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PL-17-963 Permit NO. PL-4-17-963 `yHORES Miami Shores Village 00 Permit Type:Plumbing-'Residential 10050 N.E.2nd Avenue NE ' Work Classification:Addition/Alteration Miami Shores, FL 33138-0000 Pen ot Permit Status:APPROVED Phone: (305)795-2204 Issue Date:4/14/2017 Expiration: 10/1112017 Project Address Parcel Number Applicant 1201 NE 91 Terrace 1132050010210 Miami Shores, FL Block: Lot: FELIPE VALLS SR Owner Information Address Phone Cell FELIPE VALLS SR 3663 SW 8 Street (305)219-0471 MIAMI FL 33135- 3663 SW 8 Street FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,000.00 ELPIDIO MOREJON INC (786)295-4004 Total Scl Feet: 0 Type of Work: REPAIRS TO EXISTING PLUMBING TO SAT 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 $1.20 Invoice# PL-4-17-63608 DBPR Fee $2.25 04/06/2017 Credit Card $50.00 $360.70 DCA Fee $2.25 Education Surcharge $0.40 04/14/2017 Credit Card $360.70 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.60 Work without Permit Fee $250.00 Total: $410.70 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 Inp zoning. Futherm e,I authorize the above-named contractor to do the work stated. 6 April 14, 2017 Authorized Signature Owner / Applicant / Contractor / Agent Date Building Department Copy April 14, 2017 1 .� -f-VD Miami Shores Village APR 03 7017 Building Department BY=— - - - - 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 4 INSPECTION LINE PHONE NUMBER:(305)762-4949 G FBC 201 y BUILDING Master Permit No.�16--S.�233 PERMIT APPLICATION Sub Permit No.Tu'� - BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP I CONTRACTOR DRAWINGS JOB ADDRESS: ` Te4— \ Ci : Miami SShoores ��//�� Coun : Miami Dade Zip: Folio/Parcel#: L l- '>�� 00 62-1 D Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): G/¢'lam-1�- wWl S Phone#: ` 101 Address: �� n , � l� , X21 City: Ifi-yl at� / State: Zip: Tenant/Lessse►q�Name: V / �+- n inn Phone#: C Email: l�V���� col -M(A CONTRACTOR:Company Name: `� - �'A Phone#: Address: 3 City: " ,:��; State: Zip n � Qualifier Name: � � o c Phone#: State Certification or Reg ration#: 3Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ iV�• Square/Linear Footage of Work: Type of Work: ❑ Addition F-1 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: s \V 1 1l up V1 A I(�t C" 6- UAL ddW- 1A)IL4 P6VM-z Specify color of color thru tile: lrb•0c)50 df Submittal Fee$ - (X) Permit Fee$ - CCF$_-------- CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ N�tap�$ Technology Fee$ Training/Education Fee$ Double Fee O Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 3 FOG �1 (Revised02/24/2014) 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 be approved and a reinspection fee will be charged. Signature Signature zz�[' OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 15 day of 2 by —SLI, day of n I 20 (-1 ,by wh is personally kno n to �\tt/l(M Q H.6Le� Nt 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 PI IBILIC: o DAY~,.......... -, ERA ='r MY COM #FF00 69 Sign: Sign: ,a Print: Print: 9e e Fl N to eewtee: o"aY � GEORGETTE BLACKBURN Seal: *r °•• '•�* MY COMMISSION t FF 202094 Seal: EXPIRES:June 13,2019 �j9rf ov c� ! Bonded ihru Budget Notary Senits *ss*************s*sss***s***********ssss*s***s*s***************sss*****************************s************ APPROVED BY 1W q41— /-7 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) �S Evil .....� Miami shores Village Building Department 0 �toxi> 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* A. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: BUSINESS ADDRESS: 3 w F(— CITY STATE zipe2- BUSINESS PHONE: L796 FAX NUMBER(_� CELL PHONE{_� QUALIFIER'S NAME: l D I`ID12C�� QUALIFIER'S LIC NUMBER: C�:C©sq q 4 RICK SCOTT,GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION sr CONSTRUCTION INDUSTRY LICENSING BOARD *�. • L''� 1"90057942 4I The PLUMBING CONTRACTOR N, %; r , Named below IS CERTIFIED W Under the provisions of Chapter 489 FS. . . Expiration date: AUG 31, 2018 MOREJON, ELPIDIO ELPIDIO MOREJON 933 NW 134TH PLACE " MIAMI ,FL 331821' S }� 4 ■ . `J .1 ISSUED: 07/05/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1607050001178 -------------------------- -—_....---- -...._.__._....—--------- - ......... .._._._ 003645 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY _1 6764188 LBT BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES ELPIDIO MOROCIN INC RENEWAL933NSEPTEMBER 30, 2017 MIAMI 134 PL 7037583 Must be displayed at place of business MIAF FL 33182 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS ELPIDIO MOREJON INC 196 PLUMBING CONTRACTOR PAYMENT RECEIVED CFC057942 BY TAX COLLECTOR Worker(s) 1 $75.00 08/23/2016 CREDITCARD-16-048776 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holder squalifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec Be-276. \ For more information,visit wy F jid agovhaxcoltector • t Cos w. JEFF ATWATER CHIEF FINANCIAL OFFICER 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 Florida Workers'Compensation law. EFFECTIVE DATE: 2/21/2017 EXPIRATION DATE: 2/21/2019 PERSON: MOREJON ELPIDIO FEIN: 274044596 BUSINESS NAME AND ADDRESS: ELPIDIO MOREJON INC 933 NW 134 PLACE MIAMI FL 33182 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 ELPIdIO MOREJON INC Date: / b / State of Florida County of Miami-Dade Before me this day personally appeared Elpidio Morejon who being duly sworn, deposes and says: That he will be the only person working on the project located at : 1201 NE 91 Terr Miami Shores Sworn to (or affirmed) and subscribed before me this / 0 day of--�,F- —,C., , 20�by Elpidio Morejon: Elpidio Morejon (sign) Personally known ProducedID_ '_� Type of '7 A�• int,Type,or Stamp Name of Notary o ADRW A LEONOR CLAVU0 MAURI My COMMISSION#FF141376 EXPIRES July 13.2018 (407)398-0153 FloridallotaryService.com OR ♦5Nl,c.RFs Dr s� 1 Miami Shores Village onesBuilding Department R,�p 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 ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: �22 r,�L L—Owner State of Florida County of Miami-Dade The foregoing was acknowedge before me this day of r ,20 I, By e&eAojpzeZi who ispersonally kno or has produced ' as iden }cation. Notary: °`"."-�P:;B�H GEORGETTEBLAC=RN * * MY COMMISSION 4 FF 202094 SEAL: F ea EXPIRES: June 13,2019 OF 4Fl u* oaly Servke,