PL-16-3237 Permit NO. PL-11-16-3237
On", rMiami Shores Village ut Permit Type:Plumbing-Residential
F 10050 N.E.2nd Avenue NE
IlkWork Classifrrfation:Gas
Miami Shores,FL 33138-0000 Permit Status:APPROVED
Pet
11 At Phone: (305)795-2204
FCORtDP'
Issue Date: 12120/2016 Expiration: 06/18/2017
Project Address Parcel Number Applicant
1350 NE 101 Street 1132050230020
Miami Shores, FL Block: Lot: DIRK& ELIZABETH PETERSON
Owner Information Address Phone Cell
DIRK& ELIZABETH PETERSON 1350 NE 101 ST
MIAMI SHORES FL 33138-2611
Contractor(s) Phone Cell Phone Valuation: $ 2,900.00
GAS CONNECTION&EQUIPMENT
� .M.� N Total Sq Feet: 0
Type of Work:INSTALLATION OF NEW GAS LINE FOR OU Available Inspections:
Type of Piping:
Inspection Type:
Additional Info:
Final
Bond Return: Press Test
Classification:Residential Scanning:3 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.80
DBPR Fee Invoice# PL-11-16-62200
$2.25 12/20/2016 Credit Card $ 123.30 $50.00
DCA Fee $2.25
Education Surcharge $0.60 11/29/2016 Credit Card $50.00 $0.00
Notary Fee $5.00
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $173.30
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 s ict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting tIELECT
P. uthermore,
e responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required forUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS fy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction I authorize the above-named contractor to do the work stated.
December 20, 2016
Auth t heignature:Owner / Applicant / Contractor / Agent Date
Building gepartment Copy
December 20,2016 1
Miami Shores Village RErr �
Building Department NOV 29 2016
g p
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 ��°fir_
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC201`t
PL (
BUILDING Master Permit No
.PL "
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
ELUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
t��. �ry CONTRACTOR DRAWINGS
JOB ADDRESS: l� /J.z l0/ 5%
City: Miami Shores County: Miami Dade Zia:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: eLoad: Construction Type: ► Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): L/SN' .t (�t 2,k r�"� Phone#:
Address: 135-0 A).63. 10/ 5"_1_
City: M 14"1 '54aje5 State: Zip:
Tenant/Lessee Name: Phone#:
Email: a
CONTRACTOR:Company Name:
AA A! �< Phone#: 5 ` ���'OJg�V
Address: 60 -/,z 15-
City: 10
�4 State: I- v Zip•?5Y-Z263c3��• -7
Qualifief Name: 10.4
n�]ttbyJ-L- Phone#: '�T943b
State Certification or Registration#: pq�3 Iq Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Q-100, Square/Linear Footage of Work:
Type of Work: R� Addition ❑ Alteration ❑ NewJ ❑ Re/paair/Replace ❑ Demolition
Description f Work: rnJ iU ew fjI ve `C 6�-
foo
Specify color of color thru tile:
c �
Submittal Fee$ Permit Fee$ 1✓ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
12'�) ,30
. 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. 1 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 co e c ment must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. n absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature, Signatu
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged beforemethis The foregoing i stru ent was acknowledged before me this
2 Z darty of �a V-. 120 6 by ��day of r\, 20 1� ,by
o Ie k Pe-ke-zCA) ,who is personally known to )"L�L�N�' U A-TU ,who is personally known to
me or who has produced 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: \\`\`t11llllll!ltt�r/,
Sign: LC/ Sign: ��Q�Q� •�y��
Print: Print: =MILY
Seal: Notary Public.State dDFb de Seal: „�i� `� 7P
My Mm U ea MMay 03,210 `<i>�y Po.......
o ��•,�
8ond�dlhuA—n ,Ir�c��80F0F 4514841 /F W7409fP'`'` e.. �w �471..
e` '°4`
!!!###!!!#
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000
VALID OCTOBER 1,2016 .THROUGH SEPTEMBER 30,2017
DBA: Receipt#'262-41 INSTALLATION LP GABS
Business Name Business APPL/E P
GAS CONNECTION & EQUIPMENT BusiT
• Type: LP GASB
APPL/EOUP)
Owner Name:MANUEL ATO JR Business Opened:01/07/2008
Business Location:6428 RODMAN ST State/County/CerUReg:24314/08-CLPG-14752*
HOLLYWOOD Exemption Code:
Business Phone:305-94 0-8 82 0
Rooms seats Employees Machines Professionals
For Vending Business Only
Number of Machines: VoKling Type:
Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid
75.00 0.00 0.00 0.00 0.00 0.00 75.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non-regulatory in nature.You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location.This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
MANUEL ATO JR Receipt #52A-15-00008615
6428 RODMAN ST Paid 07/26/2016 75.00
HOLLYWOOD, FL 33023
2016 - 2017
Cut Here
State of Florida
t. Department of Agriculture and Consumer Services
DititlSiOn Of Consumers , ..e,_•_,_:....ter .4,,. - •�,-- - -v.- v,.—.�..•-a•Um@f Services'�+.��... Certificate No: 23965,
Bureau of Compliance, Exam Date: October 23,2007
(850) 921-1600 issue Date: November 29,2096
Tallahassee, Florida Expiration Date: November 28,2019
Exam: 0803
MASTER QUALIFIER CERTIFICATE
This Certificate is issued under authority of Section 527.02, Florida Statutes,to:
MANUEL M. ATO
Valid For
License Number: 24314
GAS CONNECTION&EQUIPMENT
6428 RODMAN ST AAM H.PUTNa
HOLLYWOOD,FL 33023-1763 COMMISSIONER OF AGRICULTURE
r
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
---- ^
.� 5COF� OF WOF& LONGZ5T PISTANC�; 100 FT 606 C M19`�0N
TOTAL L OAP; 939,0001 TU5 6428 WPM 5f.
INSTALLATION 0� NSW " POLYPIP� HaLYwom,FL.33023
UNP�PGpOUNP TO EXITING POOLH�MF,ANP 5TATE LIC, #24314
NSW P3 Q. 2 P515Y5T�M WITH F,�GUI.A1"01?5, �XI5TIN6 TANU55 WAT FH? A1�p 199,000 DTU5 INOWMI2CC#06-LICA-14M
2 P51 p�GULAT01? WILL 13� IN51 ALI.�P FOP �XI5rIN6PMI? 40,000 PTU5
�X15TIN6 �XI5TING FANGZ 220,000 DTU5
�XI511NG POOL H�AT�I? 400,000 r3TU5
NSW C PQ 80,000 C3TU5 JZ��
2014 5FCP M31,�; 402,4 ( 2,9,22)
660
80,000 6f11
1
Ni"swf OFF VALVE and 21`51 RegAa!or
9999..
PUP )l 9000
9999..
40,000m �� •9999• • 1n9999
E X15TM WITH sl of OFF vkvE ExlsnNc /�' *00:00
iv •
Pad Heater to •0 ....
NOUSE;UN� _ '0" 0
I ft. 14''C01`PER PIPE 400,000 m ✓ NEW •9•••• : • • �— �9••
MOUNSP ON WALL 6 R.14"COPPER PIPE OUTOOR fA U55 WATIZ WPM 5 W OFF VALVE " 140 f.i"POLYPIPE •••••• • :••
MOUwp ON WAIL ItASIZ and 2P51 Veg latar / WITH TRACING WDM
199,000 6TU #0 • •• •9:�•0 ••••
NTH SFUf OFF VPIVE RANGE af/ �' • ••
220.000 6111 t�,� � I!. • • � � �••:•
TH w OFF VALVE o� � � � t �� Z V�
6 ft.I+COPPER PIPE ME,
MOUM12 ON WALL i•• ' 1SLf;:,I"COPPERPIPEMOUNTED ON WALL osP51 REGULATOR ��FORE45nNGNOUSELINE Y•� - S 23
NATURAL GAS 60 ft. " F01,WI C9iami Shf,rf�S Village
21`51 METER WITH TVACIN6 M, DATE
l�na!'OVED BY
D'-PI
GA5 PLAN
"' `)irr--PT
15OMMIC I TO,(-%IT'LIANGE WITH ALL FECERAL
c,'1
Ty STI:FS ANC F Fnt)LATInNS Sheet 1-2
5COFOF WORK, LONCZ5T 1215rANC�; 100 Fr ``A5 COMn C¶0n'
3,, 1"0f& L OAP; 939,000 PTU5 6428 ROPMAN 5f.
IN51 ALLA1'ION OF NSW POLYPIP� HHOLLYWOOD,FL,33023
UNP�PGpOUNP fO �X11NG POOLNMP, ANP �X15fl% fANU55 WAVA1Ft? 199,000 PTU5 5fATE LIC, #24304
NSW C�C3Q, 2 P515Y51�M WITH p�GULArOPS �X15TING PINI 40,000 PTU5 r�ONVPCC#011-V6-14M
2 P51 p�GULA1"Op WILL C3f INSrALL�P FOP,
pANG� 220,000 M5
�X15fl% HOUSFILM �XISrING POOL N�AV400,000 PTU5
NSW N30 80,000 PTU5
2014 5FCP M' L�: 402.4 ( 2,9,22)
� 66O
80.000 m
WIi i 5tf OFF VALVE
and 2P5,RegJawr
40ft.ill PO,.YPIPE •• • i•••�• �•
WIIHM<IN6we •••�•• Vim••••
( EXISTING ••�••� � �•— �•••
Pod Neater
••••
' / •• •• • Q
❑I� hO0,0O0 6i11 •••••• � d •
1MTH w OFF VALVR • Z ••i•
RANGE and 2P51 Reglata •• • v `
220,000 61U ( • • • �/ 0 -�- •••i
WITH 5V OFF VALVE ••• •• •
NSW • •�
60 R,#"POI.YPIPE
I /VJIiN TRACING 1M�
<7 R OUTOOR fA U55 WATEP
40.000 6i11 I DATER
WITH 5Huf OFF VALVE 199,000 6111
WITH w OFF VA-w
11-28-16
a
6A5PLAN
NATURAL 6A5 FLOOp PLAN
2P9 METER
rI?ONf OP HOUSr Sheet I-I
♦SNoles G!
3 �t
,,, _ ,,,,, MiamishoresVillage
J�
Building Department
ORiDA 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:
I. 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:
;
Owner
State of Florida
County of Miami-Dade +L--
The foregoing was acknowledge before me this day of '20
By ,y i CK � SC� who 4p=ersonallyknown o me or has produced
as identification.
�,- EMILY WARDELL
Notary: (.C/ Notary Public,Stato of fbMa
M„comm.so �03 2 20
SEAL: Bonded thru AsMcn ,ft(041140
Gas Connection and Equipment
6428 Rodman Street
Hollywood,Fl. 33023
DADE: 305-940-8820 BROWARD: 954-965-8060
STATE LIC: LPG 24314 BROWARD CC#08-CLPG-14752
Date: Q,
State of ���y�
County of m l c —4�•ti�►�—
Before me this day personally appeared Ue 1 who,being duly sworn,deposes and
Says:
That he or she? it a only person working on the project located at: J� �' , �CL ST_
q.
nftuvf M-0
Sworn to(or affirmed)and subscribed before me this day of -- 20 ,by
AA—T O
Personally known
Or Produced Identification —�
Type of Identification Produced
\y�
'Nell,
cell, /
4 .• �oK •. * /i
90• . s OZoti o�•►'-kype or Stamp Name of Notary
*. �.10420
.. .. .1�c� R7F
111111111%%%