PL-16-682 Permit NO. PL-3-16-682
�s�!ORes►,� Miami Shores Village Permit Type:Plumbing-Residential
£� Per it 10050 N.E.2nd Avenue NE
`o Work Classification:Addition/Alteration"•"" Miami Shores,FL 33138-0000 Permit Status:APPROVED
Phone: (305)795-2204
Wal 11 1, Issue Date:4/12/2016 Expiration: 10/09/2016
Project Address Parcel Number Applicant
1116 NE 92 Street 1132050270420
Miami Shores, FL 33138- Block: Lot: SUSAN PINNAS
Owner Information Address Phone Cell
SUSAN PINNAS 1140 ALFONSO Avenue
CORAL GABLES FL 33146-
1140 ALFONSO Avenue
CORAL GABLES FL 33146-
Contractor(s) Phone Cell Phone Valuation: $ 5,800.00
G&L PLUMBING SERVICE 305-551-5090 (786)225-3648
,,,,,.... __._........�. �__......�_,.,....,,... _._ Total Sq Feet: 1500
Type of Work:REPLACE EXISTING PLUMBING FIXTURES Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
Top Out
Bond Return: Final
Classification:Residential Scanning: 1 Review Plumbing
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $3.60
Invoice# PL-3-16-59024
DBPR Fee $3.38 03/15/2016 Credit Card $50.00 $419.36
DCA Fee $3.38
Education Surcharge $1.20 04/12/2016 Credit Card $419.36 $0.00
Permit Fee $225.00
Scanning Fee $3.00
Technology Fee $4.80
Work without Permit Fee $225.00
Total: $469.36
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 ELECTRICA PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AF DAVIT: ertify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction d m uthermore, I authorize the above-named contractor to do the work stated.
April 12, 2016
Aut rize nature: / Applicant / Contractor / Agent ate
Building Department Copy
April 12, 2016 1
Miami Shores Village
Building Department RECOMM
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 MAR 1 g 2016
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949 BY: -e-A
FBC 20
BUILDING Permit No. P '-rr',��
PERMIT APPLICATION Master Permit No.�C (rro --(0
Permit Type: PLUMBING
JOB ADDRESS: 11Lr r�g2W 9130-
City: Miami Shores County: Miami Dade Zip: 33 13
Folio/Parcel#: It"�j2 — d 2O
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): S0914V KfJAW EWA SPio e#:n 3);S '1 V7 J "S
Address: �k j G t,.Ie 92 ST(Z
City: State: Zip: 33
' Tenant/Lessee Name: Phone#:
Email:
C'CONTRACTOR:'Company Name: L p��j'1'I Phone I: d
Address:
U lr� Z Ai/e,
City: State: Zip: rr // (�
Qualifier Name: 06/70y r�� ! ° Phone#: 3�J_ 3/f/0 - /
State Certification or Registration#: C C O� 6 ` _Certificate of Competency#: 1
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: VK L0P%15 / -i4AUyVkf7A Phone#: 7126 3Q nue
•S.
Value of Work for this Permit: $—%4)- - - - - -"Square/Linear Footage of Work:
Type of Work: ❑Address Klteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: ?-EPLAC4r- i-7dsT ?LV M g 1K1Gt r-k x-'UFE2g-� G11
�� MAt�-T R- VA Tfi-SL-w� t�f taw en4 6-y�,I(7'
WA
50 (X3
Submittal Fee$ w ( O Permit Fee$ CCF$ . 6d CO/CC$Y
Scanning Fee$ �3- Radon Fee$ a P j8 DBPR$ 'E� Bonrrd,,$$ Q�
Notary$ 0 Training/Education Fee$ -20 Technology Fee$ `4'`Cl.b
Double Fee$ � Structural Review$�
TOTAL FEE NOW DUE$
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 ELECTRICAL WORK,PLUMBING, SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 seve .(7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a rei ction fee will be charged.
(Signatu " " Signature 41cx�) I
t
Owner o gent ,h ontractor
The fore 'ng instrument was ackn wledged bef me this The fore oing instrument was acknowledged before me this&
day of �/ 20 ,by u ►�' l ��f}�'I day of �C��/�c l�,20��,by A /`/ G
who ' p or who has produced who 1�ar> fIy` ow e or who has produced
As identification and who did take an oath. as identification and who did take an oath. ,
i
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print: ��/Zd�C� �/� rC(rj S } _
My Commission Expires: d,Pa;,;�ei,� VERONICAPHILLIPS My Commission Ex it �►`e
a : * MY COMMISSION t FF 068609 p � ?;..,�.� VERONICA PHILLIPS
EXPIRES:February 22,2018 * MY COMMISSION#FF 068609
EXPIRES:February 22,2018
?,���4 Bondedihru Budgel Notary Services ��qT op.°� Bonded Thru Budgd Notary Servi eS
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009XRevised 3/15/09)
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DATE((AWDD/YYYY)
ACC)Rn CERTIFICATE OF LIABILITY INSURANCE
01/06/2016
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).
CONT
T
PRODUCER NAME; JUAN G TUNON
ROYAL CARIBBEAN INS.AGENCY PHONE 305-642-4541 FAX 305.642.1087
fAlC.No.E%11• IAK,..1'i.9L.
1772 W FLAGLER STREET
AIIIIE .JTUNONROYALII@GMAIL.COM
ADDRE -
MIAMI, FL 33135 INSURER AFFORDING COVERAGE NAIC Y
INSURERA:ATAIN SPECIALTY INSURANCE CO.
INSURED INSURER B:TECHNOLOGY INSURANCE CO.
G&L PLUMBING SERVICE, INC. INSURER C:
13957 SW 140TH STREET INSURER D:
MIAMI,FL 33186 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 AFFOHDED 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.
INSR TYPE OF INSURANCE POLICY NUMBER MMLICY EFF POLICYYYY
XP
TR LIMITS
A GENERAL LIABILITY CIP244332 05/03/2015 05/03/2016 EACH
RENTED EKED $ 2,000,000.00
X COMMERCIAL GENERAL LIABILITY A
PR rr n $ 100.000.00
CLAIMS-MADE Q OCCUR MED EXP(Any one person) S 5,000-00
PERSONAL&ADV INJURY $ 1,000,000.00
GENERALAGGREGATE $ 2,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000.00
POLICYPRO• LOC $
MBINED SINGLE LIMIT
AUTOMOBILE LIABILITY CO
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per acctdent) S
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE- $
HIRED AUTOS AUTOS (Peraccident)
Is
UMeRELLALIAB OCCUR EACH OCCURRENCE S
EXCESS LIAa CLAIMS-MADE AGGREGATE $
QED I RETENTION$ S
B WORKERS COMPENSATION TWAC3469712 05/10/201505/10/2016 WCSTATU- IOER
TH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE Q E.L.EACH ACCIDENT S 1,000,000.00
OFFICER/MEMBER EXCLUDED? N N/A
(Mandatory In NH) E.L.DISEASE•CA EMPLOYEE $ 1,000,000.00
Ii yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT S 1,000,000.00
DESCRIPTIONOF OPERATIONS/LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required)
PLUMBING CONTRACTOR. LICENSE#CFC056755
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION TE THEREOF, NOTICE WILL BE DELIVERED IN
MIAMI SHORES VILLAGE CLQ CEWITAI#E41GLICY PROVISIONS.
10050 N.E.2ND AVENUE
MIAMI SHORES, FLORIDA 33138 Au REPRE TA vE
V_ ,
.19968120 ACORD CORPORATION. Ali rights reserved.
ACORD 25 12010/05) The ACORD name and o realstered mars f ACORD
G&L Plumbing Service, Inc.
11021 S.W. 142 Ave
Miami, FI. 33186
License # CFC 056755
Jr
State of -/Or,
County of Dclale
Before me this day personally appeared OY A I^r (f fC who bering
duly sworn,deposes and says;
That he or she will be the only person working on the project located at
�2 )t 33i36
Sworn to ( or affirmed_ b cribed before me this day of20
by o r/' -crcl
onall kv now
OR Produced Identification
Type of Identification Produced
��w:r•���¢ VERONICA PHILLIPS
* MY COMMISSION A FF 068609
EXPIRES:February 22,2018
*yype
4 � P���Thru Budget Notary Services
Prin , tamp Name of Notary I
♦ ORE Gi
1932
�C1
,,,, Miami shores Village
Mill .....
ins- —�` Building Department
�lpRipA 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 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 ACKNOWLEDG HAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signatur69W4
Ow r
State of Florida
County of Miami-Dade nn,�,, �
The foregoing was acknowledge before me this day of U,4M4(~ ,20,&.
who is personally known to me or has produced
a� ti is on.
f Notary Public-state o1 FloriW
Notary: .z x re:Apr 7,2015
i Commission N EE 150955
SEAL: �'' R;,I� Bonded Through Nriionsl Koury Assn.