRODUCTS - COMPS AGG 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 POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.y@ Lj'R TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER CCP0006254-00 (MMIDDIWYY) 10/10/2013 [N19tIDD1YYY ') 10/10/2014 LIMITS EACH OCCURRENCE $ 300,000.00 A GENERAL LIABILITY nCOMMERCIAL GENERAL LABILITY ❑ ❑ CLAIMS -MADE n OCCUR ❑ PRSO RENTED PREMISES (Ea occurrence) $ 100,030.00 MED EXP (Any one person $ 5,000.00 PERSONAL a acv INJURY $ 300,000.00 ❑ GENERAL AGGREGATE $ 300,000.00 GEM. AGGREGATE UMIT APPLIES PER: V POucI ■ ! ❑ Loc JECT PRODUCTS - COMPS AGG $ 300,000.00 $ AUTOMOBILE UABILITYD ❑ ANY AUTO ❑ AUTALLO D 1 SiSs • HIRED AUTOS • AUTOS 0 ■ SINGLE UMIT $ BODILY INJURY (Per person) $ (Per accident) $ �BROODIILEYINJURY (P� acddent) AGE $ $ ❑ UMBRELLA LIAR ❑ OCCUR ❑ EXCESS UAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED 0 RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A ❑ WCSTUMTr15 ❑ gr - E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? oaq n E.L. DISEASE - EA EMPLOYE $ H q�esdescxBreMirnder D$SGcRIP11ON OF OPERATIONS below E.L DISEASE - POUCY UMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (Attach ACORD 101, Addltionai Remerirs Schedule, V more space Is required) SEPTIC TANK INSTALLATION, SERVICE AND REPAIR CERTIFICATE HOLDER CANCELLATION I CITY OF MIAMI SHORE VILLAGE 10050 NE 2ND AVE MIAMI SHORE VILLAGE, FL 33138 FAX 305-756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ircrkt %.04.:21breg) wk. ACORD 25 (2010/05) QF ©198810 ACORD CORPORATION. All rights reserved. The ACORD name and logo are register marks of ACORD STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Existing New APPLICANT: Lisa Ayuso PERMIT #:113 -SC -1547448 APPLICATION #: AP1152331 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR949097 PROPERTY ADDRESS: 461 NE 101 St Miami Beach, FL 33139 LOT: 21 BLOCK: 91 PROPERTY ID #: 11-3206-017-0670 SUBDIVISION: Miami Highlands Sec B [SECTION, TOWNSHIP, RANGE, PARCEL NUNIBER] [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 GUAFtANTEE 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 FRCT4 COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 1 GALLONS / GPD Septic CAPACITY A [ ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS . #Pumps [ ] D [ 375 ] SQUARE FEET Trench configuration SYSTEM R [ ] SQUARE FEET N/A SYSTEM A TYPE SYSTEM: Ex] STANDARD [ ] FILLED [ ] SAID [ ] I CONFIGURATION: [x] TRENCH [ ] BED [ ] N F LOCATION OF EENCHr.ARK: CL NE 101 st, 10.30' NGVD I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED: 0 T H E R [ 0.00 ] INCHES [ 7.20 ] [I INCHES If FT ] [ ABOVE BELOW I BENCHMARK/REFERENCE POINT [ 37.20 ] [I INCHES I FT ] [ ABOVE BENCHMARK/REQ POINT EXCAVATION REQUIRED: [ 30.00] INCHES Inspector to verify the existing septic tank is properly abandoned before final approval. *Invert elevation of drainfield to be no Tess than 7.00' NGVD. *Bottom of drainfield elevation to be no less than 6.50' NGVD. 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. The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s. 64E -6.013(3)(f), FAC. SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: Teresa J Solomon Carlos M Iaaza 08/28/2014 TITLE: TITLE: Master Septic Tank Contractor Dade CHD EXPIRATION DATE: 02/28/2016 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC v 1.1.4 AP1152331 3E937161 Page 1 of 3