PL-17-1825Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. PL -7-17-1825
Permit Type: Plumbing - Residential
Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 7/26/2017 Expiration: 01/22/2018
Parcel Number
Applicant
157 NW 103 Street
Miami Shores; FL 33150-
1121360131540
Block: Lot:
CASSA GROUP LLC
Owner Information
Address
Phone
Cell
CASSA GROUP LLC
18181 NE 31 Court
AVENTURA FL 33160-
(305)610-1905
Contractor(s)
DRAIN MASTER USA CO
Phone Cell Phone
(561)688-7990
ANEW
Valuation:
Total Sq Feet:
$ 1,800.00
0
Type of Work: SHOWER VALVE KITCHEN CONNECTIONS LA
Type of Piping:
Additional Info: SHOWER VALVE KITCHEN CONNECTIONS LA
Bond Return :
Classification: Residential
Scanning: 3
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
$9.00
$1.60
$166.70
Pay Date Pay Type
Invoice # PL -7-17-64600
07/26/2017 Credit Card
07/18/2017 Credit Card
Amt Paid Amt Due
$ 116.70 $ 50.00
$ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Top Out
Final
Review Plumbing
Underground
In consideration
pertaining there
accepting this
required for EL
OWNERS AFFI
construction and
issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
LUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
ore, I authorize the above-named contractor to do the work stated.
July 26, 2017
' Authorizewner / Applicant / Contractor / Agent
Building D - •r ent Copy
Date
July 26, 2017
1
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) 7624949
BUILDING
PERMIT APPLICATION
[� BUILDING ❑ ELECTRIC fJ ROOFING
LUMBING MECHANICAL (PUBLIC WORKS
JOB ADDRESS:
City: Miami Shores County:
I Folio/Parcel#: l l - 2136 — O )? - 1 4 0 Is the Building Historically Designated: Yes NO K
' Occupancy Type: ��Load: Construction Type: Flood Zone:
Master Permit No.
Sub Permit No.
RECEIVED
JUL 171017
,5A.` „ "
FBC 20
Q� lq -;1a Z5
QGI1--6 8
0 REVISION 0 EXTENSION RENEWAL
[] CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Miami Dade Zip: 331 5 0
BCE: FFE:'
OWNER: Name (Fee Simple Titleholder): G.44555. G>10047 LL C- Phone#: 3,05 - 1,10 — I 1 0 $
Address: 18 $ L JV ?z 3k x 509
City: k'J (2.-A State: (L. Zip: 33 1 fo 0
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: DR -24;D -4 aei-e
Address: Z 30i 14 447X r
City: G(q Pi es C /9 juVOE State:
Qualifier Name: / n- 400-47&,1
State Certification or Registration #: �� 1 ! 7 d f
`
•
as 4 Phone#: ($e I) 756 -070i Cel I
`186- 413 -5511 1>CA►-1oJ d_
p: 17
Phone#:Zi(,S(/)732 75 —C7U9
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ ,18 AO Square/Linear Footage of Work:
Type of Work: 0 Addition L!1 Alteration 0 New 0 Repair/Replace 0 Demolition
U1/40 Lb �+lL - V At= \-1' 4z_ / Z-sc \-1-1A-' (`CAA) &cam -.otsy
L,M Y / vi oz.�% 145 Q S lint 9.
Description of Work:
Specify color of color thru tile:
Submittal Fee $ SO pal ci Permit Fee $ ( &) CCF $ CO/CC $
Scanning Fee $ Radon Fee $ / DBPR $ Notary $
Technology Fee $ Training/ ation Fee $ Double Fee $
!Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 1 6 ..--4 O
(Revisedo2/24/2014)
r#
Bonding Company's Name (if applicable)
Bonding Company's Address
{ City State Zip
Mortgage Lender's Name (if applicable)
1 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
I 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 absen ' of such osted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
The fo e
nstrum nt w
day of
or AGENT
Signature i
CONTRACTOR
s acknowledged before me this The foregoing instrument was acknowledged before me this
A
/MI h..
as
20 by V day of 1 �. , 20 / .� , by
is per known to f� 4,i4f J , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBUC:
Sign:
Print:
Seal:
,,i
APPROVED BY
(Revised02/24/2014)
RAYMOND A. DEQUARTO
Notary Public, State of Florida
Commission# FF 123597
IManiimx ires June 2, 2018
ff
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Plans Examiner
Structural Review
1/11,y(
n/44 ' / i/17 /f7 V
•rit Michael J. Miller
_ 11 Commission 1.00052408
Dp "Mardi 25, 2021
Not Bonded lhru Aaron Notatr
as
Zoning
Clerk
A CORD -
RATE
07/03/2017
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND: THE CERTIFICATE HOLDER.
IMPORTANT: lithe certificate holder is an ADDITIONAL INSURED, the poiiry(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 onthis certificate does not confer rights to the
certificate holder in lieu of such endorsement(s):
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
INSURED
CORAL SPRINGS INSURANCE CENTER
5645 CORAL RIDGE DRIVE
CORAL SPRINGS; FL 33076
ACT CINDY BEACH
�Na Edk
954-346-4284 1 a No 954-346-4175
Miss: CBEACH9000(AOLCOM
DRAIN MASTER •USA, CO
3907 N. FEDERAL HIGHWAY #331
POMPANO BEACH, FL 33064
COVERAGES CERTIFICATE NUMBER:
iNSURER(S) AFFORDING COVERAGE
INsuReR'A: SCOTTSDALE INSURANCE
INSURERS: PROGRESSIVE
.NAIL/
INSURER
INSURER D:
INSURER E
INSURER. F:
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 CONDR1ON 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 SHOWN MAY HAVE BEEN. REDUCED BY PAID CLAIMS.
SUBR
WVD
INSRLI R
A
B
I TYPE OF INSURANCE
GENERAL L ABiLJTY
X COMMERCIAL' GENERAL LWBILm
CLAIMS -MADE X' OCCUR
GENT- AGGREGATE LIMIT APPLIES PER.
n POLICY 1 GjI JJERC n LOC
AUTOMOBILE UABILITY
INNSR
X
POLICY NUMBER
97044
POLICY EFF
ArWDDOYYM
6/2/2017
POUCY EXP
(MMID0 /YYY)
6/2/2018
EACH OCCURRENCE
LOUTS
ENTED
PREMISESMAGE (EaEaEence)
s 500,000
50,000
MED EXP (Any one person)
5 . 5,000
PERSONAL & ADV INJURY
s 1.000,000
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS:-:COMP/OP AGG _
$ 1,000,000
ANYAUTO
_ Alff0 "ED X - AC"ESUiED
HIRED AUTOS . ANON_ -0NVNED
UMBRELLA: UAB
EXCESS UAB
02176360-0
4/25/2017
.4/25/2018
COMBINED ) fNGLE LIMIT
BODILY INJURY (Per person)
S
$ 500,000
S
BODILY INJURY (Per ecdden0
(P OHMAGE
s
S
.:DED:) 1 RETENTION S
OCCUR
CLAIMS -MADE.
WORKERS COMPENSATION
AND. EMPLOYERS' LIPLINU Y Y 111
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
1 yes � �
DESCRIPTION OF OPERATIONS below
EACH OCCURRENCE -
S
AGGREGATE
S
NIA
ITovIiMSI TER
S
EL EACH ACCIDENT
EL DISEASE -EA EMPLOYEE
S
DESCRIPTION OF OPERATIONS 1 LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Scheckde, if more space is required)
Plumbing works • "N.
CERTIFICATE HOLDER
EL DISEASE - POLICY UMR
5
MIAMI SHORES VILLAGE
10050 NORTHEAST 2ND AVENUE
MIAMI SHORES, FL 33138
(
ACORD 25 (2010/05)
1
P
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
The ACORD name and®1988-2010 ACORD CORPORATION. _ Alt rights reserved.
logo are registered marks of ACORD
DRAIN MASTERS U.S.A. CO.
July 03, 2017
State of Florida
Broward County
Before me this day personally appeared Peter Gureckis who,being duly sworn, deposes and
says:
That he will be the only person working at the project located at:
157 N.W. 103rd Street Miami, FI. 33150
Best Regards
ete Gurecki
'krSOv'4(Li Kka�h_
Sworn to me on thisd 07 day of July 2017
By: Vl<Gkc e) 3 • M,
V.P.W, Michael J. Miller
Commission if GG052408
= Expires: March 25, 2021
``r
,,,,o, ,,,, Bonded •
thru Aaron Notary
Miami Shores ViHage
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 Exem tion
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 parttime or fall -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. Constniction exemptions are valid for a period of two years or until a
vobirtsry 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 T
The foregoing was acknowledge before me this 24.9 day of ,J O , 2011.
Bye s
rs,41-e_fie, who is personally known to me or has produced
as identification.
LUIS OUVERA
Notary Public, State of Florida
Comm.seon
F 955560
x
My comm. expires
Jan. 28, 2020