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PL-16-1770Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number Expiration: 12126/2016 Applicant 357 NE 92 Street Miami Shores, FL 33138- 1132060136390 Block: Lot: RONALD & JOANNE RODRIGUE Owner Information Address CeII RONALD & JOANNE RODRIGUEZ 357 NE 92 Street MIAMI SHORES FL 33138-3133 Contractor(s) Phone CeII Phone ELITE INSTALL SOLUTIONS INC (954)461-1340 Valuation: Total Sq Feet: $ 200.00 0 Type of Work: ELECTRIC WATER HEATER REPLACEMENT Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $9.00 $0.80 $114.60 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -6-16-60335 06/29/2016 Check #: 4368 $ 64.60 $ 50.00 06/24/2016 Check #: 4365 $ 50.00 $ 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 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 to to do the work stated. June 29, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date June 29, 2016 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-263070 Permit Number: P L-6-16-1770 Scheduled Inspection Date: July 14, 2016 Inspector: Hernandez, Rafael Owner. RODRIGUEZ, RONALD & JOANNE Job Address: 357 NE 92 Street Miami Shores, FL 33138 - Project <NONE> Contractor: ELITE INSTALL SOLUTIONS INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number Parcel Number 1132060136390 Phone: (954)461-1340 Building Department Comments ELECTRIC WATER HEATER REPLACEMENT Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Infractio Passed Comments INSPECTOR COMMENTS Inspector Comments False (06\ki(° 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 ❑ ELECTRIC ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: City: Folio/Parcel#: RECEIVED JUN 24 2016 FBC 20(4 Master Permit No L_(4- ic3 Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL CONTRACTOR DRAWINGS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Shores County: Occupancy Type: Load: OWNER: Name (Fee Simple Titleholder): City: 4 I S} Or.2 State: P-1 N/A • Address: Construction Type: Miami Dade Zip: Is the Building Historically Designated: Yes Flood Zone: BFE: NO FFE: ,Li us Phone#: WT,OG/IGIlrjb • Tenant/Lessee Name: Email: Phone#: CONTRACTOR: Company Name:,. I I-1, I t 5J I v1S � 'l /� Phone#: 1401 u) 34 G-_ , Address: \4 am � G9 . City: V ---jt (t .4 ')� Stater 1 S kcd? Qualifier Name: State Certification or Registration #: DESIGNER: Architect/Engineer: /'P( - Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: Phone#: Certificate of Competency #: Cr -C-1424 ® 1 4 - Type of Work: ❑ Addition, ❑ Alteration 111New . Description of Work: Wakir la% Repair/ff Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ /44 0 Scanning Fee $ 9 ' Uu Radon Fee $ Cil CCF $ ®- G co/as DBPR $ 00 Notary $ Technology Fee $ c7 • CAD Training/Education Fee $ � J 0 Double Fee $ Structural Reviews $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ 9, 2 Bonding Company's Name (if applicable) Iv Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) 1'0\ 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 reinsfee will brged. p Signature OWNER or AGENT The foregoing instrument was acknowledged before me th' Signature The fore CONTRACTOR oing instrumen was acknowledged before me this 3 day of f» �- , 20 02- J by day of (me , 20 /6 , by t�f✓ ft + $-7 1, who is personally nown to (1 tS Calkwho i ersonall known o me or who has produced /,e 36a 4i28 9'S -as me or who has produced identification and who did take an oath. NOTARY PUBL . Sign:; Print: Seal: TE MY COMMISSION 81815 EXPIRES: DEC 08, 2018 Bonded through 1st State Insurance ****************************** identification and who did take an oath. NOTARY PUBLIC: Sign: Print: as Seal: STEPHANIA fMr1ONTOYA I 9j�a�Y Pi✓a�"t. P'1 tt4Y COMMISSION #FF220189 '•: ; .,g t' - iES• .APR 14, 2019 ° J� d thru(u�hi lot ctaie Insuran e ****************************`***********�*************** APPROVED BYPlans Examiner Structural Review (Revised02/24/2014) Zoning Clerk RICK SCOTT. GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 MCCALL, JAMES J ELITE INSTALL SOLUTIONS INC 12973 SW 112TH ST #169 MIAMI FL 33186 ISSUED: 08/19/2014 DISPLAY AS REQUIRED BY LAW SEQ # 11408190002401 006792 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 7168347 BUSINESS NAME/LOCATION ELITE INSTALL SOLUTIONS INC 14150 SW 129 ST MIAMI FL 33186 OWNER ELITE INSTALL SOLUTIONS INC Worker(s) 3 RECEIPT NO. RENEWAL 7446970 LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 PLUMBING CONTRACTOR CFC1429014 PAYMENT RECEIVED BY TAX COLLECTOR F75,00 09/29/2015 CREDITCARD-15-051923 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is nota license, permit, or a certification of the holder's qualifications. to do business. Holder mum comply with any governmemal or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO, above must be displayed on all commercial vehicles - Miami -Dade Code Sac 8a-276. For more information, visit mivw.miamicladmovitaxeollector --- ---1 60 ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/23/2016 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(ies) 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 Ileu of such endorsement(s). PRODUCER Legacy Insurance Consultants 3512 E. SILVER SPRINGS BLVD #59 OCALA, FL 34470 Phone (786) 248-1958 Fax (866) 552-8509 CONTACT NAME: PHONE FAX (A/C No Extl• (A/C, No): E-MAIL (nfo le ac Insure.Com g y PRODUCER CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED ELITE INSTALL SOLUTIONS INC. 14150 SW 129 ST. MIAMI, FLORIDA 33186 INSURER A : SECURITY NATIONAL INS CO 21199 INSURER B : GRANADA INSURANCE CO 29742 INSURER C : . 11/01/16 INSURER D : $1,000,000 INSURER E : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER F : ■ 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. INSR LTR OF INSURANCE ADDLTYPE NSR INSR SUER WVD POLICY NUMBER EFF IMM/DDPOLICY/YYYY) UCY EXP ( MM/DD/YYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR SES1119767-01 11/01/15 11/01/16 EACH OCCURRENCE $1,000,000 / DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 ■ CLAIMS -MADE ✓ MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $1,000,000 1 1 ■ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑✓ ^ POLICY I LJE C DI LOC PRODUCTS - COMP/OP AGG $1,000,000 $ B AUTOMOBILE ey LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS 0110FL00022441 01/24/16 01/24/17 COMBINED SINGLE LIMIT (Ea accident) $ 300,000 BODILY INJURY (Per person) $ INC. BODILY INJURY (Per accident) $ INC. PROPERTY DAMAGE $ INC. 1 ✓ HIRED AUTOS NON -OWNED AUTOS I I/(Per accident) $ _ UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ - DEDUCTIBLE RETENTION $ $ _ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- TORY LIMITS ER EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ GARAGE LIABILITY ANY AUTO DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CFC1429014 PLUMBING, WATER HEATER INSTALLS MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVENUE MIAMI SHORES, FLORIDA 33138 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977 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* * NON -CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 9/24/2015 PERSON: MCCALL FEIN: 464353590 BUSINESS NAME AND ADDRESS: ELITE INSTALL SOLUTIONS INC EXPIRATION DATE: 9/23/2017 13727 SW 152 STREET #322 MIAMI FL 33177 SCOPES OF BUSINESS OR TRADE: HOUSEHOLD AND COMMERCIAL APPL JAMES J 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 Date: State of: County of: ELITE INSTALL SOLUTIONS INC 14150 SW 129TH STREET MIAMI, FL 33186 954-610-1340 06/23/2016 Florida Miami — Dade Before me this day personally appeared GERMAN HERRERA who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 357 NE 92nd Street, Miami Shores, FI 33138 Sworn to (or affirmed) and subscribed before me this 20th day of JUNE 2016 by STEPHANIA MO TOYA E' is=,iiiA MONTOYA Cl;",iFSi@N #FF220189 ,p,_:,: APR 14, 2019 nra;r i 1st State Insurance Personally Know Or produced identification Type of identification produced + hores illage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Com 6• ensation Insurance Exem .dtion 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 . ircumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the %•ntract+ 's company for day labor, part-time employees or subcontractors. BY SIt.iNTNG BELOW YOU AC YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONT I -NTS. State of Florida County of Miami -Dade HI -The foregoing was acknowledge before me this a� day of _ _ ib , 20__. By who is personally known to me or has produced as identification. Notary: SEAT.,: L STE1H.' tAMONTOYA MY COMMISSION #FF220189 EXPIRES: APR 14, 2019 !loaded throuih 1st4a1e k;surance