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PL-16-1501Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 R c t 6-1500 Inspection Number: INSP-260054 Permit Number: PL -6-16-1501 Scheduled Inspection Date: October 24, 2016 Inspector. Hernandez, Rafael Owner: DAMMRICH, DANIEL & MARYANNE Job Address: 1223 NE 102 Street Miami Shores, FL 33138 - Project <NONE> Contractor: ACTION PLUMBING OF MIAMI INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number Parcel Number 1132050250140 Phone: (305)278-6900 Building Department Comments KITCHEN AND 1 BATH RENOVATION REPLACE BATH TUB VANITY AND WATER CLOSET IN EXISTING LOCATION REPLACING KITCHEN SINK Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number lutnbing R± igen Addition/Aital on OVED Expiration: 1 / 16 Applicant 1223 NE 102 Street Miami Shores, FL 33138- 1132050250140 Block: Lot: DANIEL & MARYANNE DAMMRII Owner Information Address Phone Cell DANIEL & MARYANNE DAMMRICH 1223 NE 102 Street MIAMI SHORES FL 33138- 1223 NE 102 Street MIAMI SHORES FL 33138- Contractor(s) Phone ACTION PLUMBING OF MIAMI INC (305)278-6900 CeII Phone Valuation: Total Sq Feet: $ 6,000.00 230 Type of Work: KITCHEN AND 1 BATH RENOVATION Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $3.60 $3.38 $3.38 $1.20 $5.00 $225.00 $3.00 $4.80 $249.36 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -6-16-59991 06/09/2016 Credit Card $ 249.36 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 AFF const uctio . n AVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating Futhermore, I authorize the above-named contractor to do the work stated. Lt t_.horiz-Vir"nature: Owner / Applicant / Contractor / Agent Building Department Copy June 09, 2016 Date June 09, 2016 1 s It Miami Shores Village 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 BUILDING PERMIT APPLICATION ❑BUILDING D ELECTRIC ® ROOFING ®PLUMBING ❑ MECHANICAL El PUBLIC WORKS JOB ADDRESS: 1223 NE 102nd Street f Rgc-mnrPTY JUN 01 /U16 FBC 20N Master Permit No. 12 -C -1(e) Sub Permit No. FL -A(0 `• 150 1 0 REVISION ❑ EXTENSION DRENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zio: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Dan & Maryanne Dammrich Address: 1223 NE 102nd Street Phone#: 3055886381 City: Miami Shores State: FL Tenant/Lessee Name: Email: madammrich@gmail.com Zip: 33138 Phone#: CONTRACTOR: Company Name: Action Plumbing of Miami Address: 18545 SW 104 Avenue Phone#: 305-278-6900 city: Cutler Bay Qualifier Name: Harlin Collins State Certification or Registration #: CFC1428021 State: FL Zip: 33157 Phone#: 786-556-7306 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: 54MSquare/Unear Footage of Work: 12'3 Type of Work: 0 Addition IN Alteration ❑ New 0 Repair/Replace ❑ Demolition Description of Work: LEVEL 1 ALTERATION - Replacing bathtub, vanity and water closet in existing location, replacing kitchen sink. Materials = $3220 Labor = $2780 Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $—A • Radon Fee $ DBPR $ 2, 52 CCF$ 3- 60 Technology Fee $ i Structural Reviews $ (Revised02/24/2014) CO/CC $ Notary $ . • Training/Education Fee $ ® Double Fee $ XJ Bond $ tt�� TOTAL FEE NOW DUE $ (9 Tq • �� 6, n 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. Signatur 0 N or AGENT The foregoing instrument was acknowledged before me this (tt day of Avr1( ,20k,(4) ,by S r ya n ne Y1vv\ r lc h , who is personally known to me 4 d as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: jeifcc des (20LI 1 n •,r jA MY COMMIS�SIONN # FF055358 S. tj EXPIRES: January 19, 2018 Bonded Thal Notary Public Undo/Atm Signature The foregoing instrument was acknowledged before me this 13 day of Apr 1 1 , 20 ILc , by Hely 3• (_Murk S ,who is ersonally know me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: to as Print: 6-l.ku G__ . • (.f/Li It Seal: Y 40.`"" Wwo GLORIA J.CHIAPETTA * * MY COWASSION t EE 840619 EXPIRES: February 4, 2017 Banded Thru Budget Ndsy Santos ************************************************************************************************************ APPROVED BY (Revised02/24/2014) R4 ��• Plans Examiner Structural Review Zoning Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 COLLINS, HARLIN J ACTION PLUMBING OF MIAMI INC 18545 SW 104 AVE CUTLER BAY FL 33157 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 range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly, We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE RICK SCOTT. GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS ' PROFESSIONAL REGULATION AND CFC1428021 ISSUED: 08/31/2014 CERTIFIED PLUMBING CONTRACTOR COLLINS, HARLIN J ACTION PLUMBING OF MIAMI INC IS CERTIFIED under the provisions of Ch 489 FS Expnaton date AUG 31 2016 L1408310003879 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CFC1428021 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 COLLINS, HARLIN J ACTION PLUMBING OF MIAMI INC 18545 SW 104 AVE CUTLER BAY FL 33157 ISSUED 08/31/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1408310003879 000044 x rj Local BUMs -Miami-Dade ur 3735 BUSINESS NIA M !LOCA, ACTION PIMAl 18545'S 1 dispisaysti at plata of business DL ra uartt tis G rity C> Cti pter8A _ Art -9 10 OWN AC 1011 PLU viEING OF MIAMI INC IIAFI IN:COLLINS QUALIFIER'. tttfc►rkej(s) to pAYMENT tiECEIVED SY TAN COLLECTOR $8250 ;:10/05/2015 CREDIT ARD -16-000882 Thpolocal Rusinesn$aIt geceiet oldygmfirms poymbntaft a tocol ®usinass Tax. The Reaohist is nota license, Thoonit,orausinaoatloel'afthehonor'taqualificatiois, orlt'r�tstness. HoldermustcomplywithhanyBannn ntel 0i1 t9Gi�alrarnmentdi r pBaYory h edit qui cI e P troiiicttappIu to the The R'E .0 T . chose ralei.a ltisplayad ar all commeee(sI velicc;- aatl-duri C de Sac 8114315 - For tette information, s ita miamideda gid lti is r } l CERTIFICATE OF LIABILITY INSURANCE �KAWD °'"YYY' 04!21118 04/21 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: (f the certificate holder is an ADDITIONAL INSURED, the pollcy(Iss) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain po110109 may require an endorsement. A statement on this certificate does not confer rights to the certificate holder M Lieu of such endorsement(s). PRODUCER Briar Bay Insurance Agency 14229 S Dixie Flay Miami. FL 33176 Phone (305) 251-5546 Fax (305) 251-9947 CONTACT IPPOUTO ROMANO NAIVE: PH No. Ext): (305)251-5546 1 ra, Nov (305)251-9947 ADDA : insuranceebriarwayinsurance.corn INSURERS) AFFORDING COVERAGE NAIC e INSURERA: GRANADA INSURANCE N INSURED ACTION PLUMBING OF MIAMI 18545 SW 104 Ave MIAMI, FL 33157- (305) 278-fi900 INSURER 8 ; 04!14/2018 INSURER C : EACH OCCURRENCE INSURER o : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E: 5COMMERCIAL GENERAL LIABILITY INSURER F : nnmmet►. w,unco. $ 5,000.00 • • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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, PAID EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BYYLICY ILNQR TYPE OF INSURANCE JNSR a `-g POUCY NUMBER �pF jDDLISUBR MMIpOIYYYY) ppCLLAIMS. (MIMiD LIMITS Trc A GENERAL UABIUTY N 0185FL00069445 04!14/2018 04/14/2017 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000,00 5COMMERCIAL GENERAL LIABILITY $ 5,000.00 ❑ CLAIMS -MADE 5 OCCUR MED EXP (Any one person) PERSONAL BADV INJURY $ 1,000,000.00 ■ GENERAL AGGREGATE $ 2,000,000.00 . PRODUCTS - COMP/OP AGG $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: $ ❑ POLICY ❑ FT El LOC AUTOMOBILE LIABILITY Ea ED(SINGL£ LIMfT $ BODILY INJURY (Per person) $ • ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED ❑ AUTOS In SCHEDULED pPefaccidentlAMAGE $ -OWNED • HIRED AUTOS ❑ AUTOS $ • ❑ EACH OCCURRENCE $ II UMBRELLA UAB El OCCUR AGGREGATE $ II EXCESS LIAO ❑ CLAIMS -MADE $ • DED II RETENTION$ WORKERS COMPENSATION AND EMPLOYED° LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory M NH) I( yes, describe urs DESCRIPTION OF OPERATIONS below N /A ❑ C STLIMITS 5 ER - E.L.EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION PLUMBING OP OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Romarks Schedule, if mon apace Is required) I MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 AVENUE MIAMI SHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROV ' j - AUTHORIZED REPRESENTATIVE IPPOLITO ROMANO a `-g ACORD 25 (2010105) CIF ®1988-2010 ACORD CORPORATION. All rtrts reserved. The ACORD name and logo are registered marks of ACORD Adjustable Flow Clean JetTM: The water flow action may be adjusted from vigorous to soft by rotating the nozzle clockwise for vigorous massage and counter -clockwise for soft massage. NOTE: You may balance the air volume control and nozzle adjustment for the most desirable condition. Small Jet Softer Massage — \� (counter -clockwise) More Vigorous Massage 11/41.0000, (clockwise) Large Jet — Softer Massage (counter -clockwise) 11111600••••,More Vigorous Massage (clockwise) LifetimeTM Drain Model 1599 (required on Models 7236LN, 2422LN, 2425LN, 2771UV) Overflow: Partially fill tub, then enter tub before completely filling to prevent overflow. Toe Tap Drain: Depress drain cap to open or close drain. Access Panel (Model 2425L/V) Remove access panel to service motor. Toe Tap Drain Overflow 15 Access Panel (Model 2425W only) 753737-100 Rev. J JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION 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: 4/4/2016 PERSON: COLLINS FEIN: 650121762 BUSINESS NAME AND ADDRESS: ACTION PLUMBING OF MIAMI INC EXPIRATION DATE: 4/4/2018 HARLIN 18545 SW 104 AVE MIAMI FL 33157 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 Notice to Owner Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 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. Signat Owner State of Florida County of Miami -Dade The foregoing was acknowledgeMR` before me this ➢a day of I , 20 ( . 1 " ` By 412—° -P N It -' 'I ttl who is personally known to me or has produced ��. (\c?_ as identification. Notary: SEAL: ®p R4 Notary Public State of Florida ° r qt.Sindia Alvarez . Lia My Commission rr 1,0750 nes®` Expires 09/03/2018 Action Plumbing of Miami Date: May 17, 2016 State of Florida County of Dade Before me this day personally appeared HARLIN J COLLINS who being sworn, deposes and says: That he will be the only person working on the project located at 1223 NE 102ND STREET, MIAMI SHORES, 33138. Sworn to (or affirmed) and subscribed before me this 17th day of May 2016, by Q4.0 Personally know 1! OR Produced Identification Type of Identification Produced Print, Type or Stamp Name of Notary ONMERCEDES CASTILLA ;,4MY COMMISSION # FF 055358 EXPIRES: January 19, 2018 7l f' Bonded Tim, Notary Pudic underwriters