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PL-15-1341Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -6-15-1341 Permit Type: Plumbing - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 10/8/2015 Expiration: 04/05/2016 Parcel Number Applicant 5 NE 105 Street Miami Shores, FL 33138-2030 1121360060090 Block: Lot: RED RIVER USA LP Owner Information Address Phone Cell RED RIVER USA LP 3250 NE 1 Avenue MIAMI FL 33137- 3250 NE 1 Avenue MIAMI FL 33137- Contractor(s) Phone UNIVERSAL PLUMBING CORP (305)887-3131 CeII Phone Valuation: Total Sq Feet: $ 2,500.00 00 Type of Work: REMODELING 1 SINK LAVATORY KITCHEN Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.80 $3.38 $3.38 $0.60 $225.00 $9.00 $2.40 $245.56 Pay Date Pay Type Invoice # PL -6-15-55817 10/08/2015 Credit Card 06/03/2015 Credit Card Amt Paid Amt Due $ 195.56 $ 50.00 $ 50.00 $ 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 construction and zoning. Futhermore, I authorize the above-named contractor to do th Authorized Signature: Owner / Applicant / Contractor / A Building Department Copy will be done in compliance with all applicable laws regulating d. October 08, 2015 Date October 08, 2015 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) 762-4949 RECEIVY JUN 0 3 2015 FBC 20 0 BUILDING Master Permit No. 457-59/ PERMIT APPLICATION Sub PermitNo./9/ /,s-' /3Jj ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP gPLUMBING CONTRACTOR DRAWINGS JOB ADDRESS: C$ /" C (os s s/ City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Te /2 ; ext U5y P Phone#: IgG 3-6 6 Address: �n 5/ ?9i20'5 -j .44 4 `-t•' /;.t,• 3 3 /34' City: State: Zip: Tenant/Lessee Name: _ Phone#: Email: CONTRACTOR: Company Name: drj;ve/ZrJ 4/‘ /94,4m y a /2 Phone#✓ a 07 (-� -I Address/L L(( L '�p �J7 City: /1-4 t'e 4 / State: -Z1/109 Zip:ip333 t 5 Qualifier Namei'2'l `'GG1G/. C9 �G.`�9 Phone#✓/YZ 4" `?f'-'/ State Certification or Registration #: • C7 * --C l C%1 6'C(2 ( Certificate of Competency #: C7 C( 6/02 i4 2/ DESIGNER: Architect/Engineer: •-Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ 'Alteration ❑j New n Repair/Replace Description of Work: /2g ,i2c.. / etu a Nc7 • ti4 atizr'ri I ❑ Demolition r 6-h) �- la ug7ai n y . s 10t._.• n •� u Specify co- lorrof color thru tile: trs_."C./.‘i Submittal Fee $ -, r Permit Fee $ 22.- . +`Y CCF $ fl, CO/CC $ Y! "C,* % t Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ -Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ /9°5. S (Revised02/24/2014) 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 •E 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 �.r OWNER or AGENT Signature 'CONTRACTOR The foregoing instrument was-ackrr. -.:-..efore me this The foregoing instrument was acknowledged before me this n y. a (• day off/ / 7Q , 20 /, s , by G( day of ,4 P/ 7Z ' 4, 20 -(5 , by /�� Rates , who is personally known to r , , who is personally known to PL � me or who has produced T T [/L • as me or who has produced �" 1 t_ as identification and who -did take an oath. NOTARY PUBLIC: NOTARY PUBLI identification and who did take an•oath. Sig c Seal: o*Notary Public State of Florida Joanna M Feliciano • My Commission FF 082753 iaQl'**Expiesa*MMVIB'1 ******* APPROVED BY (Revised02/24/2014) Print: Seal: Li OURDES MARIN MY COMMISSION 00009107 EXPIRES April 17, 2017 .com ******************************************************** ******* co -3-(r Plans Examiner Zoning Structural Review Clerk 06/02/2015 TUE 12:08 FAX 21001/001 ACC) R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS /15 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 THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 G & E Insurance Consultants,inc. 9880 S.w.40th Street Miami, FL 33165 228.8988 RER(S)AFFORDINGCOVERAGE Phone (305)228-8988 28-8988. ..... Fax (305)228-8969 GRANADA INSURANCE COMPANY INSURED INSURER A : UNIVERSAL PLUMBING CORP INSURER e: INSURER C: 141 East 60 St Miami, FL 33013- (305) 804-5484 CONTACT. ... ....................... NAME; GRICEL GONZALEZ PHONE (A/C, No, Ext);... (305)228-8988 E-MAIL ADDRESS;.....,..,,,grice15620@comcast.net INSURER,D,;....., INSURER E : FAX (ac, No): (305)228-8969 NAIL H COVERAGES _INSURERp_;.._.__..__—___— — .._._._... - _ .__..... ........-... CERTIFICATE NUMBER: REVISION 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. NSR LT ADDLSUBR R .-...__.., TYPE OF INSURANCENSR,!_WYD . „ POLICY NUMBER : POLICY EFF POLICY EXP ,' ........ . . _ (MMlDD/YYYY) ' (MMlDD/YYYY) LIMITS • GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY i j,j CLAIMS -MADE ?V OCCUR 500 OED GEN'L AGGREGATE LIMIT APPLIES PER: �....., ,...... ARO. POLICY.... c:'JECT.........4-:'LOC ... AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS UMBRELLA LIAB t" 1 OCCUR : EXCESS LIAB...,.......................... ... I I CLAMS -MADE ..: DED -...J RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE I OFFICER/MEMBEREXCLUDED? N!A (Mandatory In NH) if yes, describe under DESCRIPTION OF OPERATIONS below N N 10185FL00059289 05/08/2015 05/08/2016 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) PLUMBING COMMERCIAL AND RESIDENTIAL SERVICES 'UNIVERSAL PLUMBING CORPORATION LIC #CFC 1428421 CERTIFICATE HOLDER CITY OF MIAMI SHORES VILLAGE 10050 NE 2 AVE MIAMI SHORE VILLAGE FL 33138 FAX 305 756 8972 ACORD 25 (2010/05) QF CANCELLATION EACH OCCURRENCE_ ; DAMAGE TO RENTED- -- P,Rf<MISES,(Ea,occNrrence)" MED EXP (Any one person) .......... PERSONAL & ADV INJURY GENERALAGGREGATE PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT (Ea accident). " BODILY INJURY (Per person) BODILY INJURY (Per accident). PROPERTY DAMAGE (per accident) EACH OCCURRENCE ..............................._. AGGREGATE ...: WC STATU- TORY. LIMITS, : OTH E.L. EACH ACCIDENT E. L. DISEASE,- EA EMPLOYEE $ .... .... ............ .......................... E.L- DISEASE - POLICY LIMIT; $ s 1,000,000.00 $ 100,000.00 s 5,000.00 ..................................... $ 1,000,000.00 5 1,000,000.00 $ 1,000,000.00 $ S $ S 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 © 1988-20 The ACORD PORATION. All rights reserved. e;andlogo are registered marks of ACORD 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: 5/18/2015 PERSON: GARCIA FEIN: 264039076 BUSINESS NAME AND ADDRESS: UNIVERSAL PLUMBING CORP 141 E 60 ST HIALEAH EXPIRATION DATE: 5/17/2017 MICHEL FL 33013 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS 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 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 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 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' compensati. - insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING B 1 U ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. i Signature: `, �t O er State of orida County of Miami -Dade 'J The foregoing was acknowledge before me this 2(0 day of , 20 (C. By J/ U,L S /GL/J67/C1 Wr (/1 --Z 1C -2,•)11C-1?. Notary: SEAL: who is personally known to me or has produced as identification. ;a:**:%, ELLIOTSOTO * MY COMMISSION # EE 10702: EXPIRES: August 5, 2015 0r4rFOF Fide) Bonded Nu Budget Notary Services New Construction Remodeling and Repair Licensed & Insured as,„4 ,41•0 417 4 State certified plumbing contractor Back Flow Preventer certification Medical Gas Certification PLUMBING & MECHANICAL CFC -1428421 CMC -1250146 RESIDENTIAL o COMMERCIAL* INDUSTRIAL Tel 305-824-3131 Fax 305-824-3134 universalpms@gmail.com State of Florida. County of Miami Date: 04/13/2015 Before me this day personally appeared Osvel Castellon, President of Universal Plumbing Corp • who being duly sworn, deposes and says: That he will be the only person working on the Project Locates at: 5 NE 105 ST. Print Name STATE OF FLORIDA COUNTY OF MIAlvII-DADE Sworn to and subscribed before me tys 13 day of by -el f/92€1» Personally known X or I.D. Clerk: LOURDES MARIN MY COMMISSION #FF009167 EXPIRES April 17. 2017 FloridallotaryService.corh