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PL-18-128 Permit NO. PL-1-18-128 �sKORj Miami Shores Village Permit Type:Plumbing-Residential 10050 N.E.2nd Avenue NEn Work Classification:Gas t Miami Shores, FL 33138-0000 PePermit Status:APPROVED - a FN .11D Phone: (305)795-2204 Issue Date:311312018 Expiration: 09/09/2018 F Project Address Parcel Number Applicant 1270 NE 94 Street 1132050100160 BRUCE ROSENTHAL Miami Shores, FL Block: Lot: Owner Information Address Phone Cell BRUCE ROSENTHAL 1270 NE 94 ST MIAMI SHORES FL 33138-2947 Contractor(s) Phone Cell Phone Valuation: $ 250.00 FOREVER GAS CORP (305)298-0193 Total Sq Feet: Type of Work:CONNECT FLEXLINE PROVIDED WITH GENE Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Return Press Test Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CC'F $0.60 Invoice# PL-1-18-66148 1313 FIR Fee $2.00 03/13/2018 Check#: 1714 $ 114.60 $0.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 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 ce ,,Jfy that he foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction�F�t above-named contractor to do the work stated. March 13, 2018 Autho—rized Signature:Owner / Applicant Contractor / Agent Date Building Department Copy March 13, 2018 y 7 i t Miami Shores Village Building p D e a rt m e n t RECE�v Ep 16. 1011 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 E Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 t FBC 2011 BUILDING Master Permit No. EL 1 u 171-1 PERMIT APPLICATION Sub Permit No. PL-*I G-1 Z1 I BUILDING F1 ELECTRIC ROOFING I F-1 REVISION F-� EXTENSION RENEWAL I 9 PLUMBING F-1 MECHANICAL PUBLIC WORKS [:] CHANGE OF .❑ CANCELLATION F-1 SHOP CONTRACTOR DRAWINGS JOB ADDRESS: /Z 7 6 � _ � City: /Miami Shores _ County: Miami Dade Zip: Folio/Parcel#:' 0 / (SCJ > Is the Building Historically Designated:Yes NO V/ Occupancy Type: _Load: Construction Type: GS Flood Zone:` BFE: FFE: I / p�/c� OWNER:Name(Fee Simple Titleholder): aUL� Sei �11�- / Phone#: ,�J794f 60 KV Address:,,/ �� City:T t&ALJ ox-e-,j State: Zip: ?1 Tenant/Lessee Name: /j a Phone#: Email: CONTRACTOR:Company Name: x%l�'�f� -S �Y Phone#: .�®`� Address: ,F6,F-,,k" �vv� City: State: . Zip: Qualifier Name: Phone#: 30SS���"6�9� ¢ 4 State Certification or Registration Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: c� City: State: Zip: L Value of Work for this Permit:$ Squa?e/Linear Footage of Work: Tip607 Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace / '❑ Demoliti n Description of Work: ,� Lpa s Az;14 n / N / U1I :;.1 r' ^7`:7ri't'y,.A. �, I.�Jid""'Ft r17tU.x t. ` Specify color of color,thru-tfiile:; y ; t; Y; `' . 'GS r(fid �Cy,'!>'a_ ra •� t,;.,i y . Submittal Fee$ Feb$ i ff(/V CCF$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ I , . Ib o k , (Revised02/24/2014) Bonding Com`pany's Name(if applicable) Bonding Company's Address ' •fr r City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address e . I ; f City > a 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, l FURNACES, BOILERS,HEATERS,TANKS,AIR CONDITIONERS, ETC..... J 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 o a building pp f g 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 obse'nce of such posted notice, the inspection will not be approved and a reinspection fee will be charged. , Signature Signature.*.;;,"1. 'OWNERorAGENT aCARACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this n day of r 20_ 3 by day~of E (�- 20 � ?S by 9O5-CrA(a, 1 ,who is personallyknoow .n to 0� -% C-1667 6h?—, ?—,who is personally known to me or who has produced as me or who has produced as, I en i ica ion and who did take an oath. identification an who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: s t Sign: Sign: Print:—_ t li�� l �� )/rt S C vI Print: k n r C � r r� Seal: r°;•••.�� ALEJANDRA GRIGORES CU Seal: s°`� �"4�. ALEJANDRA GRIGORESCU * MY COMMISSION 1 FF 143529 # , MY COMMISSION 1 FF 1429 ' EXPIRES:July 21 2018 - , EXPIRES:Jing 21,2018+ ate,""e Bonded lbru sudgM Notary senkes _ _ ,� � ry t a�v� fended lhru eud�et Nervy senlce� APPROVED BY 1 l Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) w ' ,5 ORES Grp Miami shore's Village - -o�� Building Department oRm�' ' 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 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. f1. 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: Owner` State of Florida County of Miami-Dade 2 The fore�oing was ackn dge before me this day of ft&Q ,20 B "�Yy L e" SAY!7 - who is personally known to me or hasproduced y p y as identification. Notary: �`;:•�•:4� ALEJANORAGRIGORESCU SEAL: * * MY COMMISSION II FF 143529 EXPIRES:July 21,2018 a'+rf ��e Banded TNv EudgM N*rySenlces d • r Forever Gas Corp 18111 NW 68th Ave. Apt# 1105 Hialeah, Fl. 33015-3989 Date: January 3,2018 State of: Florida County of: Miami Dade Before me this day personally appeared Roberto Gonzalez,who, being duly sworn,deposes and says: That he will be the only person working on the project located at 1270 NE 94 St., Miami Shores, FI. 33138. Contractor Signature Sworn to(or affirm d)and subscribed before me this 3 day of U . 2018 -may: ----------ql� N Personally know Or produced identification Type of Identification Produced MJ:JMIDRA GRIGORESCU * * MY MMMISS10N t FF 113629 EXPIRES:July 21,2018 J�'je OF R�Ae Bonded Thru Budget No"Semice6 r Print,Type or Stamp of Notary r Cut Here ' - State of Florida s a'' Department'ofAgriculture-and Consumer Services ' Division of Consumer Services ° F" Ca ibfiwto N 26440 ,Buieau of Ccrn^l'BP. ?. o: r_Exam Date:gAugus(, 2013 p (850)'621'-1600 Issue Date:"September 18,2016:. Tallahassee, FlOnda Expiration Date: September 17,2019 Exam: 0803 -MASTER,QUALIFIER CERTIFICATE This Certificate is issued underauthority.of Section 527.02:Florida Statutes,to: ; 4 .. ROBERTO GONZALEZ-. Milid'For license Numtier.,28379 FOREVER GAS CORP• a ` 18111 NW 68TH AVE APT 1105 ADAM H HIALEAH,'FL'33015 3989 - COMMISSIONER OF AGRICULTURE - i C De artment of A riculture and nsumer Servic s Division-of Consumer Services License Number. 283 9., f Bureau of Liquefied Petrofeum-Gas-Inspection Expiration Oat&. August 31,2016 (850)92-1-1600 Data of Issue:'September_1,201.7 POST LICENSE TallahasseFlorida ` :CONSPICUOUSLY ` Type en $ d Class:08000 3 z Liquefied Petroleum Gas License LP=GAS INSTALLER ' GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESSRENDERS THIS LICENSE' INVALID' This license Is Issued under autiiortty'of Section 527.02,Florida Statutes;to: FOREVER GAS CORP _ 18111 NW 68TH AVE APT 1105 ""IS H.PU TN 41ALEAH, FL130.15-3989 ADAONER - ,COMMISSIONER'OFAGRICULTURE. _ t 012356 - - - - - - - Local Business Tait Receipts r Miami—Dade County State of Florida' LB -THIS ISNOT A BILL-DO NOT PAY 6978051 RE C BUSINESS NAME/LOCATION EXPIRES .:RENEWAL FOREVER GAS CORP 7253636 SEPTEMBER`30, 2018, 1 f3'111'NW 68 AVE°1105, Must be displayed at place'of business MIAMI FL 33015 Pursuant to County Code' Chapter SA`-Art.9&10 SEC.TYPE OFBUSINESS PAYMENTRECEIVED OWNER - OWNEFOREVR GAS CORP 205 LPG INSTALLER, BY TAX COLLECTOR- t LPG28379 $100.00-09/18/20]7 a - CREDITCARD-17-0585601 This local Business Tax Receipt only confirms payment of the Local Business Tex.The Recaipt is not aVliiccensse, 4 permit,ora certification of the holder's qualifications,to do business.Holder must oomph with arty 9a or aonpovernmemel regulatory lays and requirements which apply to the business. 1 The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec Ba-M For more information,visit•--`'�miemidade.-ovh■xco f .. sIlector' , 1 i , A JIMMY PATRONIS 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' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 8/312017 EXPIRATION DATE: 8/312019 PERSON: GONZALEZ ROBERT FEIN: 271764059 BUSINESS NAME AND ADDRESS: FOREVER GAS CORP 18111 NW 68 AVE,APT 1105 , HIALEAH FL 33015 SCOPE OF BUSINESS OR TRADE: Oil or Gas Pipeline construction 6 Drivers I 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 benerds 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 ti,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 she#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 08-13 QUESTIONS?(850)413-1609 I _-_-- -_- ACOREO CERTIFICATE OF LIABILITY INSURANCE DA'M(M IDD"""° 10120/17 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 INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is 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 certif tate holder in lieu of such endorsement(s). PRODUCER CONTACT CLAUDIA M DE LA ROSA Claudia's Insurance PHONE (786)293-9141 Ja (786)293 No)_ -9142 18901 SW 106th Ave 132E-MAILDRclaudia@claudiasinsurance_com Miami,FL 33157 I I AFFORDING COVERAGE Phone (786)293-9141 Fax 86 293.9142 NaIC INSURER A: ARCH SPECIALTY INSURANCE COMPANY INSURED 21189 INSURER B: FOREVER GAS CORP zl. INSURER C: 18111 NW 68 AVE 1105 INSURER D: HIALEAH,FL 33015 (305)298-0193 INSURER E: INSURER F: COVERAGES 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 MAYBE 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. ILLTR. TYPE OF INSURANCE ADD UB POLICY EFF POLICY EXP GENERAL LUU3d,lTY M Imm AM POLICY NUMBER LIMITS EACH OCCURRENCE $ 1,000,000.00 © COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea oownenae $ 100,000.00 A ❑ F1 CLAIMfIS NIADE © OCCUR F] N N AGLOO41747-01 10/172017 10/172018 MED EXP(Any one person $ 10,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PERGENERAL AGGREGATE $ 2,000,000.00 PRODUCTS-COMP/OP AGG $ 2,000,000.00 R] POLICY IJ PRO 1:1 LOC $ AUTOMOBILE LIABRITY COMBINED SNGLE LIMIT Ea acddent ❑ ANY AUTO ❑ OWNED USD BODILY INJURY(Per person) $ AUT ❑ AUTOS BODILY INJURY(Per accow $ s• i.r ❑ HIRED AUTOS ❑ AUTOS'NON-OWNED r... AOS' PROPEDAMAGE $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE ! AGGREGATE $ ❑ DED Ej RETENTION$ i WORKERS COMPENSATION $ AND EMPLOYERS LIABILITY Y/N ❑WC STATU ❑OT-' - ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ElN/A E.L.EACH ACCIDENT $ (Mandatory In NH) If yes describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS bebw E.L DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Addhional Remarks Schedule,I more apace is regWred) GAS APPLIANCE SERVICE,INSTALL AND REPAIR LPG 28379 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE'CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE AUTHORIZED REPRESENrAT1VE MIAMI SHORES,FL 33138 t: TEL 305-795-2204 FAX 305-756.8972 _ (�y G ACORD 25(2010/05)OF ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered(narks of ACORD I