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PL-16-1653Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 ?DPP ib -i40 Inspection Number: INSP-260949 Permit Number: PL -6-16-1653 Scheduled Inspection Date: October 24, 2016 Inspector: Hernandez, Rafael Owner: PUFF, MARTIN Job Address: 1208 NE 98 Street Miami Shores, FL 33138 - Project: <NONE> Contractor: GAS CONNECTION &EQUIPMENT Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Gas Phone Number (786)553-7400 Parcel Number 1132050090360 Building Department Comments INSTALLATION OF GAS LINE FOR NEW POOL HEATER. 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 R�w Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -6-16-1653 Permit Type: Plumbing - Residential Work Classification: Gas Permit Status: APPROVED Issue Date: 7/15/2016 Expiration: 01/11/2017 Parcel Number Applicant 1208 NE 98 Street Miami Shores, FL 33138- 1132050090360 Block: Lot: MARTIN PUFF Owner Information Address Phone Cell MARTIN PUFF 1208 NE 98 ST MIAMI SHORES FL 33138-2561 (786)553-7400 Contractor(s) Phone GAS CONNECTION & EQUIPMENT (305)940-8820 Cell Phone Valuation: Total Sq Feet: $ 1,200.00 0 Type of Work: INSTALLATION OF GAS LINE FOR NEW PO 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 Amount $1.20 $3.38 $3.38 $0.40 $5.00 $225.00 $3.00 $1.60 Total: $242.96 Pay Date Pay Type Invoice # PL -6-16-60189 06/14/2016 Credit Card 07/15/2016 Credit Card Amt Paid Amt Due $ 50.00 $ 192.96 $ 192.96 $ 0.00 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, WINDOW $ •O,, RS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing informati construction and zoning. Futhermore, I authorize the above-na e,, • - ,r w; Authorized Signature: Owner / Applicant / / C. /actor / Agent curate and that all work will be done in compliance with all applicable laws regulating o do the work stated. Building Department Copy July 15, 2016 Date July 15, 2016 1 41)\\C° Miami Shores Village rx,o 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 BUILDING PERMIT APPLICATION FBC 20 ( 4 Master Permit No. Sub Permit No. 1)(..A 1653 ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP �` CONTRACTOR DRAWINGS JOB ADDRESS: /2(U A• e . 9/ � T ee ---7r City: Miami Shores County: Miami Dade Zip: %,3'7 Folio/Parcel#: 11' 3.z o5- CX.3 -0360 Is the Building Historically Designated: Yes CO Occupancy Type: Load: Construction Type: Flood Zone: /V0 BFE: FFE: OWNER: Name (Fee Simple Titleholder): Mae."' Ai PUS Phone#: Address: )201-f1): e , 9F 3 e City: fll // 7 . r /90/4'6- State: i�_ C • Zip: ,! s.3/ 3S— Tenant/Lessee Name:. Phone#: Email: CONTRACTOR: Company Name: 646 CGn>rt c atictn. �,� , Phone#: S / � WO Address: 6 4/21 fm ' s ed - I City: / trVa State: /z..,•(, Zip: a ? Qualifier Name: /impl1 oto' 4' ��/.� `�Phone#: 9''2?C"'-7E/3 State Certification or Registration #: . `o2`1,31t{ Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 6300c Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ /Alteration CI New _ Description of Work: �r 4ry//f?4c.., 00`t (.2/ti ,v ❑ Repair/Replacep IU RV/ ❑ Demolition Specify color of color thru tile: Submittal Fee $ �i Permit Fee $ 2-f'— CCF $ I `� CO/CC $ 0 Scanning Fee $ Radon Fee $ • 3C DBPR $ 3 9 Notary $ eS Technology Fee $ ' GC) Training/Education Fee $ 0 ` 4 0 Double Fee $ A Structural Reviews $ P Bond $ 0 (Revisedo2/24/2014) TOTAL FEE NOW DUE $ 192. 9c, 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 ofkomm ncement 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. Signat CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this Z S day of '1-1--Q , 20 \-(Q . , by _ . day of 1\-,1p,..71 , 20 (, by i .rte + '� '�,C1�" ► n ,who is personally known to� (�I L lit. MAXI M LtFN �, w o�'i personally known to me or who has produced 3r- L-1/4.7% l.1/4.r. a . �l�— J `►mss me or who has produced as J identification and who did take an oath. NOTARY PUBUC: Sign: Print:--7«^►� identification and who did take an oath. NOTARY PUBLIC: Sign: �V �( Nom(-aaI Print: SealURANIA CRUZ Seal: Notary Public, State of Florida Commission# FF 949227 My comm. expires Jan. 10, 2020 ******eeee-iiwwww :-.ssrrr************************* APPROVED BY (Revised02/24/2014) 6-16 Plans Examiner 040P% Notary Public State of Florida ^ Sindia Alvarez 2f*t}ylr, IMIOJInF+>F » sa8e*** *************** Vo, 0.0' Expires 09103/2018 Zoning Structural Review Clerk State df 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 Date: Issue Date: Expiration Date: Exam: MASTER QUALIFIER CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes, to: MANTEL M. ATO Valid For License Number: 24314 GAS CONNECTION & EQUIPMENT 6428 RODMAN ST HOLLYWOOD, FL 33023-1763 POST LICENSE CONSPICUOUSLY Division of Consumer Services Bureau of Liquefied Petroleum Gas Inspection (850) 921-1600 Tallahassee, Florida • 23965 October 23, 2007 November 29, 2013 November 28, 2016 0803 ADAM H. PUTNAM COMM! License Nwtnber: Expiration Data: Date of Issue: License Fee: Type and Class: Liquefied Petroleum Gas License LP GAS INSTALLER GOOD FOR ONE LOCATION ONLY THIS LICENSE ANY CHANGE OF IN OF THIS BUSINESS This license is issued under authority of mon 627.02, Florida Statutes, to: GAS CONNECTION & EQUIPMENT 6428 RODMAN ST HOLLYWOOD, FL. 33023-1763 24314 August 31, 2016 September 1, 2015 5200.00 0803 COMMISSIONER OF AGRICULTURE CalauFlot malturrgariolt cap Manuel AXo O8-03LPGas A Thai germ knononsolog tad 3n saidintelne Sas pones tat pond a ounlinEwhor an LP gni Inalosif in lin ~of abOle to Cerporati. Ronda Sulam& IVO wale IOTA UCESISE TO VD IMADIESS 1>e STATE OF r AM& c W OMMIESIONER ofACRIC RTUR>E CERT NO: 23963 November 28, 2016 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA: Business Name: GAS CONNECTION & EQUIPMENT Owner Name: Business Location: Business Phone: Rooms Tax Amount 75.00 MANUEL ATO JR 6428 RODMAN ST HOLLYWOOD 305-940-8820 Seats Number of Machines: 0.00 Transfer Fee NSF F Employees Receipt #"INSTALLATION LP GASS APPL/IU: Business Tylpe: (INSTALLATION LP GASS APPL/EOUP) Business Opened:01 / 07 /2008 State&County/Cert/Reg:2 4 314 / 08 -CLPG-14 7 52 * Exemption Code: For Vending Malmo Only � Penalty 0.00 0.001 Machines Vending Type: Prior Ye Professionals Years I Collection Cost 0.00 0.00 Total Paki 75.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VALIDATED Malang Address: MANUEL ATO JR 6428 RODMAN ST HOLLYWOOD, FL 33023 This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt d0es,not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 2015 2016 Receipt #O1A-14-00008817 Paid 08/05/2015 75.00 ACC)I i) CERTIFICATE OF LIABILITY INSURANCE DATE (maroomyyy) 05/23/16 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 CONSTRUTE 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 pollcy(iss) must be endorsed. It 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 Neu of such endorsement(s). PRODUCER CONTACT Jeffrey Willis Annette Willis Insurance 18401 N.W. 27 Ave Miami, FL 33056 Phone (305) 625-2403 Fax (305) 625-6472 I INSURED Gas Connection And Equipment 6428 Rodmnan Street Hollywood, FL 33023 305 (a C, Nol: (305) 625-6472 PHON { j: (305) 625-2403 E-MAIL _.M0RF$S: jeff.wilts@annettewiiiisinsurance.com INSURER(S) AFFORDING COVERAGE INSURERA: Nautilus Insurance Company INSURERB: -- INSURER C INSURER 0: INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 I ADD UBR POLICY F POLICY EXP -LTYPE OF INSURANCE TR : POUCY NUMBER {MM ...Law MMIDDIYYYY !GENERAL UABILITY G COMMERCIAL GENERAL LIABIUTY L J CLAIMS -MADE F/ OCCUR s1 LI GEN'L AGGREGATE LIMITAPPLIES PER: t� POLICY E JFfL LOC AUTOMOBILE UAJ3ILI Y C j ANY AUTO ALL OWNED SCHEDULED U AUTOS AL�-1- AUTOS i HIRED AUTOS AUTOS 1-1 UMBRELLA LIAR LI OCCUR I ; EXCESS UAB ❑ CLAIMS -MADE DED :_1 RETENTION$ 09/10/2015 09/10/2016 OMITS EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED $ 50,000.00 PREMIS a • - • MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 1,000,000.00 PRODUCTS - COMP/OP AGG $ 1,000,000.00 J COMBIa cciNEeD�SINGLE LIMIT(Ea BODILY INJURY (Per person) S 5 —i H BODILY INJURY (Per accident l S PROPERTY DAMAGE $ (Per accident __ .. _.. _...__........... . :5 EACH OCCURRENCE �S AGGREGATE WORKERS COMPENSATION ANO EMPLOYERS LABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N 1 A OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, deecribe under DESCRIPTION OF OPERATIONS below _ $ L J 8 YTIJiIiQS OTH- E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I mora space is required) State LPG 24314 CERTIFICATE HOLDER CANCELLATION Miami Shores Viiage Building Department 10050 NE 2nd Avenue Miami 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 POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) QF ®1988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATER STATE OF FLORIDACHIEFFINANCIAL O DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COM ATION 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: 7/122014 EXPIRATION DATE: 7/11/2016 PERSON: ATO MANUEL M FEIN: 272151509 BUSINESS NAME AND ADDRESS: ATO ENTERPRISES LLC GAS CONNECTION AND EQUI 6428 RODMAN STREET HOLLYWOOD FL 33023 SCOPES OF BUSINESS OR TRADE: OIL OR GAS PIPELINE GAS MAIN OR CONSTRUCT' CONNECTION ? CONST Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by tiling 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... appy only within the scope of the business or trade wed 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 it, at any time alter the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requkenfents of this section for Issuance of a certificate. The department shell revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1509 Gas Connection and Equipment 6428 Rodman Street Hollywood, FI. 33023 DADE: 305-940-8820 BROWARD: 954965-8060 STATE LIC: LPG 24314 BROWARD CC# 08-CLPG-14752 Date: "wC6'46 State ofPlcR'&/ () County of M CAM (-1, Before me this day personally appeared �G/tidC fIv who, being duly sworn, deposes and Says: That he or she will be the only person working on the project located at: 1(20 )0' 67, 7 F --S Sworn to (or affirmed) and subscribed before me this .7-C, day of M`4\‘'? . 20 Lk , by M -P RX' MiL'4 N0A C)R 45. v'` Notary Punlic State of Florida Sindia Alvarez `�eQ My Commission FF 156750 0,e.° Expires 09/03/2018 Personally known Or Produced Identification Type of Identification Produced F L V2.1 Print, Type or Stamp Name of Notary Notice to Owner — Workers' Com p Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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: State of Florida County of Miami -Dade The foregoing was acknowledge before me this Z- day of \--'(- , 20 L (0 . By A` -,C L \-4: -RL) who is personally known to me or has produced Notary SEAL: as identification. . bllc.' r. Commis My 00mm. expires Jan. 10, 2020 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 * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 7/11/2016 EXPIRATION DATE: 7/11/2018 PERSON: ATO MANUEL M FEIN: 272151509 BUSINESS NAME AND ADDRESS: ATO ENTERPRISES LLC GAS CONNECTION AND EQUIPMENT 6428 RODMAN STREET HOLLYWOOD FL 33023 SCOPES OF BUSINESS OR TRADE: OIL OR GAS PIPELINE GAS MAIN OR CONSTRUCT! CONNECTION ? CONST Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by fling 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 shalt 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