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PL-17-860 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 '_ '- Inspection Number: INSP-288026 Permit Number: PL-3-17-860 Scheduled Inspection Date: August 21,2017 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: CLIFFORD, DEBORAH A Work Classification: Addition/Alteration Job Address:300 NE 101 Street Miami Shores, FL Phone Number (305)335-6685 Parcel Number 1132060135330 Project: <NONE> Contractor: LASSETER PLUMBING CO INC Phone: (305)525-5075 Building Department Comments CHANGE OUT WATER LINE DRAIN LINE REF WATER Infractio Passed Comments LINE DISHWASHER LINE , SINK INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-286785. CREATED AS 14 REINSPECTION FOR INSP-279757. no access 2:30pm Hall bath rough Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid August 18,2017 For Inspections please call: (305)762-4949 Page 13 of 28 j Pet ttt tQ. PL17-860 ; Miami Shores Village P X7T1t Tjtpe Pl�llmlbing ,;tosidentlal <y 10050 N.E.2nd Avenue NE 11 Wb*0 cam' off : ddMo Alt0M0ol"1 p�m M Miami Shores,FL 3313&0000 . '_ Por1»rt 5tatus:APPRdVED Phone: (305)795-2204 OR Issue 0 '"017 Expiration: 10/22/2017 Project Address Parcel Number Applicant 300 NE 101 Street 1132060135330 CLIFFS ON THIRD AVENUE LLC Miami Shores, FL Block: Lot: Owner Information Address Phone Cell CLIFFS ON THIRD AVENUE LLC 1490 NE 103 Street (305)335-6685 MIAMI SHORES FL 33138- 1490 NE 103 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,500.00 LASSETER PLUMBING CO INC (305)525-5075 (305)893-7180 _._. Total Sq Feet: 0 Type of Work:CHANGE OUT WATER LINE DRAIN LINE RE Available Inspections: Type of Piping: Inspection Type: Additional Info:CHANGE OUT WATER LINE DRAIN LINE RE Top Out Bond Return: Final Classification:Residential Scanning:1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 Invoice# PL-3-17-63493 DBPR Fee $2.25 DCA Fee $2.25 03/29/2017 Check#:1015 $50.00 $ 117.30 Education Surcharge $0.60 04/25/2017 Check#: 1054 $ 117.30 $0.00 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $2.40 Total: $167.30 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 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. April 25, 2017 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy April 25,2017 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 R 2 9 2017 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 a`^^ FB 2019- �+ BUILDING Master Permit No. ' `C ( l ` ys PERMIT APPLICATION Sub Permit No.F L �I - V G V ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL KJKLUMBING [:] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP � CONTRACTOR DRAWINGS JOB ADDRESS: 3lA_y'-p a /N f Q 9 5�-er^ ' City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 5330 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: C l ii ` --335 -GaCo OWNER:Name(Fee Simple Titleholder): I�T S 00 3rd, iPhone#: Address: ` qct City: \\'10(y)B s 1 S State: fes' Zip: Tenant/Lessee Name: Phone#: Email: C� n CONTRACTOR:Company Name: Losse lfr PI1.mbi , �nc , Phone#: 10(J Address: Wee .zZZM �� eNjea City: we5 -Pc(r Fes. State: Zip: Qualifier Name: J0 hf1 _'5E-k*- - Phone#: 05_9q3_9 I�� State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Val"Workfo-r_W Parma:$ -U-00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New / ❑ Repair/Rep/lace ❑ Demolition / Descriptionof Work: C ' G o.,z Specify color of color thru tile: Submittal Fee$'�_:C 4 Permit Fee$ !�� ® CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ �I�• �� (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' subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first . pection which occurs se days after the building permit is issued. In the absence of such posted notice, the inspection 1 be approved and a einspecti fee will be c arged. Signatur , t Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this ® �n d'ay of /��� 20 ('7 by day of���Ir/ ` ,20� , by S1�i- -lr;,� ��1�a ,-- is personally known to ��� � �,who is personally known too me or who has produced as me or who has produced����'� � � 18 a� identification and who did take an oath. identification and who did take an oath. �— NOTARY PUBLIC: NOTARY,.•••'••••�glF sii NOTARY PUBLIC: C tea;' �•��r e vy o a b1a�2ii•. �_ • 0:C Sign: =:^n= Sign: e —� Print: s`%"•`� 2 baa• Print: Seal: P%�SpROp�O �\a\Xa\e\\ Seal: - tP�`c•. PAyCOMMSS10N1kGGB44802 d �Notaory Public U nZmletwriters Boed �k/rie ae�k��k+k APPROVED BY �"'n tt'(��11� ' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ACORU0 DATE(MWOONYYY) CERTIFICATE OF LIABILITY INSURANCE 11/3/2016 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 Gina Salvat NAME: Mack, Mack & Waltz Insurance Group, Inc. PHONE (954)640-6225 640 -6226A1C No: 1211 S Military Trail ADDRESS:gsalvat@mackinsurance.com Suite 100 INSURERS)AFFORDING COVERAGE NAIC# Deerfield Beach FL 33442 INSURERAOhio Security Ins. Co. 24082 INSURED INSURER B Br: efield Employers Ins. Co. 10701 INSURERCoerkley National Ins. Cc 38911 Lasseter Plumbing Company, Inc INSURER 0: 865 N.E. 130 Street INSURER E: North Miami FL 33161 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1682935156 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 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. WTSRR TYPE OF INSURANCE DL UBR POLICY NUMBER MPWDOLIDY EFF MPOWDD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE I—XI OCCUR PREMISES EeENTED occurrence $ 100,000 BLS 56272467 9/1/2016 9/1/2017 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: L GENERAL AGGREGATE $ 2,000,000 X POLICY F-1PRO JECT F-1LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMEa aBccINEDident SINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BhS 56272467 9/1/2016 9/1/2017 BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Uninsured motorist combined $ 1,000,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OT - AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) 83021471 5/25/2016 5/25/2017 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 C Equipment Bloater M ,41002286 9/1/2016 9/1/2017 Scheduled Equip.Limit 5,430 Unscheduled Equip Limit 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached B more space Is required) License #CFC041696 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Greg Waltz/GSALVA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 rgrrl4ntt RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC041696 The PLUMBING CONTRACTOR Named below IS CERTIFIEDnD R "b Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 v "a LASSETER,JOHN MARK LASSETER PLUMBING COMPANY 13925 NE 1ST AVE MIAMI FL 33161 �.YiL`. ISSUED: 07/04/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1607040001563 -z P aoas4 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 922097 � LBTI/ �/ BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES LASSETER PLUMBING CO INC RENEWAL SEPTEMBER 30, 2017 865 NE 130 ST 922097 Must be displayed at place of business NORTH MIAMI FL 33161 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED LASSETER PLUMBING CO INC 196 PLUMBING CONTRACTOR BY TAX COLLECTOR CFC041696 Worker(s) 7 $45.00 07/26/2016 CHECK21-16-100929 This Local Business Tax Receipt only confirms payment of the local Business Tax.The Receipt is not a license, permit,of a certification of the holders qual"Ification%to do business.Holder must comply with any governmental or noagovermerdal regulatory laws and requirements which apply to the business. The RECEIPT NOL above most be displayed on all commercial vehicles-Miami-Dade Code Sec M-276. For more information,visit www.miamidade.aovjlaxcollactor 4L S® Electronic Articles of Organization Ll 50008 00 13 For FILED AM May 12 2015 Florida Limited Liability Company Sec. Of State smmason Article I The name of the Limited Liability Company is: CLIFFS ON THIRD AVENUE, LLC Article II The street address of the principal office of the Limited Liability Company is: 1490 NE 103RD STREET MIAMI SHORES, FL. 33138 The mailing address of the Limited Liability Company is: 1490 NE 103RD STREET MIAMI SHORES, FL. 33138 Article III The name and Florida street address of the registered agent is: DEBORAH A CLIFFORD 1490 NE 103RD STREET MIAMI SHORES, FL. 33138 Having been named as registered agent and to accept service of process for the above stated limited liability company at the place designated in this certificate, I hereby accept the appointment as registered agent and agree to act in this capacity. I further agree to comply with the provisions of all statutes relating to the proper and complete perforniance of my duties, and I am familiar with and accept the obligations of my position as registered agent. Registered Agent Signature: DEBORAH A CLIFFORD Article IV L15000084313 The name and address of person(s) authorized to manage LLC: FILED 8:00 AM May 12 2015 Title: AMBR Sec. OY State {DEBORAH_A-CLIFFORD smmason 1490 NE 103RD STREET MIAMI SHORES, FL. 33138 Title: AMBR ( STEPHEN J CLIFFORD, 149077E-103RD STREET MIAMI SHORES, FL, 33138 Signature of member or an authorized representative Electronic Signature: E3 ORAH A CLIFFORD .' I am the member or authorized representative submitting these Articles of Or anization and affirm that the facts stated herein are true. I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S. I understand the requirement to file an annual report between January 1 st and May 1st in the calendar year following fonnation of the LLC and every year thereafter to maintain "active" status.