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PL-18-820 Permit O. PL-3-18-820 sti'Q1s o,� Miami Shores Village permit Type:Plumbing-Residential 10050 N.E.2nd Avenue NE Work Classification:Gas Perillot Miami Shores,FL 33138-0000 Permit Status:APPROVED hF— s Phone: (305)795-2204 �ORLD� Issua Date:414/2018 Expiration: 10/01/2018 Project Address Parcel Number Applicant 373 NE 101 Street 1132060135230 ' MELISSA 8 RICARDO MAZZITEI Miami Shores, FL 33138-2424 Block: Lot: Owner Information Address Phone Cell MELISSA&RICARDO MAZZITELLI 373 NE 101 Street (319)321-1561 (319)321-1561 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 100.00 EPJ GAS SERVICE CORP (786)299-6311 Total Sq Feet: p Type of Work:INSTALL GAS TANK Available Inspections: Type of Piping: Inspection Type: Additional Info:INSTALL GAS TANK Final Bond Return: Press Test { Classification:Residential Scanning: 1 Review Building F Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.50 Invoice# PL-3-18-66970 DBPR Fee $2.25 DCA Fee $2.00 04!04/2018 Credit Card $ 158.85 $0.00 Education Surcharge $0.20 Permit Fee $150.00 Scanning Fee $3.00 a Technology Fee $0.80 Total: $158.85 t In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing informa io is cc to and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-n me r to do the work stated. 4 April 04, 2018 Authorized Signature:Owner / Applic / o actor / Agent Date Building Department Copy April 04, 2018 1 RF CF 4F Miami Shores Village MAR 29 201$ I� Building Department ' ""10050-N.E.2nd Avenue Miami Shores Florida 33138 \ Tel:(305)795-2204 Fax:(305)756-8972 I INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 ill , BUILDING , Master Permit No.RC 12 16 3485 PERMIT APPLICATION _ Sub Permit No. p l ❑BUILDING r ❑ ELECTRIC" ❑ ROOFING S ❑ REVISION t ,,,- '❑EXTENSION ❑RENEWAL,, ®PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑CHANGE`"OF ❑'CANCELLATION' F-� SHOP"` CONTRACTOR DRAWINGS- JOB RAWINGS.,JOB ADDRESS: 373 NE 101 ST t n d, City: _Miami ShoresCounty Miami Dade --Zip: 33138 , f:"- +7i P 1 }.O :. '(F � y A' , �.p, 1-r ...r . •.44^ .v. ♦. Y . .. • _�wt� Folio/Parcel# 11-3206-013-5230 y T ,s " r, �,_ P Is,the Building Historically Designated iYesi e*- , NO-ki + r a (.Y 4•' -.,Yw a. y.• r : . -'. a' ,-z .i , . .r• r k Occupancy Type: -v.. -, i,Load: r `.-r A Construction Type: is e F ¢ r Flood Zone:i - r., BFE:; IA,a FFE:4. , �j'a 1 .,_... . . . _ _ MELISSA CL MAZZITELLI ~ 1 J "s`q OWNER:Name(Fee Simple Titleholder): Phone#: 373 NE 101 ST Address: •a. * r\• r x% I ... , , . MIAMI SHORES " _. i FL "* +' ' ` ' 33138 ; City:' State' Zip: Tenant/Lessee Name:. ' Phone#: ' r Email: CONTRACTOR:Company Name: EPJ GAS SERVICE CORP Phone#: 305-361-2929 Address: 510,REDISH CIRCLE- r + r City. CLEWISTON ' State: FL iZ p: 33440 `t i ` `+ '' '' ' ' . +''+ -ir Qualifier Name: EDUARDO PENICHET.. Phone#: State Certification or Registration#: LPG 02609` + Certificate of Competency.#: �~ S s� DESIGNER;Architect/Engineer: _ Phone#: '�- Address: +City: '"State: Zip? , r '.rs Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ElAddition E:1Alteration 1:1New ❑ Repair/Replace ❑ Demolition . Description of Work: INSTALL GAS TANK t5urw.rietcet ,°';e♦r.;_ ;a�xhrw��.rM+mt.ug- + 'S. i{iq�"C'lt�rl.t�YI�,,W! utr .'I^J rr��e • y 1� � - .,. ....,.. � ~a I^, _� ::a Spedhr color Of color'thrci - tikA -.11 - PermiSubmitalFee$ Fee� nn / ,CCF Scanning Fee$ Radon Fee$ DBPR$ a a� Notary$ �' y Teclinology Fee$ cilJ Training/Education Fee$0' 2C) Double Fee$ Structural Reviews$ ',Bond$ s. TOTAL FEE NOW DUE$ C I' ' eS (Revised02/24/2014) 1 Bonding Company's Name(if applicable) - 1, }" is t ,... • ,' . �_ �Jt r Bonding Company's Address I City State 1 r Zip Mortgage Lender's Name(if applicable) . Mortgage Lender's Address' i City w ,State"r.+ 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 tc the issuance of a permit and than all work will be performed to,m_ eet 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: 1 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 TWIMFOR-IMPROVEMENTS-TO YOUR PROPERTY. IF YOUINTEND 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 d reinspection fee will be charged. Signature 0—, + Signature NER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this Kay of 20 8 by 28 day of MARCH 20 18 ,by m r�a who is personally known to EDUARDO PENICHET w is personalI n to me or who has produced _VU.L-S' L4"106— as me or who has produced '. ask identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: r t � t • Sigri• " Sign: i 00eA-,4a Print• /1�r' 1 t7U ✓t LUIS BERGOUIGNAN Seal: =�a• '`! Seal: Jo ICHAELANTHONY BERGOUIGNAN COMMISSION#GG 186284 MY COMMISSION#GG,093923 "i a`,=• EXPIRES:March 23,2022- - - 1 EEXPIRES:August 2021 r�oF oP•• Bonded Thru Notary Public Under� BMW rn Notary Public li11ds lidos,. APPROVED BY (/` `SIO _ Plans Examiner,, if Zoning +w Structural Review Clerk (Revised02/24/2014) EPJ Gas Service Corp. t March 29, 2018 State of Florida County of Miami Dade r Before me this day personally appeared ���Gpd ���t Glut=�` who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: } 3'7 3 u•E, l o s� Contractor sWature Sworn to (or affirme and subscribed before me this 2 9 day of . 20LO by r Personally known_ OR Produced Identification Type LUIS BERGOUIGNAN MY COMMISSION#GG 186284 EXPIRES:March 23,2022 hoc nR 60 WW 7hrU Notary Public Urderwrl m rint, ype or Atamp Name of Notary 4 . 1 f { { { 1 r , { r S�oR>ES s� Miami S hores ,Village- w"" ""'�' Building Department res tox 10050 N.E.2nd Avenue lOR1EDp` 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. 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. , I 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: E Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of ,20, ; t By EL/ Jr.09 �ZJt��' who is personally known to me or has produced QuL2S �� as identification. Notary: LUIS BERGOUIGNAN L. „ MY COMMISSION#GG 186284 L: EXPIRES:March 23,2022 M S` Bonded Thru Notary Public Underwdter$ I i _ 1 ! A � (MMRIDIYYYI� CERTIFICATE OF LIABILITY INSURANCE DATE 04102118 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 COVERAG�AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUI G INSURER(5),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I IMPORTANT: If the eertiticate holder is an ADDITIONAL INSURED,the policy(ies)must ba 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). I PRODUCER CONTACT CLAUDIA DE LA ROSA Claudia's Insurance P E FA No EM). (786)293-9141 86 293-9142 18901 SW 106th Ave 132 L daudia@daudia,irtsurar ce.com Miami,FL 33157 INSu S AFFORDIN COVERAGE NAIC 9 Phone 86 293-9141 Fax 86 293-9142 INSURER A: ARCH SPECIALTY INSUF ANCE COMPANY 21199 INSURED INSURER B: Epj Gas Service Corp. INSURER C: 510 REDDISH CIRCLE INSURER D: CLEWISTON,FL 33440 (786)229-6311 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REIRSION NUMBEMR: 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 CONTRACTOR 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. !LTR TYPE OF INSURANCE AD UB POLICY EFF POLICY EXP InRvm POLICY NUMBER MMIDOWnffl (MMfDDNYYYI LIMITS (.. GENERAL LIABILITY 4EAH OCCURRENCE S 2,000 000.00 © COMMERCIAL GENERAL LIABILITY PDAR lAGE T eE EDB' e s 150,000.00 A El El COMMS-MADE © OCCUR AGL0041883 01 ME EXP one z 10,000.00 ❑ N N 10/09/2017 10/09/2018 SONAL 6 ADV INJI L RY s 2,000,000.00 ❑ GE ERAL AGGREGAT S 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PR UCTS-COMP AGG s 2,000,000.00 0 PRO-POLICY ❑ ❑ LOC $ AUTOMOBILE LIABILITY E BIND ac iISINGLE LI R ❑ ANY AUTO BOOILY INJURY(Per pf rsm) S ❑ AULL TOS OWNED ❑ SCViAUTO£DULED ILY INJURY(Per dent $ A ❑ HIRED AUTOS ❑ AAUTOS NED PR PPE nDAMAGE $ 1 S ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑-EXCESS LIAR ❑CLAIMS_MADE AG'REGATE s DED RETENTION s WORKERS COMPENSATION WC STATU- OTH- ' AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E- DISEASE-EA EM LOYE $ f If yes,describe under DESCRIPTION OF OPERATIONS belay E. DISEASE-POCK LIMIT 1 $ i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Addalonal Remarks Schedule,N more apace is required) LPG APPLIANCE INSTALL SERVICE AND REPAIR LPG#26019 ` I t I I � I I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DES RIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, OTICE WILL BEIDELIVERED IN I 10050 NE 2nd Ave ACCORDANCE Wrrt THE POLICY OVISIONS. I Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE Fax:305-756-8972 �FLfF i l,Q L 1 0 1988-2010 ACORD CORPORATION. ACORD 25(2010105)OF The ACORD ameo areregiste and log g gisteAll rights reserved. red marks of ACORD ' i I i i � I I