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PL-16-3013 i, -114 Miami Shores Village � �,�� ?11�7",j P1 mbing-R#lSii elil l 10050 N.E.2nd Avenue NE �t O1f At t �o"Afteration Miami Shores,FL 33138-0000 F@p Phone: (305)795-2204 Expiration: 5/27/2017 I 11128/2t�16 Exp. Project Address Parcel Number Applicant 790 NE 91 Street Number: 8 1132060390080 Miami Shores, FL Block: Lot: R GREGORY CHARLES Owner Information Address Phone Cell R GREGORY CHARLES 790 NE 91 ST#8 MIAMI FL 33138-3250 Contractor(s) Phone Cell Phone Valuation: $ 1,800.00 BLUE LINE PLUMBING INC. 954/920-4900 Total Sq Feet: 0 Type of Work:INSTALL W/C LOW AND REPLACE TUB WIT Available Inspections: Type of Piping: Inspection Type: Additional Info:INSTALL W/C LOW AND REPLACE TUB WIT 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-11-16-61911 DBPR Fee $3.38 11/03/2016 Credit Card $50.00 $192.96 DCA Fee $3.38 Education Surcharge $0.40 11/28/2016 Check#:2605 $ 192.96 $0.00 Notary Fee $5.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $242.96 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. OWN FFIDAVIT: I rtify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constr ctio and zonin F h or I authorize the above-named contractor to do the work stated. November 28, 2016 Aut d Signature: r / Applicant / Contractor / Agent Date Building Department Copy November 28,2016 1 1 'I�vr�V � Zulu Shores Village Building Department BY- 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20((- BUILDING Master Permit No. P., C WO Q, PERMIT APPLICATION Sub Permit No. P / - �l ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION EXTENSION EJRENEWAIL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP n ' �� CONTRACTOR DRAWINGS JOB ADDRESS: �1 i t' I' � $ '11 lorAk Sh� L• City: Miami Shores County: Miami Dade Zip: 3'Zi Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type:�� p,Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): w4�R.j' Phone#: 'r� ( 'S Address: 1V � �`G•�� �'?�' City: r'(�1p �}}��� State: �L� Zip: .4&a +�8 Tenant/Lessee Name: Phone#: Email: 11 q CONTRACTOR:Company Name: b6i_ "tie, P6 %WtAi TY3e- Phone#: dos`(o s 5f�/Z'Z Address: 4 5 91 6 rio Sk 61" 54"A City:�..Q1j-�(9��-� C�0.�R. —State: P-11 Zip: S'31 Ll Qualifier Name: `1tq'8 Z)-'CAPhone#: -{!!)—,t* ClZ 6�n G8 State Certification or Registration#: e FC -�-�9_Certificate of Competency#: DESIGNER:Architect/Engineer: �iiY�R 6�'�QS � , `^y�yW -1 �• Phone#:hz 2461'1 b Address: -!Pc,---A City: State: Zip: � +�p(�J Value of Work for this Permit:$ L g�-0`5 �Sq /LinearrFF000tage of Work: PA Type of Work: ❑ Additioon1 El Alteration ❑ New 12 Repair/Replace Demolition Description of Work: ,1 rt S�ct Ll Wl ¢ �.O✓� ��� tri w l;bL. S yW ~ c solo4pftolor thru tile: Submittal Fee$ Permit Fee$ a CCF$ � ' 2® CO/CC$ Scanning Fee$ Radon Fee$ ` �$ DBPR$ 5 • Notary$ f5 Technology Fee$ I V Training/Education Fee$ . (40 Double Fee$ Structural Reviews$ Bond$ r® TOTAL FEE NOW DUE$ 1 C4 Z ° (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 regulAing 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.4', Notice to Applicant:As a"ition to the issuance of a building-pgamit with an estilnpted-yalue exceedii9$2500, tpe 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 r►fust 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. �a Signature ® l Signature OWNER or AGENT TRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this V day of 120 W by day of /l ldV 20 1 l0 by Ch Fq tILC r. who is personally known to S u who is personally known to me or who has produced 1 )It'tV`e i I�C`C�y as me or who has produced !/��Oo�'?SYS D'�3 3—� as identification and who did take an identification and who did take an oath. NOTARY PUB NOTARY PUBLIC: Sign: Sign: ` pu0g Print: Print: /I'J S 010Z'LZ JIMsejldx3 VW00 AN 'YANADY PR 3IETO 3' i Seal: '' ��= Seal: IDI�OId i0 Blois-mod Rmiou '•� _.: MY COMMISSION#FF 214031 '•,,, a EXPIRES:March 25,2019 SWtlatl A3W111l16 �►`` ze��' o?• Bonded Thr.Notary Public Underwriters k rk*�+k*ffik��k k k.k k k**k+k�*k k***4k.k k kk*k k k/ffi k kk*ffiN k rk k k k k k##k k k k k k k k k k k k kk k M k k k k k k k k k k k#k k rk+k k k k k kk k k k Nk+k k k k k#+k k k rk k k APPROVED BY /� ° Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) No. 3 Dorchester Falk. Petit Malley, Trinidad, West Indies. Contact: (868) 299-4734. 5`h August, 2011. TO WHOM IT MAY CONCERN This letter is to confirm that I, Randolph Gregory Charles, of the above address, am the owner of Apartment 8, 790 North East, 91St' Street, Miami, Florida, 3 313 8, United States of America. I hereby authorize any uncle, Reginald Charles Fuller, of No. 10750 forth West, 22nd Avenue road, Miami, Florida, 33167, United States of America, to be my agent for my said Apartment. I also hereby authorize the said Reginald Charles Fuller to carry out all renovations, repairs and/or alterations to my Apartment including changing cupboards; electrical installations, wining and/or file works or whatsoever is required. Reginald Charles Fuller is also authorized to sign on my behalf any .?.-.. »..+ ,o.v.var .5 !-. iraa n as sv r vc� / D f--- the s to E b�attC a,:�Y4�Ibmeantatnor. A%, tissues stZ< vbtauaana any �.em t`5y as a ,,as 7uaw renovations, repairs and/or alterations to be done to my Apartment. If any further information is required, I can be contacted at my address and%or.telephone number in Trinidad. ..A...�j�...... ..................... Randolph Gregory Charles Signed by the above-named Randolph Gregory Charles (Republic of Trinidad and Tobago Driver's Permit No. 153724 E) in my presence at Second Floor, No. 55 Edward Street, Port of Spain, Trinidad, West Indies,this —$qday of August, 2011. r FLORIDA SHORT-FORM INDIVIDUAL ACKNOWLEDGMENT FS 695.25 State of Florida The foregoing instrument was acknowledged before a County of �10 i1"`1ss���jr me this ��, day of Day Month ear 1 by ��' a� � '���' K> t Name of Person Acknowledging • who is personally known to me or who has produced ) og Type of Identification EVONE P JONES 0 Notary Public-State of Florida as identification. My Comm.Expires Aug 22.2014 �, l Commission #EE 19695 ) Notary Public '.�,,.•� Bonder•TtirnuCh Natinnl Nntati.Assn Signature of No ry Public ) Name of Notary Typed,Printed or Stamped Commission No. 0?5— ) I OPTIONAL JuiLl Though the information in this section is not required by law, it may prove valuable to persons relying on the • document and could prevent fraudulent removal and reattachment of this form to another document. Top of thu nb here l Description of Attached Document Title or Type of Document: �� G' s9, �; cy `. �� �� Document Date: ��.-- Number of Pages: Signer(s) Other Than Named Above: /AYI;`"?It ) ©2000 National Notary Association•9350 De Soto Ave.,P.O.Box 2402•Chatsworth,CA 91313-2402•www.NationalNotary.org Prod.No.5181 Reorder:Call Toll-Fre 1-800.876-6827 A ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/28/2016 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). PRODUCER CONTACT Allison Brinkerhoff BOLT Insurance Agency PHONE (600)216-4171 No: 9023 Town Center Parkway ADDRESS:support@boltinsurance.com INSURERS AFFORDING COVERAGE NAIC# Lakewood Ranch FL 34202 INSURERA:SIS Insurance INSURED INSURER S: Blue Line Plumbing, Inc. , DBA: Blue Line Plumbing INSURER C: 4591 NW 40th Street INSURER D: INSURER E: Lauderdale Lakes FL 33319 INSURER F: COVERAGES CERTIFICATE NUMBER:CL16102803558 REVISION NUMBER: THIS IS TO CERTIFY THAT XE 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 O AY PERTAIN, THE INSURANCE AFFORDED 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 ADOLTS-UN ADO-UNPOLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD I WVIL POLICY NUMBER tMMfDD1YYYY1 (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAE TO A CLAIMS-MADE 7 OCCUR PREMISES ERE, rren $ 50,000 PCIC5043-PCAS16052-03 3/2/2016 3/2/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY EIPECOT- El LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: I $ AUTOMOBILE LIABILITY COEMBINEDd nt SINGLE LIMIT $ a ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADIE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE•EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more apace Is required) Job description: Plumbing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE A Brinkerhoff/ABRIN s ``- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 rprlt4cri 04 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION a CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 we 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 DACRES, GLASFORD HULAND BLUE LINE PLUMBING INC 4591 NW 40TH STREET LAUDERDALE LAKES FL 33319 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range0-v STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque DEPARTMENT-OF BUSINESS AND restaurants,and they keep Florida's economy strong. PROFESSIONAL_REGULATION Every day we work to improve the way we do business in order CFC1425902 _ 16SU_ED: 08/10/2016 to serve you better. For information about our services, please _ log onto www.myfloridalleense.com. There you can find more CERTIFIED PLUMBING.-CONTRACTOR information about our divisions and the regulations that impact DACRES, GLASFORD HUt'.AND . you, subscribe to department newsletters and learn more about BLUE LINE PLUMBING,IVIG the Department's initiatives. ;. r Our mission at the Department is:License Efficiently, Regulate Fairly.We constantly strive to serve you better so that you can IS CERTIFIED under the provisions of Ch.489 FS. serve your customers. Thank you for doing business in Florida, Expiration date I AUG31,2018 zone L16.489 FS. and congratulations on your new license! 01469 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1425902 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 DACRES, GLASFORD HULAND;." ❑ t BLUE LINE PLUMBING-IN`C" _� 4591 NW40THSTREET LAUDERDALE LAKES FL 33319 ❑. ISSUED: 08/10/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1608100001469 1 100% s ' 'hilt tiT4 Y. �y .r. JEFF ATINATER CHEF FINANCIAL OFFICER STATE F FLORIDA DEPARTMENT OF NANCIAL SERVICES DIVISION OF WO RS'COMPENSATION + "CERTIFICATE OF ELECTION TO BE EXEMPT FROM ORIDA WORKERS'COMPENSATION LAW•' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual fisted below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 3/5/2015 EXPIRATION DATE: 3/4/2017 PERSON: DACRES GLASFORD FEIN: 651029447 BUSINESS NAME AND ADDRESS: BLUE LINE PLUMBING INC 4591 NW 40TH STREET LAUDERDALE LAKES FL 33318 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pamuam to Chapter440.05(14).F.&.en after of a cogmmtdn w w etees exemption fmm eda dmpter Oytibg a xe•xame otelec m uMer fids sedbn 'd may net recover henelrts orunder Ods dwpter.Fumullyd CO chapter 44x05(12).F.B..Ca t�of to be exert.-apply mq'wiWn the soopa of the bx or W an the mow of election d be sx cerftatas Pemxd m gwpla 440. 13.F NoMmofeWfon b be exanpt mal of election to be exempt shag he suft)ect to revoxabn B aaW tine atter dm fikg ofthe no0w w 0xa issue el'0xa terms,the pmsm nomadonSre mdw orwNflwtam WV-meed the xeQu-MftffithIs seed-f or iss+mxce Of a oexti0eam.lire depmUx tsha0 me�d.a cwAm,.t DFSF24OWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 0813 QUESTIONS?(850)413.1609 https://apps8.fldfs.com/erreportviewer/report'Viewer.aspx?data=kdvpginc9D7Q3gH6TER6... 3/11/2015 V- Blue Line Plumbing Inc 4591 NW 40TH Street Lauderdale Lakes Florida 33319 954-9204900/305-9685427 CFC 1425902 bluelineplumbing@comcast.net Nov 1st 2016 State of Florida County of Broward Before me this day personally appeared 11/1/16 who, being duly sworn,deposes and says: That he or she will be the only person working on the project located at 790 North East 91st Street, Apartment#8 Miami Shores Florida 33138. ^^((� Sworn to (or affirm and subscribe before me this-------I-----day of�1PN(e� -20 ���Q ------ ------ =- ---------------- Personally know--------------------------- OR Produced Identification----- -------------------p Type of Identification Produced- )6(4 Print,Type r Stamp Name of Notary r'ABRITTNEY ADAMS Notary Public.State of Florida Commission#►FF 984858 My Comm.Expires Mar 27,2020 h� • BpnQed-thr0�h NitbRel Notary Assn - • rr Miami shores villagE R Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Notice to owner i Fax: (305) 756.8972 workers Cont ensation Insurance Exemption p ion Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida allows corporate officers in the construction industry to exempt themselves from this requirement for an g g permit. Pursuant to the Florida Division of Workers,Compensation Statutes. Fla.�Stat. § 440.05 obtaining a building Employer Facts Broch�ureon project prior to Au employer in the construction industry who employs one or more art_ employees,including the owner,must obtain workers'compensation coveraF tune or full-time or members of a limited liability companyp ge• Corporate officers exempt if. (LLC) in the construction industry may elect to be 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 theminimum 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 com an allowed to be exempt. Construction exemptions are valid for a period of two voluntary revocation is filed or the exemption is revoked by the Division. p Y members are p years or until a Your contractor is requesting a permit under th day labor,part-time employees or subcontractors is workers'compensation exemption and has acknowledge that be or for your project.The contractor has provided an affidavit be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not stating wire vshe will not use workers'compensation insurance coverage from the cor, r that he or she will BY SIGNING BELOW YOU ACKNOWLEDGE tractor's company for day labor,part-tiL1e employees or subcontractors.of CONTENTS.. WLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS Signature:�� Owner State of Florida County of Miami-Dade The foregoing was acknowledge before_ me this Z8 day of be,,20 I BY(���C.���tt1Q1 tr�`eS 4"Utt�Q,t►• Who is personally known to me or has produced t i identification. Notary: "lad. YANADY PRIETO —� '`-0 MY COMMISSION#FF 214031 SEAL. 'a EXPIRES:March 25.2019 -Fp Bonded Thru Notary Public Underwriters