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PL-17-1869 (2)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 0PUBLIC WORKS JOB ADDRESS: ' Z \ b IQ C. 3 �k City: Master Permit No. RECEIVED JUL 2g 0 2011 C 4-1 5+1 FBC 201.1 et, -IR`(og Sub Permit No.n -16(09 ❑ REVISION ❑ EXTENSION RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Shores County: Folio/Parcel#: I\' 1)2- o S 0 27 - 0 6 0 Occupancy Type: Load: Miami Dade Zip: 1.,,3% Is the Building Historically Designated: Yes NO X Construction Type: tjJ Flood Zone:BFE: FFE: OWNER: Name (Fee Simple Titleholder): Notes C J ► . 1S .3 L Phone#: Address: ')-: t & �►`� `c— Cj � � City: `I 1 )NCI IZ-C.L State: i L Zip: 3-3) 3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: I,"/ pkviN, ,,y _ce y„ d e le- Address:f City: ,[..moi , /4' —a , State: Fz Zip: 3JO/f Qualifier Name: (,/ vi dl's/) ft 5 Te- -e6 Phone#: State Certification or Registration #: C FC / ! 2 / V ° Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Value of Work for this Permit: $ 3 J S 0. Square/Linear Footage of Work: ii 2.0 6c/07 /I/vie -U/ Phone#e7) 3g. // Type of Work: ❑ Addition Alteration9❑ New ❑ Repair/Replace Description of Work: i kC.9 i� NCI 60,AktGonAs P.e mode - Zip: ❑ Demolition Specify color of color thru tile:2.(l� Submittal Fee $ 50, Permit Fee $ ,2yr� CCF $ �O CO/CC $ 1' Scanning Fee $ '6 • Radon Fee $ 3 3b DBPR $ 3 ' �� Notary $ Technology Fee $ Training/Education Fee $ G.80 Double Fee $ 225 .UV Structural Reviews $ `1-P4AL—r `r : (Cp • (X) (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ 22 . i 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 AGENT The foregoing instru as acknowledged before me this Signature CONTRACTOR The foregoing instrument was acknowledged before me this ����I \ day of J ' , 20 1- , by 11 dayofJ , 20 I by N �:/1�J� c: A R C'�/J� rwho is personally known to i �. U. PJ S'l , who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY PUBLIC: Sign: hfi91 tV 1 Print: N\ .'� Seal: (�h (salft:I4ARA0ltV1OH MY COMMISSION 4 FF 912304 ,; EXPIRES: December 23, 2019 4„571 ,. Bonded Thm ?votary POTic Underwriters Sign: VC{(Zru") `2`• Print: Seal: ************************************************************************************************************ APPROVED BY (Revised02/24/2014) 79 Plans Examiner Zoning Structural Review Clerk iami 3 hores Village 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 fall -time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the constmction industry may elect to be exeuiJtiF 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: State of Florida County of Miami -Dade The foregoing was acknowledge before me this a,O day of By N o•C. (. r l 9„.0,o ,20, l . who is personally known to me or has produced as identification. Notary: \ a0-1 4 cLL i SEAL: *"4 4 MARINA R ADKEVICH MY COMMISSION # FF 912304 EXPIRES: December 23, 2019 '. Bonded Thru Notary Pe= Dndernriters I & M Plumbing Services, Inc All your plumbing needs 6407 NW 201st Ter Miami, FI 33015 Phone 786-380-6911 Fax 786-219-3383 Date: State of Florida County of Miami -Dade Before me this day personally appeared T1 G‘ duly sworn, deposes and says: who, being That he or she will be the only person working on the project located at: 12-/C /VC 93 /11 wt;l1c e /Ft 33/3eK Contractor Signature Sworn (or affirmed) and subscribed before me this 47/ day of k (f/ . 20/7, by ',./(, 77 r Personally know •O .-Produ d Identification �'�'�,��?<=o�� Type of Identification Produced Print, TS amp Name of Notary . 'b,, 1 SIS of Florida pP� My Commission 6pires 04x2312019 Commission No. FF STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTJON INDUSTRY UcENSING BOARD lICENS UIVISER CFC1428409 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 STEELE BARRIOS, JUAN R 1 & M PLUMBING SERVICES,.iNC 6407 NW 201ST TERRACE HIALEAH FL 33015" ' '• '. ' ISSUED: 06/1472016 • DISPLAY•AS REQUIRED' BY LAIN' SEQ# L1606140001131 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BH.I. - DO NOT PAY 7183437 t3LISINESS NAME/LOCATION I & M PLUMBING SERVICES INC 6407 NW 201 TER HIALEAH FL33015 OWNER 18 M PWMBING SERVICES INC C/O JUAN R STEELE RARkJOS PRES RECEIPT NO. RENEWAL 7484076 BT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Cade Chapter OA -Art 9 & 10 SEC. Trve OP t31JSINBSS 196 PLUMBING CONTRACTOR CFC1428409 PAYMENT i?S:EIVED WY TAX COLLECTOR $75.00 07/14/2016 CHECK21--16-087539 Ibis Luca! Business Tax Receipt only cae5nuspeymentattbeLocal Business Tu. The Reggio isnet alicense, pChn t. ora oeRilioatioo of the holder s nuanced/mu. to du business. Holder must comply web any governmental orncegaystemental regulatory laws andmquiremeots which epptxto the business. The RECEtPTNO. shove Meat be displayed on ell co mtercial vehtetea- MIeml-Dade Code Sue an -VE for mare itlfatnmtion,vlsitwww.miantidade aovhnxesusrxar • JEFF ATWATER CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES • DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW'S CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 3/24/2017 EXPIRATION DATE: 3/24/2019 PERSON: STEELE BARRIOS JUAN R FEIN: 320456339 BUSINESS NAME AND ADDRESS: I& M PLUMBING SERVICE, INC 6407 NW 201 TER HIALEAH FL SCOPE OF BUSINESS OR TRADE: L[cen sed Plumbing Contactor 33015 IMPORTANT: 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 Made 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 certificate at any time for failure of the penton named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1809 ACORU®DATE lois.'..-*' OF LIABILITY INSURANCE p rmoori xY) 07118/2017 07/18/2017 THIS CERTIFICATE 18 ISSUED AS A NATTER 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 POUCIES 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 to an ADDITIONAL INSURED, the policypes) 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 Ample Insurance Company PO Box 829 Oakland FL 34760 CONTACT tO F. Molina ! K� Na. rats: 305-264-9900 1 Fel Nos: EaaDARgess; fmolfna@ampfefns.com I ER(8)AFFORDINGCOVERAGE NAI: INSURERA: COVINGTON SPECIALTY INS CO COMMERCIAL GENERA!. UABILITY INSURED 1 & M PLUMBING SERVICES, INC 6407 NW 201 TERR Miami FL 33015 INSURERS: VBA499151-00 INSURER C : 11/09/2017 INSURER D : $ 1,000,000 INSURER 0 : DISURER F:. DAMAGE TO RENTED PREMISES IES OP:W maml VERAGES REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 ITR TYPE OF INSURANCE AWL WED SUER WVD POLICY NUMBER P013C1t EFF nlMA1AMIYYI outsu/YYYYI LIMITS A X COMMERCIAL GENERA!. UABILITY VBA499151-00 11/09/2016 11/09/2017 EACH OCCURRENCE $ 1,000,000 QAIMSMADE X OCCUR DAMAGE TO RENTED PREMISES IES OP:W maml 8 100,000 X 500 ded per claim MED EXP (Any one person) S 5,000 X 500 dad per claim PERSONAL &ADV INJURY $ 1,000,000 GENT. AGGREGATEMIT APPUESPER: POUCY ❑ ❑ LOC I OTHER: GENERAL AGGREGATE S 2,000,000 PRODucrs- COMP/OP AGO $ 1,000,000 S AUTOMOBILE — _ _ UABIUTY ANY AUTO ALL OWNED AUTOS FGD AUTOS —' _AUTOSPROPEFl SCHEDULED AUTOS COIABINED SINGLE Limn*s BODILY INJURY (Per person) S BODILY INJURYpp(Per=IdealS ) $ S UMBRELLA LAB EICESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE S DED 1 I RETENTION $$ WORKERSCOMPEMSATIONA. AND EMPLOYERS' UABOUTY ANY PROPAIETORIPAR� Y J N NiA I T E L EACH ACCIDENr S OFRt4BERE7UXMlDED1 (Mandatory If under DESCRIPTION OF OPERATIONS below EL. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LINT S DESCRIPTION OP OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101. Additional Remarks mule, may be attached I mare space le required) ***Plumbing Juan Steele License no. CFC 1428409 CERTIFICATE HOLDER Miami Shores Village Building Department 10050 NE 2nd AVE I Mian Shores, FL 33138 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 c _� _ ACORD 25 (2014/01) IN 1888-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD