PL-16-921 erivO P'L-4-19-921 y
sKO1 s°,i Miami Shores Village P lilt y(? lutnbinq-Reaidentidt_:
' 10050 N.E.2nd Avenue NE P'e Work:0a5sffiCOW AdditiorMott. :
Miami Shores,FL 33138-0000
Phone: (305)795-2204 Perm'Ststus` �
Issue tete:4/8126416 Expiration: �0/05!2016
Project Address Parcel Number Applicant
1090 NE 92 Street 1132050270410
MIAMI UP 2 VIEW LLC
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
MIAMI UP 2 VIEW LLC 720 NE 62 Street (305)778-5745
MIAMI FL 33138-
Contractor(s) Phone Cell Phone $ 11,500.00
Valuation:
PIPELINE PLUMBING INC (954)553-3276
Total Sq Feet: 0
Type of Work:INSTALL NEW PLUMBING IN MASTER BATH 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 $7.20 Invoice# PL-4-16-59300
DBPR Fee $4.50 04/06/2016 Credit Card $50.00 $286.20
DCA Fee $4.50
Education Surcharge $2.40 04/08/2016 Credit Card $286.20 $0.00
Notary Fee $0.00
Notary Fee $5.00
Permit Fee` $300.00
Scanning Fee $3.00
Technology Fee $9.60
Total•; $336.20
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.
r
April 08,2016
Authorized Signature: r / Applicant / Contractor / Agent Date
Buildin partment Copy
April 08, 2016 1
Miami Shores Village 6
� A ® I
Building Department � :
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 .V
TFBC 20`'�'
BUILDING Master Permit No.-P—QA J - :3213
PERMIT APPLICATION Sub Permit No
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 4�i�SON 2 7 1)d
City: Miami Shores County: Miami Dade Zia:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): � � IA,6.? toie — Phone#: ,3,-;,1 9:7. f
Address: 22 42 L/Y-�? �
City: &-tna-2 State: T��J?a /rr9 Zip: /
Tenant/Lessee Name: Phone#:
Email: 4:�WQ,�2/0 L�'2&d 91 d2 Q) h��" ,
CONTRACTOR:Company Name: / /� f'U R Vrij I' j �fAlPhone#: 'T51 553 X226
Address: /i 70 2 S'Cv �11 .S'T
City: r-'; LA VD i State: Zip: .33 3 3�±)
Qualifier Name: _ �o� ��,,s y0 Phone#: '! ySy
State Certification or Registration#: C.asa;% r Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ ®� f°� "� Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: /fi, T' dim Y4
7-&4 -� l U
E 1®ft9% TlIg 5l rorf� 7`)WZ 7 r9 6®A I
Specify color of color thru tile:
?yl- &-411s70AAMD Dp-
Submittal Fee$ Permit Fee$ ®�� '� CCF$ CO/CC$
Scanning Fee$ ` P Radon Fee$ DBPR$ Notary$ b
Technology Fee$P '60® Training/Education Fee$ C), 40 Double Fee$
Structural Reviews$ 0 Bond$ P
TOTAL FEE NOW DUE$ ZQ 6 ^ �k:J
(Revised02/24/2014)
11
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
OWNER or AGENT NTRA
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
r' day of 20 r Lo by `S day of S►Ar- S 20 a by
(Y-i-\j^•E NS who is perste known to
-S(Z- FF�w►° cS[3Wwho is personally known to
me or who has produced '' SSP G Z-i as me or who has produced Iq— 121� - as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
..E z
Sign Sign• e
�iiCf '10�a -
Print: Print: _ -
n Notary Publ� Cn: cit _
Seal: Mwtica Luzarta9g Seal: i8 ,r miss
My Commfsaion EE 175909 -i' Fri'f 0�' t
)`'•.•• �So ...•' \�:
APPROVED BY \ / 7� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Local Business Tax Receipt
Miami—Dade County, State of Florida
—THIS IS NOTA BILL — DO NOT PAY LBT
2555168
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
PIPELINE PLUMBING INC RENEWAL SEPTEMBER 30, 2016
DOING BUS IN DADE CO 2680966 Must be displayed at place of business
MIAMI FL 33000 Pursuant to County Code
Chapter 8A-Art.9&10
OWNER SEC.TYPE OF BUSINESS
PIPELINE PLUMBING INC 196 PLUMBING CONTRACTOR PAYMENT RECEIVED
BY TAX;COLLECTOR
Worker(s) 1 CFC052658 $75.00,09/19/2015
CREDITCARD-15-047399
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's qualifications,to do business.Holder must comply with any governmental
or nongovernmental regulatory laws aad requirements which apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276.
For more information,visit www.mlamidade.gov/taxcollector
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD o�
CFC052658 t "
The PLUMBING CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
JESSUP, JEFFREY MICHAEL
PIPELINE PLUMBING INC Y
11902 SW 48TH STREET - - -
COOPER GITY FL 33330-
ISSUED:
3330 ISSUED: 07/27/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407270002058
4 Fax:(305)756-8972
►co O® CERTIFICATE OF LIABILITY INSURANCE DATE(AiAAfDDNYYY)
01/15/2016
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 pollcy(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 CT
NAME Laura Murray
Finney Insurance Corporation PHONE 954966-5533 AI No:954-989-8208
5601 Sheridan Street AE,r ss- johnf@finneyinsurancecorp.com
Hollywood,FL 33021 INSU S AFFORDING COVERAGE MAIC#
INSURER A: Allied Propeft&Casualty 42579
INSURED INSURERS:
Pipeline Plumbing Inc
JEFFREY JESSUP INSURER C:
11902 SW 48th St INSURER D:
Cooper City, FL 33330-4460 IN E:
INSURER F
COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2
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 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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POUCY NUMBER MM/DD MMIDD LIMITS
A X COMMERCIAL GENERAL LIABILITY ACPGLP05926106686 05/15/2015 05/1512016 EACH OCCURRENCE $ 500,000
TO RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 100,000
MED EXP(Any one parson) $ 1,000
PERSONAL&ADV INJURY $ 600,000
GENIL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000
X POLICY❑JEST F�LOC PRODUCTS-COMP/0P AGG $ 1,000,000
OTHER: $
AUTOMOBILE LIABILnY COMBINED SINGLE LIMIT $
CET,r'
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS er acddent
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIM CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATIONP OTH-
AND EMPLOYERS'I ABILITY Y/N STATUTE ER
ANY PROPRIETORIPARTNERIEXECUTIVEE.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? F-1 N I A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If yes describe under
DESCRIPTION OF OPERATIONS below EJ_DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required)
Plumbing Contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2 Avenue
Miami Shores Village, FL 33138 AUTHORCM9 REPRESENT
LLM
All rights res
81988-2014 ACORD CORPORATION. Aerved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Printed by LLM on January 15,2016 at 10:38AM
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: 6/13/2015 EXPIRATION DATE: 6/12/2017
PERSON: JESSUP JEFFREY M
FEIN: 650272806
BUSINESS NAME AND ADDRESS:
PIPELINE PLUMBING INC
11902 SW 48TH STREET
COOPER CITY FL 33330
SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING
CONTRACTOR
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 fbWasuance 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
l �
PIP�LI1aV�
P L U M B 1 N G
11902 S.W.48'Street
Cooper City F133330
CF C052658
Office/FAX:954.680.4415 Cell: 954.553.3276
Date: ��� I
State of 0 R J0 A
County of M.,R,mA A V�
Before me this day personally appeared being duly sworn,deposes and says:
That he or she will be the only person working on the project located at: e 6 9i' t, 5--rek'nr
Sworn to(or affirmed)and subscribed before me this W2 day of�" ,20J9,by
Personally known
Or produced Identification
Type of Identification Produced e L i LEN S�
a°gyp Po®� Notary Puhiic State of Florida
Sindia Alvarez Print T or Stam Name of
ca My commission FF 156750 Type P Notary
hroFo� Expires 0910312018
1�Baa
.., „,„ Miami shores Village
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-
1
f:
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:
-�--T—
wger
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this IG day of S oN ry v A 1L” ,20 S .
By tilt (J cA M who is pe nally known to me or has produced
,Ag S F'G ct- as identification.
a Notary: Pu Notary Public Stere of FbridaMonica Luzarl'a9aSEAL: L�,01
� MEzy�C O^ SEB 41y808
��✓ I� P -?L k6 '?z/ Fax: (306)756.8972
�►co Ua CERTIFICATE OF LIABILITY INSURANCE 511
D01NFY)
5/191220 0166
THIS CERTIFICATE IS 16SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE'DOE&NOT AFFIRMATNELY OR NEGATIVELY AMEND,OMNI)OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFIGATE HOLDER.
IMPORTANT: If the Cartitleate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the forms and conditions of the policy,certain polloiss may require an endorsement. A statement on
this Certificate does not confer fi bts to the certificate holder in lieu of such endorswe s.
PRODUCER
tONTAICITpier Estrella
Finney Insurance Corporation 964 966-111M Na:9S SSM208
6801 Sheridan Street 2ty insuranesco .com
Hollywood,FL 33021 MURMS)A>"foRDINocOYFRAOI; woo
I NSLIKE R A Allied Bno*&CasUally 42579--
MBUR�
Pipeline Plumbing Inc INBUROi B:
INsuRERc:
JEFFREY JESSUP
11902 SW U Street
N
Cooper City,F1_33330 I ,
N Mff
COVERAGES CERTIFICATE NUM13ER: 00000000-72218 REVISION NUMBER: 4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVNTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUE=D OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY MVE BEEN REDUCED SY PAID CLAIMS.
ILIM NGIN AVUL gum?
TMOFINSURANCE POLI,fir UUM
A X COMM ImAJLr-mERAL u"U1Y ACPGLP05936106686 0rif151201S 01111501? EACH kiCURRENCE $ 500,000
TV Rem AU
CLAIM MADE FX O00UA `;Es(FA*=Mm; a 100-0-00
MIDIiXP ft ane $ 1,000
PENAL&ADVINJURY $ 500,000
GRN'LAGGREGATE LIRMITAPPUSS PER: GENERAL AGGREGATE S 1 000 000
X P�ICY�jEC- �LOG PRODUCTS-COMPIOPAGO $ 1000,000
OTHER: $
AUTOMONAUABILJTY COMBINED R S
Ea aatlaent
ANY AUTO BODILY INJURY(Pwparsmt) S
OWNSCHEDULED
UONLY �OSQDILYINJLRY(�
r�a� S
ONON-OWNED PRO EAUTONLY AUi�
S
t $
Uate)Rta,LA LMHCLAAr,-
OCC EACH OOCURROKS $
EXCIMSLUM ADE AGGREGATE $
DED I I 9=14TI0144—
p7� S
WORKMAN LO UW LIAINUTfE
ANY PROPRIMRIPARYNER ecunw Yf a ELFJICHACCIDENT S
ORnsf0g in NN} ER EXCLUDED? N/A i=L DISEASE-FA SMPLO $
OFF OOPEhalaw
If yymassdeSOtibe URF-L.DISEASE.POUCY LEMR S
D65CRI
DESCRIPTION OF OPERATIONS f LOCAMOI VMiICLES(ACORD 101.Additional Rmaa,eahW urs,may ba atbleAad R mora spam Is nmq�drmd)
Plumbing Contractor.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED poRlems 9E CANCELLED BEFORE
Village of Miami Shores THE EXPIRATION DATE TH RKEOF,NOTICE WILL BE DELIVERED IN
10060 NE 2 Avenue AOCOrRDANCE MH THE POLICY PROVIsIONB.
Miami Shores Village,FL 33138 Aunty REPRESEN�gILVE
FEE
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD
Printed by FEE on Moy 19,2016 at 11:54AM