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Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Parcel Number
Expiration: 01/22/2017
Applicant
8701 NE 4 Avenue Road
Miami Shores, FL 33138-0000
11-3206-046-0660
Block: Lot:
CYNTHIA LAM
Owner Information
Address
Phone
Cell
CYNTHIA LAM
8701 NE 4 Avenue Road
MIAMI SHORES FL 33138-
Contractor(s)
FIX PLUMBING CORP
Phone
(786)343-8127
CeII Phone
Valuation:
Total Sq Feet:
$ 1,200.00
0
Type of Work: REMODEL KITCHEN; REMODEL BATHROOM A
Type of Piping:
Additional Info:
Bond Return :
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$1.20
$2.25
$2.25
$0.40
$150.00
$3.00
$1.60
$160.70
Pay Date Pay Type
Invoice # PL -7-16-60709
07/26/2016 Credit Card
Amt Paid Amt Due
$ 160.70 $ 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 zopi'n"cf. Futhermore, I author' the above-named contractor to do the work stated.
July 26, 2016
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Date
July 26, 2016
1
41.
BUILDING
PERMIT APPLICATION
0 BUILDING
4PLUMBING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION UNE PHONE NUMBER: (305) 762-4949
REC ET\.T 1
JUL 25 2016
BY:
FBC20j4
Master Permit No. RC15-2795
0 ELECTRIC ❑ ROOFING ❑ REVISION
Sub Permit No. A 2-06G
❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 8701 NE 4th Ave Road
0 EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
County:
Miami Dade Zip: 33138
Folio/Parcel#: 11-3206-046-0660 Is the Building Historically Designated: Yes NO X
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address: 8701 NE 4 Ave Road
Construction Type:
Cynthia K. Lam
Flood Zone:
BFE: FFE:
Phone#: 305-333-2177
aty: Miami Shores
Tenant/Lessee Name: N/A
State: Florida
Zip: 33138
Email: Lamsync2@gmail.com
Phone#:
CONTRACTOR: Company Name: Fix Plumbing Corp.
Address: 1091 West 55th Place
Phone#: 786-343-8127
aty: Hialeah
State: Florida
Qualifier Name: Rainier Medina
zip: 33012
Phone#: 786-343-8127
State Certification or Registration it: CFC 1428618 Certificate of Competency it:
DESIGNER: Architect/Engineer: N/A Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 1,200.00 approx. Square/linear Footage of Work:
Type of Work: 0 Addition 0 Alteration (l New
0 Repair/Replace 0 Demolition
Description of Work: Remodel kitchen; Remodel bathroom and convert tub to shower
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $ ` G 0
Structural Reviews $ 5?)
(Revised02/24/2014)
Permit Fee $ I 6 ✓ CCF $ CO/CC $
Radon Fee $ "Z • DBPR $ - - • 2- Notary $
Training/Education Fee $ 0 i Q Double Fee $
Bond $
TOTAL FEE NOW DUE $ 1 -O
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. !n the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me me this
-V' day of Iu4 ,2016 ,by
IL{,•• /� f Yl , who is personally known to
me or who has produced fZt0fl(4t)frb�uh!V as
identification and who did take an oath.
NOTARY PUB C:
Sign:
Print:
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71wIP -; • ODISA VAJAL
Seal: ,1 ;,� 1
o: k ° - gotaiy Public - State of Florida
Q My. Comm. Expires Oct 16, 2018
£,1�19 Commission # FF 148170
iii######N###########################/##########################################
APPROVED BY /"
1 ?.
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Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
9 day of 10'\ , 20 \ , by
22`1 L 14who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC: ,2o gt.r.?y��
Sign:
Print:
Seal:
Caldera
N # FF190254
anuary 15, 2019
ONNOTARY.COM
Plans Examiner
Zoning
Structural Review 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
MEDINA RIMER L
FSS PLUMBING CORP
PO BOX 2257
1-sIALEAH FL 3300'2
ConoralulOaree.111 this kerma yoo become ane of Om newly
one millian Pisfictiatis ficensed by tbs Department of Butinese and
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DETACH HERE
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
CFC1428618 Issuer) 06529/2014
CERTIFIED 131.3,0118ING CONTRACTOR
Nitwit& RENIER
FIX PLUMENCI CORP
iS CERTIFIE0 unact Pie trw C41.499
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KEN t AMON, SECR ARV
STATE OF FLORIDA
DEPARTMENT OF SLISR4ESS AND PROFS IONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING '24 ARD
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FFI ED
apttl 489 FS
AUG 31, 2016
MEDINA, REINTER L
FIX PLUMBFNG CORP
8025 NW 8 ST APTO 1
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07/22/2016 01:16PM 7868038463 ALHAMBRA
CERTIFICATE OF LIABILITY INSURANCE
PAGE 01/01
-me gaimobinore)
07/22/2016
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 TI4E CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is en ADDITIONAL INSURED, the panpipes) 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
ccrt(floate holder in Ileu of such andorsement(s)-
PRODUCER
Alhambra Insurance Agency
832 SW 67 Ave
Miami, FL 33144
Phone (305)
INSURED
FIX PLUMBING CORP
1091 WEST 55 PL
HIALEAH
774.9210 Fax (786) 803.8463
FL 33012
COVERAGES
CERTIFICATE 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.
COATACT'
NA�tB 'w.r.
Yellsa Mederoe
(305) 774-9210
��IAIL slhambrainSuranceagenCyegmall.c0m
iNsuRERIS1 AFFORDING COVERAGE
ADDRESS.
INSURER A :
INSURER 6 :
IA/C, No): (76) 803-8463
NAIL
United States Liability Insurance Company
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REVISION NUMBER:
INSR
TYPE OF INSURANCE
COMMERCIAL GENERAL LIABILITY
❑ CIAIM&MADE LJ OCCUR
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,J'OLICYNUMBER JI�MMIDDMYYYa IMMIODIYVYY1
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Q POLICY 0 j£& 0 LOC
❑ OTHER
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07/12/2016 07/12/2017
LIMITS
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TO RENT
:9MJAIMEo occurrence),
MEP EXP (Any ono person
$ 1,000,000.00
$ 100,000.00
s 5,000.00
PERSONAL & ADV INJURY
$ 1,000,000.00
GENERAL AGGREGATE
s 1,000,000.00
PRODUCTS - COMPIOP AGG
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❑ OO
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ANY PROPRIETOR/PARTNERIEXECUTNCLi
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DESCRIPTION
ndorDESCRIPTION OF OPERATIONS below
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BODILY INJURY (Per person)
BODILY INJURY (Par occident
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$
$
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AC0QRB0ATE $
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Atteoh ACORD 101, Additional Remarks Seltadule, If mere apace le required)
Plumbing.
CERTIFICATE HOLDER
CANCELLATION
MIAMI SHORE VILLAGE BUILDING DEPARTMENT
10050 NE 2 AVENUE
MIAMI SHORES, FL 33150
ACQRD 26 (2014/01) OF
E.L EAC 1 ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
B.L. DISEASE - POLICY LIMIT
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 REP
191988.20
The AC
CORD CORPORATION. All tights eacierved.
name and logo are registered narks of ACOI?D
JEFF ATWATER
MEP FINAICIAL. MICE* STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERSCOMPENSATION
a CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW " •
CONSTRUCTION INDUSTRY EXEMPTION
Tttr, ce/tifees that the ihdvbfeal ratted below has eleoted to be exempt Earn Florida Verviters' Ca
EFFECTIVE DATE: 51M2OTE EXPMATION DATE: 5=018
PERSOt MEDINA RENE
FEIN 451
BUSINESS NAME AND ADDRESS:
FIX PLUMBING COR
1 OD MST 55 PI,
HIALEAH
FL ,32Jal 2
SCOPES OF BUSINESS OR TRADE°
LICENSE!) PLUMBING
CONTRACTOR
tourtutn r.,:tv.9arr F an inCifplittef, %tot) *Luz. ithwivtiatl fmn ta2 cratlef NM* turtrzrUt OrATIn ki-Tr.*1 Wa, Warirra
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votrtn Ile same tto,r,Jravi WO* Estetzi tot Nu' ci kt Ez4tokliigfrist RIIITIrel MIKAN 4.4aCtil .*„ WM" nf,h6g2sYs In be
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ramcd .31 itt Mita!, oiPtiMbei ,agest two,' qui neetuntmptea dei% israirwci coVattla. Me dmertrneist trA0vim
ORI-C2-DtAr..-252 CERTIFICATE Of ELECTITA4 TO BE Milan REVIEfO0613 CRESTIONV (652141113 Ise"
1
Miami Shores Viiiage
Building Department
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. 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:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this k day of 3k')
J L , 20
By 0_y» NIT -1-1 IA K0 L. -UN)
who is personally known to me or has produced
��-(► L�CICN gC-- as identification.
��y POONotary Piiblle Siete of Florida
° `Sindia A1ifSrez
oe My Commission FF 158750
9` of 0.04 Expires 09/03:2018
FIX PLUBMING CO1tP.
1091 West 55th Place
Hialeah, Forida 33012
Telephone: 786-343-8127
State of Florida )
)ss:
County of Miami -Dade)
Before me this day personally appeared Reinier Medina who, being duly sworn, deposes
and says that he will be the only person working on the project located at 8701 NE 4th Ave Road,
Miami Shores, Florida 33138.
Sworn to and subscribed before me this ?e) day of July, 2016 by REINIER MEDINA
l�
who is personally known to me or has produced LIt J 02— as
identification.
REINIER MEDINA
l Nohem
•
COMM
onmo
aldera
190254
15, 2019
ARY.COM
NOTAR
Print:
Seal: