PL-10-141Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795 -2204
533 GRAND CONCOURSE
Miami Shores, FL 33138 -2464
1132060171350
Block: Lot:
DONNA HURTAK
Fees Due
Bond Type - Owners Bond
CCF
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Amount
$300.00
$3.00
$1.00
$300.00
$6.00
$4.00
Total: $614.00
Building Department Copy
533 GRAND CONCOURSE
MIAMI SHORES FL 33138 -2464
Contractor(s)
JOE LEWIS SPECIALTY SEPTIC
Phone Cell Phone
(305)662 -7979
Valuation:
Total Sq Feet:
Type of Work: PLUMBING
Type of Piping: SEPTIC & DRAINFIELD INSTALLATION
Additional Info:
Bond Retum :
Classification: Residential
Authorized Signature: Owner / Applicant / Contractor / Agent
Invoice #
PL -1 -10 -36923
Check #: 8267
Total Amt Paid Amt Due
$ 614.00 $ 614.00 $ 0.00
Bond #: 1921
Date
Expiration: 07/28/2010
$ 5,000.00
0
For Inspections please call:
(305)762 -4949
Available Inspections:
Inspection Type:
HRS Approval
Abandonment
Final
Rough
Landscaping
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.
January 29, 2010
January 29, 2010 1
of
Inspection Number: INSP- 134438 Permit Number: PL -1 -10 -141
Scheduled Inspection Date: May 28, 2010
Inspector: Hernandez, Rafael
Owner: HURTAK, DONNA
Job Address: 533 GRAND CONCOURSE
Project: <NONE>
Contractor: JOE LEWIS SPECIALTY SEPTIC
Building Department Comments
900 GALLONSEPTIC TANK INSTALLATION & 225 SQ FT
DRAINFIELD IN TRENCH CONFIGURATION
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
fl
May 27, 2010
Miami Shores, FL 33138 -2464
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
For Inspections please call: (305)762 -4949
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060171350
Phone: (305)662 -7979
Page 1 of 7
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type: Plumbing
Architect/Engineer's Name (if applicable)
•
Type of Work: ' Addition `' ''':Alteration
Describe Work: //V 1741/ p✓LCi
Z 70S ,oro,10, Ate-41
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
JAN 287010
Permit No.' l 10 —141
Master Permit No. 410 -1
Owner's Name (Fee Simple Titlehdlder) ,/ �� ` / Phone #
Owner's Address 6 3 6o c t n a,e r
City /1/4H/ $/ State Zip ` *8
Tenant/Lessee Name Phone #
E -MAIL:
Job Address (where the work is being done
City Miami Shores Village County Miami -Dade Zip
FOLIO / PARCEL # g -0/7 -/ 3J9
Is Building Historically Designated YES C2,
Contractor's Company Name Jot, LC4A,j Seed &If /y s' Phone # 3 0 5 d 779 9
Contractor's Address 3 0 7S .S.A/ C/ AV.0
City In >i2.AAi A-4 State .F /. Zip 33 d2 3
Qualifier Name Jn t. / el..., ..t . J r- Phone # 7 . — 2. 6 3 -/ 7 2,3
State Certificate of1Registration lhho. S L • ®d Certificate of Competency No.
EMAIL: tc,vs /et.'77 G 49-1 / weep,
Phone #
Value of Work For this Permit $ S/00 0 Square / Linear Footage Of Work: It 2.. ZS
❑New l Repair /Replace ❑ Demolition
9'Q e4L it.4
Tidy/ F.`9/ 1
******** * * * * *** * * ** * *,* * ** ** * * * **** * *** F ees * * * * *, ** * *** * ** *** * ** ** * *** ***** * *** * ** * ***
Submittal Fee $ Permit Fee $ / +-160 CCF $ CO /CC
Notary $. Training /Education Fee $ Technology Fee $
Scanning $ . Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side -
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR. CONDITIONERS, ETC
OWNER'S AFFIDAVIT: f 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 , •BE,FORE RECORDING YOUR NOTICE OF
COMMENCEMENT: "' ,
� 4 `
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will of b appro and a es do ee II be charged.
Signature
Owner or Agent
The for 4 ng instrument was acknowledged before me this 7! The for
day of � � , 20 4, by ``�' /J'zee— L ay of
who who has produced who is per
and D .t e dO
iVIY ` COMMISSOI #130917231
EXPIRES August 21, 2013
4*7 3e -oi 6 F
personally kn
As ide
NOTARY P IC:
Sign:
Print: Milira/
My Commission Expires:
Zip
Sta
Signature 7�
Sign:
Print:
/Contractor
ng instrument was acknow dged befo me this
,2, by
orally known to me or who has produce
1
ARY PUBLIC:
My Commission Expires:
*** des *** **** ** *xx,ex******xx**********x***9e xxxxe4xuvw4exxx **xx** **** *** ****xx*****
APPLICATION APPROVED BY:
(Revised 02/08/06)
cation and who did take an oath.
dexx*******xx
071// )$Q
Plans Examiner
Engineer
Zoning
9
FEIN: 262847579
BUSINESS NAME AND ADDRESS:
LEWIS SPECIALTY SEPTIC LLC
1776 POLK ST @163
HOLLYWOOD, FL 33020
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE 06/27/2008 EXPIRATION DATE: 06/27/2010
PERSON: JOE LEWIS JR
SCOPE OF BUSINESS OR TRADE:
1- DRAINAGE 2- SEPTIC TANKS
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06
H
E
R
E
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
IMPORTANT
F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who
0 elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.05(12), F -S., Certificates of election to be
exempt.. apply only within the scope of the business or trade listed on
the notice of election to be exempt
Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
Registered Septic Tank Contractor
JOE LEWIS
3075 NW 61 AVENUE
MIRAMAR FL .33023 -
JOE LEWIS SPECIALTY SEPTIC
Business Authorization: SE0081499
SR0081599
Registration Expiration Date: September 30, 2010
QUESTIONS? (850) 413 -1609
b5r (200b6 lZt5
X2009
:300580e1
009183.,'5
SEE OTHER SIDE
DO NOT FORWARD
LEWIS SPECIALTY SEPTIC LLC
JOE LEWIS JR
3075 SW 61 AVE
MIRAMAR FL 33023 '
10111111111111111111111/ I199I911611/11999I19 1991999191919919999
FIRST -GLASS
UPS POSTAGE
PRODUCER Admha4 Insurance, Inc.
17340 NW 27th Ave
Miami Gardens, FL 33056
Phone (305)621 -2939
INSUR O JOE LEVVI S SPECIALITY SEPTIC LLC
1776 Polk St #163
Miami, FL 33056
COVERAGES otsuNGs F.
THE MACES' OF H 4SURANCE LISTED" AVE BEEN MOOED TO THE h+ISORED WIMEOREOVEFOR THE POLICY Pig= tiarviirtitriticiam
ANY REOUREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THEOERPFIONIE I AY SEEMED OR
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICES OESCREED HEREIN t SUBJECT T TOAD. THE TERMS, EXCLUSIe3N&PND CONDITIONS OF SUCH
POLICES. AGGREGATE : UMXT$S MAY HAVE BEEN REDUCED BY PAID Cam.
t114844 Ati&s T1tt o INIMAisICE
_
SAL WOLIN
CMMERCIAL GENERAL UABIUTY ;08 -12551
GEN'L AGGREGATE LIMIT APPLIES PEW
POLICY : ; PROJECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
AU. OWNED AUTOS
SCIEDULEDAUTOS
HEED AUTOS
NON °WN3 AUTOS
EXCESS/UMBRELLA LABIUM
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION S
WORKERS EN ICIrLIAM LIABILITY
AID
ANY PROPRIETOR A-RA MER ! EXEGUTNE
OR! MEMBER EXCLUDED?
Eyes, describe under
SPECIAL PROVISIONS below
OTHER
DEM:WY ON OF OPERATIONS/ t.00AT1ONS M VE
CERTIFICATE F4OLDER
ACO D 28 (2O0th Of
CERTIFICATE OF LIABILITY IUR
MS CERTIFICATE tISSUED : AS A `I
=YAW COMMON) Rows
1418 c P PATE DOGS
INSUREDS AfFENUDNEICEMP4GE
CLAIMS MADE +f OCCUR
Fax (305;621 -1370
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
10050 NE 2ND AVE.
MIAMI SHORES FL. 33138
INSURER A EI' SCI: E
INSURER 8
IPA C.
!SEWER D.
BISU E;
POLiCYFI<R GY t'
100,000
0924109 09/24110 , +. 10,000
0O0
tNERAL AGOREGA`FE 100,003
• PRODUCTS - COMP /OP AG G 100,000
COMBINE SINGLE
i(E8
AUTOOI LY'- EAACCIDENT
OTHER THAN :ACC
AUTO ONLY; AGO
EACH pc+ M E
:
.ES d EXCLUSIONS ADDED BY EIMOREDMENT J SPECGAL fiS
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i E L EACI7 At C DENT
Irk. LREr y -
wars
CANCEI AiION
SHOW) ANY OF THE AIME ORSCRIDED POLICIES RE CANCELLED BEFORE THE
EXPIRATION DATE noateof, TTY' ISSUING INEAVEILL ENDEAVOR TONSIL
15 . c s mines Nance 10 THE cE 1 sou** warm
TIG BUTTALURE TACO SO SRAM • DRUABILITY
OF ANY KM—UPON TIE HisiMER, " `' Ate.
H
E
R
CONSTRUCTION PERMIT FOR: OSTDS Abandonment
APPLICANT: Jerome Hurtak
PROPERTY ADDRESS: 533 Grand Concorse Miami, FL 33138
LOT: 23-26
PROPERTY ID #: 11- 3206 - 017 -1350
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 [ ] GALLONS / GPD CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ ] SQUARE FEET SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [ / ][ ABOVE/BELOW P3ENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [ / ] [ABOVE/ BELOW ]BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES
Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of
the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The
tank shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected
by the health department after it has been pumped and ruptured but before it is filled with sand and covered.
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
BLOCK: 96 SUBDIVISION:
DH 4016, 10/97; revious Editions May Be Used)
v 1.1.4 AP947955 SE -1
PERMIT # -SC- 1115561
APPLICATION # :AP947955
DATE PAID:
FEE PAID*
RECEIPT #:
DOCUMENT #: PR795248
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
EXCAVATION REQUIRED: [ ] INCHES
TITLE: Engineer Specialist II
: Engineer Specialist II
Dade CHD
EXPIRATION DATE: 04/08/2010
Page 1 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Jerom Hurtak
PROPERTY ADDRESS: 533 Grand Concourse Miami, FL 33138
LOT: 23 -26
PROPERTY ID # : 11- 3206 - 017 -1350
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 [ 900 ] GALLONS / GPD Septic CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 225 ] SQUARE FEET Trench confiauration SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD
I CONFIGURATION: [x] TRENCH
N
F
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED:
0
T
H
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
BLOCK: 96 'SUBDIVISION: MiamiShores
LOCATION OF BENCHMARK: FFE : 13.54' NGVD
DH 4016, 10/97 (Previo Editions May Be Used)
v 1.1.
- [ ] FIT.T.Fn [ ]
[ ] BED [ ]
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR ¶I ID. NUMBER]
MOUND [ ]
[ 26.30][ INCHES FT ][ ABOVE BELOWIBENCHMARK /REFERENCE POINT
[ 50.30 ] [) INCHES I FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT
[ 0.00] INCHES EXCAVATION REQUIRED: [ 24.00] INCHES
1.Install 900 g septic tank.
2.Install 225 sq ft drainfield in trench configuration
3.Invert elevation of drainfield to be no less than 9.85' NGVD.
6.Bottom of drainfield elevation to be no less than 9.35' NGVD.
The licensed contractor is responsible for installing the minimum category of tank (64E- 6.013(3)(f), FAC).
Joseph R Piverger
▪ TITLEi zr Fng er cialist II Dade CHD
AP947954
TITLE: Engineer Specialist II
PERMIT #: 13-SC-1115560
APPLICATION #:AP947954
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT # : PR797072
EXPIRATION DATE: 04/27/2010
5E806097
Page 1 of 3
Site Plan submitted byv
Plan Approved t
By 7 40
(
DH 4015, 10/96 (Replaces HRS-H Form 4016 which may be used)
(Stock Number: 5744-002-4015-6)
•"!
PART II SITEPLAN
, 6
r
Signature
Not Approved
„
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number ,/
Scale: Each block re resents 10 feet and 1 inch = feet.
laillraTIONEMIIIIIIMIRIMIE ENE=
111111111111111111111111111111111111111111111011111111111111
11 111111111111 111M211111111111111111111111111111111111
1111111111111 1111111111111111119LMENIIIIIII
o 111111111111111111.111/2-arAMEMilii1111.1111111111
11•111111111••11111111•11 111111111111111111111111111
111111111111EMEmr%
•
11111111111111111
•
1r 11111111111111116111211E1111
• 1111111111111111111.
1111111111111111111111111151
11111111111111111111111111111111111111111111111101111111111111111
11111111111111111111E111111111e12111111111115 111111111111
II MEMO 1 11.11111111111111111110111111111M1111111111
1 111 1111111MINI111111111111111111.11111111111 111111111111
111 11111111111111111111111 111111111111111M1111111111111111111
• 111111111111/ 111111111111111111111111111111111 11111111111111
•
111111111=111111111111111111111111111IN'AVANIIIII
Notes:
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
•
Title
Date
County Health Department
Page 2 of 4