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PL-15-3137Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Rcl4-2z34 Inspection Number: INSP-249660 Permit Number: PL -12-15-3137 Scheduled Inspection Date: November 03, 2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: KERMANI, AMIR Work Classification: Gas Job Address: 1680 NE 104 Street Miami Shores, FL Project: <NONE> Phone Number (305)965-0170 Parcel Number 1122320320440 Contractor: AMERIGAS PROPANE AND SUBSIDIARIES Phone: 305-883-8600 Building Department Comments REWORK OF EXISTING GAS LINE Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments AmeruGas America's Propane Company /Q6 xJ /627/Sr ADDRESS PL -/2 - /S_- 3/37 PERMIT NUMBER THIS SYSTEM HAS BEEN MANOMETER TESTED FOR 15 MINUTES. STARTINCHES W.C. FINISH 1* '3 INS ALLER /0• INCHES W.C. DATE AmeriGas 10052 N.W. 89 Avenue MEDLEY FLORIDA 33178 This installation will meet all Florida Statutes 527.06 LP Division rule 4B-1.01, The South Florida Bldg. code NFPA 54, NFPA 58 and regula- tions of The State Fire Marshall. STATE OF FLORIDA, COUNTYOFMIAMI-DADE Signature of Qualifier Print Name ..FOVe2t ,Sworn to and Subscribed before me this 097 day of PA '`r,�� ; Sig V 10 've'''' Bonded through National Notary Assn. A 'ubli> .: �a AHIA� rida it nn i a 93.4455 an ilikrgaio2o (SEA ): Personally known V OR, Produced Identification Type of ID Produced 10052 N.W. 89T" Avenue — Medley, FL 33178 — Tel. (305) 883-8600 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -12-15-3137 Permit Type: Plumbing - Residential Work Classification: Gas Permit Status: APPROVED 1sste Date: 1/1312016 Expiration: 07/11/2016 Parcel Number Applicant 1680 NE 104 Street Miami Shores, FL 1122320320440 Block: Lot: AMIR KERMANI Owner Information Address Phone Cell AMIR KERMANI 3180 S OCEAN DRIVE HALLANDALE BEACH FL 33009- (305)965-0170 Contractor(s) Phone Cell Phone AMERIGAS PROPANE AND SUBSIDIA 305-883-8600 Valuation: Total Sq Feet: $ 1,500.00 00 Type of Work: REWORK OF EXISTING GAS LINE Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.25 $0.40 $5.00 $150.00 $9.00 $1.60 $171.70 Pay Date Pay Type Invoice # PL -12-15-58108 12/18/2015 Check #: 1076 $ 50.00 $ 121.70 01/13/2016 Check #: 1053 $ 121.70 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Final Press Test Review Plumbing 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 thea ove 0a(ped cpntry for to do the work stated. January 13, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date January 13, 2016 1 q\NP'��� Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) 9(; i4M / /1�/ 1tMQ/)1 Phone # 3©S - q(iS-c7 f'70 Permit No. pi / Master Permit No.12_04 LI— 2.23 Owner's Address f(j1O Aisezipritypr a City /vVitof l Sl+ 0 State '' L Zip Tenant/Lessee Name W/4 Phone # Email Job Address (where the work is being done) ) 'O City Miami Shores Village County Miami -Dade FOLIO / PARCEL # Zip 33138' Is Building Historically Designated YES NO Flood Zone Contractor's Company Name f (Y\ EZI CT AS 0 pA WJE_ Contractor's Address 10052 , 1J Q t UC Phone # 305- O U 3 _ Row Statej+ OA City 4.E Zip ��1� Qualifier Name e) bi.fe LLl SOK) Phone # 305' S93- e (X7c) State Certificate or Registration No. LO(', (j(OU C q Certificate of Competency No. nn Contact Phone Bj 3 �.- - - c ) E-mail v dZ l • (At % S C3 rJ ( RovE e i G AS- Co wl. Architect/Engineer's Name (if applicable) Phone # vo Value of Work For this Permit $ /5--00 Square / Linear Footage Of Work: Type of Work: ❑Addition NeKration ❑New ❑ Repair/Replace ❑ Demolition Describe Work: nZ lOki21C 0 Z.1.% ST t N C' % 11. c LI N.IE . • ***************************************Fees******************************************** Submittal Fee $ . �4 . Permit Fee $ Notary $ 5 C� Scanning $Q ' CO Double Fee $ Structural Review. $ 14 /56;2./ CCF $ 1.2_0 CO/CC $ Training/Education Fee $ O ' / 0 Technology Fee $ Radon $ 2 . 25 DPBR $ Z a 2S Bond $ 0 I•co Violation date: Total Fee Now Due $ 1 2. See Reverse side -4 Bonding Company's Name (if applicable) v �' 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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. Owner or Agent The foregoing instrument was acknowledged before me this ( day of Dom- , 2(1 , by 4/11 l 2 /-lc// e)-if-idl who is personally known to me or who has produced <i62' who is As identification and who did take an oath. NOTARY PUBLIC: Signature (14 AaQ(2_, Contractor The foregoing instrument was acknowledged before me this 1 ' ay of �L'C. 20 )5,by ? J 414SD✓t o me or who has produced as identification and who did take an oath. Sign: Print: My Commission Expires: It1u1►►tr�r///i '% co .•••a- - y LL= .'8).)c.":-.3.. .. •••.........S�P\\\�. *******************************46,1* II1111* *k****************************:t******* t**************************** /1 P-15 Plans Examiner Zoning NOTARY PUBLIC: Si ;•o,��� Pro ' „ G-' or. E ir s s,�� F �: mrma3iwi # PF 0539 COYtirrMS10 i41g9V9h National Notary Assn. 1 - —�-- — APPROVED BY (Revised 07/I0/07)(Revised 06/10/2009) Engineer Clerk checked LICENSE t ICUOUSLY 000.647 State of -Florida Department of Agriculture and consume .Ser.icesry Division of Consumer,Services Bureau of Liquefied Petroleum Gas Inspection, (850).921-1600' Tallahassee, Florida License Number: Expiration Date: Date'of Issue: License Fee: Type and Class: Liquefied Petroleum Gas License CATEGORY I =LP GAS DEALER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is issued under authority of Section 527.02, Florida Statutes, to: AMERIGAS PROPANE, L.P. 16052 NW 89TH"AVE MEDLEY, FL 33178-1444 Local Business Tax Receipt Miami -Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY 2095289 BUSINESS NAME/LOCATION AMERIGAS PROPANE LP 10052 NW 89 AVE MEDLEY FL 33178 OWNER AMERIGAS PROPANE LP RECEIPT NO. RENEWAL 2203289 00899 August 31, 2016 September 1, 2.015 $425.00 0601 ADAM H. PUTN M COMMISSIONER -OF AGRICULTURE EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 SEC. TYPE OF BUSINESS 205 DEALER/DISTR/INSTALLATION LPG000899 PAYMENT RECEIVED BY TAX COLLECTOR 5270.00 08/04/2015 CREDITCARD-15-039680 This Local; Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental 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 Sec 8a-276. For more information, visit www.miamidade oovhaxcollector • 12/18/2015 13:47 3058845891 AMERIGAS Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apalachee Parkway Tallahassee, Florida 32399-6500 PAGE 02/02 Master Qualifier Mailing Address Licensed Location Address ROBERT ALLISON AMERIGAS PROPANE, L.P. 10052 NW 89Th AVE MEDLEY, FL 3317&1409 AMERIGAS PROPANE, L.P. 10052 NW B9TH AVE MEDLEY, FL 33178-1444 Certificate Number License Number 13554 00899 This Master Qualifier Certificate is issued pursuant to Chapter 527, Florida Statutes. This certificate is valid only for the person and licensed holder listed. Any changes to the Master Qualifier status (such as transfer or termination of employment) must be reported to the Bureau of LP Gas Inspection at (850) 921-1600 immediately. The Master Qualifier Certificate is valid only through the date noted on the Certificate, A notice of renewal will be sent to you in advance of your expiration date. A Master Qualifier Certificate may be renewed if certification of a minimum of 16 (sixteen) hours continuing education is provided along with the renewal form. If training cannot be documented, an examination must be taken. If there are any errors on the certificate, please submit all changes in writing to: Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apalachee Parkway Tallahassee, Florida 32399-6500 Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services Bureau of Liquefied Petroleum Gas Inspection (850) 921-1600 Tallahassee, Florida certificate No: Exam Data: Issue Date: Expiration Date: Exam: MASTER QUALIFIER CERTIFICATE (NON -DESIGNATED) This Certificate is issued under authority of Section 527.02, Florida Statutes, to: ROBERT ALLISON Valid For License Number: 00899 AMERIGAS PROPANE, L.P. 10052 NW 89Th AVE MEDLEY, FL 33178.1444 13554 June 7, 1982 August 8, 2015 August 7, 2018 0801 ADAM H. PU gi aw,i COMMISSIONER OF AGRICULTURE 'A`� I CERTIFICATE OF LIABILITY INSURANCE D11f17)201"""15°"'""' 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 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 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 lieu of such endorsement(s). PRODUCER • . Marsh USA Inc. 1717 Arch Street Philadelphia, PA 19103-2797 Alin: Philadelphia.certs©marsh.com / Fax 212-948-0360 272145-AmerF'GAW-15-16 Amerig CONTACT E: INC N Ext): FAX C. No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC i INSURER A : ACE American Insurance CernpmY 22667 INSURED AmeriGas Propane, L.P. and Subsidiaries PO Box 858 Valley Forge, PA 19482 INSURER B : Indemnity Ins Co Of North America 43575 INSURER C : ACE Fire Underwriters Insurance Company 20702 INSURER o : Agri General Insurance Company 42757 INSURER E : INSURER F : w.v.• u I uoGn.+ 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. INSRR TYPE OF INSURANCE ADDL /NSD SUER WVD POLICY NUMBER POUCY EFF (MMIDD/YYYY) POUCY EXP (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG27393214 07/01/2015 07/01/2016 EACH OCCURRENCE $ 2,500,000 CLAIMS MADE X OCCUR DAMAGE TNTED (EaREoence) PREMISES $ 2,500,000 MED EXP (Any one S 10,000 person) PERSONAL S ADV INJURY $ 2,500,000 GEM_ AGGREGATE LIMIT APPLIES PRO- PER: GENERAL AGGREGATE $ 5,000,000 X POLICY JECT LOC PRODUCTS - COMP/OP AGG $ 5,000,000 OTHER: $ A AUTOMOBILE LIABILITY ISAH08856928 07/01/2015 07/01/2016 COMBINED SINGLE LIMIT (Ea accident) $ 2,500,000 X ANY AUTO ALL OWNED — SCHEDULED BODILY INJURY (Per person) $ AUTOS AUTOS NON BODILY INJURY (Per accident) $ X HIRED AUTOS X -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB_ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION $ $ $ B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N WLR 048150068 (AOS) 07/01/2015 07/01/2016 X PER STATUTE OTH- ER r.C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A WLRC4815007A (AZ, CA, MA) 07/01/2015 07/01/2016 E.L EACH ACCIDENT $ 2,000,000 (Mandatory in NH) If yes, describe under SCFC48150093 ) 07/01/2015 07/01/2016 E.L DISEASE - EA EMPLOYEE $ 2,000,000 D DESCRIPTION OF OPERATIONS below WLR C48150081 (TN) 07/01/2015 07/01/2016 E.L. DISEASE -POLICY LIMIT $ • , 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space Is requlrad) Certificate Holder is included as an additional insured with respect only to work performed by the named insured where required by wnlen contract. Additional insured does not apply to Workers' Compensation. Master Qualifier License #00899 Certificate Number 13554 CANCELLATION Miami Shore- Vil1ane • Bui1ding Department 100-5.0 . NE 2nd Avenue Mi®rni SHores,_FL 33138_ SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �) OLn.. area tc. ey ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3/ 3 cGczO 2PSi STATE AND COUNTY RULES AND REGULATIONS �—lZr0K w as?..A0G £ L�S6kTr t • • • • • •• • • • •• • •• • • • .•• • • • • •.. • • • •• •. • • ••• •• • • •• CssT • •• 2p5t • t i' • S`lsT£Ori • • • oq'c::ucwt..L • go WA: ••• • •• • •••• • • •••• • • •• • • • • • • • • sd I2 Lca (hc L coat: zo t -rn1-t' ' 402., t4 C 33) l oa' (`-r 4S ?� CSS. D 2S� r_ZIll CASA-4cu2P61 r03COU -1LI L o t7 b L.k[ o DLA 1' 4 . Wu AmeriGas. 10052 NW 89 Ave., Medley, FI 33178 Tel. 305- 883.8600 Fax 305-884-5891 JOB: KF 2 rr11A 1 _: �(e) NE t.v4 sr. Im t to tmt DATE:12-1-t REVISED: SCALE: KTS DRAWN BY: Awe 1G 0.9 APPROVED BY: AFFIDAVIT: This installation shall comply with NFPA 54, NFPA 58, as well as all state & local codes and regulations. GENERAL SITE PLAN Page_ of �,is signature of -Qualifier - - PRINT NAME: Qualifier f a bee; \u.+sl» Saturn to and subscribed before me this day of QG . 20 IS by %'411"-d541444911rogilmaylaidial-r p�PpY PLB •i LYANN PEREZ (SEALS Notary Public - State of Florida ' '• ▪ My Comm. Expires Sep 27, 2017 Commission # FF 05901 Bonded Through National Notary Assn. or Procfuced Irrentifica on' — — —1 — — Type of identification Produced' RLINE NE 104T STREET uar PASCUAL r PERKDDIAN R•3250 .41.0 Ten•4494 14.109'1411 LOT 24 BLOCK 4 12-0 GAI101.b L. P T.A1.SIC COLUMN I.4KL4 DYPI CRAM WK PENCE ITV) 150.11' MEASURED TO MIENS GE•151 S95'Z739•W G ONE STGIRY • :.IDENCE 1680 NE 104 1 ET FINISH FLOOR ELE ATION=+8.37' GARAGE EVA ON -+6.13' LOT 22 BLOCK 4 P" SITE PLAN SCALE : 1= 10' • •• • • • • ••• • • • • • • • • • • • • • • • •••• • • • • • • • • • • • • •• •••• • • • • • •'• • N•TE: • • • • • • •—1.1•11.1OM.mm ma.. ma[7AWOr0..b7.bM. ma AYR was II... 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G.YYP•b lad• Daft. .N0.1al. b.. ml Y• am lamm121.1., I.OMIN. WY.YmmPY..M'r.1Mal b vl m.i.MYebr.5m....Mama Gala Gomm Mallalasala mama* N00'01Y00E FLOOD PROGRAM LEGEND: RESIDENTIAL MWICONEINIC110X RPMN.REOIOIRUC al MO M70]IREDME M 03101111Wal OON0I UMW Ma MYN(000. NET Waal WN R OfMYC IRRRI UaT.00MIAFFIlA TMO M ELEVATNRSURVEY EIWYMWEAOWWLOMS. Mal MOM OBOE, WO ROSS. OOTWIOF ROW & Vaal 31 MOrthOTMW ACOMOCOST FCMRIOROC1. IME T.OWIB1 ATMM Oa NOMROR 7EVAIO11 PURVEY OWWRO OJONOLOAEW FLOOR LOWER WOE. MO MOYFECRO/O Of ROAD a[VAIWR Waal, MOM OIROM nRATpRMwewa 1ME MRIMA RAMO4 WWMOE INMIEM AEON: aeM..r.Owl..vn.c IlL'r. LOT MOM Re LEO& RSCIIPIION LOWER I CM•0U AUJYD 1000* R7W7 OMR . Llr .uY .a.r PROTECT S10IR00000 TREES M.M COW. M MUOW PROVOS rfiRM M01.12&WFLIERSMgRO TREES W ON gIORFARR 7 SEA WALL,, i 4 j 1 1 .W, //21111401. 01.11•1: 01W.1OR CI R 1.1 1 SP -1