PL-17-378 Permit NO. PL-2-17-378
`st'°REs Miami Shores Village IP
Permit Type:Plumbing-Residential
10050 N.E.2nd Avenue NE +
Miami Shores,FL 3313&0000 Pen I Work Classification:Addition/Alteration
Phone: (305)795-2204 Permit Status:APPROVED
F�ORiDp`
Issue Date:7/31/2017 Expiration: 01/27/2018
Project Address Parcel Number Applicant
922 NE 91 Terrace 1132060000030
Miami Shores, FL Block: Lot: BBJJB LLC
Owner Information Address Phone Cell
BBJJB LLC 922 NE 91 Terrace (954)558-3959
MIAMI SHORES FL 33138-
922 NE 91 Terrace
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone $ 3,500.00
Valuation:
COPPER STONE CONSTRUCTION& C (561)697-8638
_.. __. _... . ........�.. _... _....._ �.. Total Sq Feet: 0
a
Type of Work:INSTALL NEW WATER VALVES,AND FALC Available Inspections:
Type of Piping: Inspection Type:
Additional Info:INSTALL NEW WATER VALVES,AND FALC Top Out
Bond Return: Final
Classification:Residential Scanning: 1 Review Plumbing .
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $2.40
DBPR Fee Invoice# PL-2-17-62935
$3.38 02/14/2017 Credit Card $50.00 $191.16
DCA Fee $3.38
Education Surcharge $0.80 07/31/2017 Check#:2405 $ 191.16 $0.00
Permit Fee $225.00
Scanning Fee $3.00
Technology Fee $3.20
Total: $241.16
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 fore oing information is accurate and that all work will be done in compliance with all,applicable laws regulating
construction and zoning. Futhermore,I author' a above-nameq contractor to do the work stated.
my 31, 2017
Authorized Signature:Owner / Ap5plicant / Contractor / Agent Date
Building Department Copy
July 31, 2017 1
Miami Shores Village ;
Building Department - '
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel: (305)795-2204 Fax: (305)756-8972 c
INSPECTION LINE PHONE NUMBER:(305)762-4949 J�h
FBC 20)
BUILDING Master Permit No.PC n -'3 5
PERMIT APPLICATION Sub Permit No. PL 11 _3�8
F-1 BUILDING F-] ELECTRIC ❑ ROOFING ❑.REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Q a� CONTRACTOR DRAWINGS
JOB ADDRESS: %d�,2 N,�. G Derce-
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): LA,— : b-nc4Z4 Phone#:
"/
Address: V A14 VJ' I' 7"0ryA(e
City:�d_tfiT''��t Ai cliNS State: F/cr- A� Zip: B12Y
Tenant/Lessee Name: Phone#:
Email:
}3)v:s I9i Yh/f�a Cvlr
CONTRACTOR:Company Name:_C.D�'�'�Y s/`e7r►l� Lo:��r✓y�ita/) Q op-5i11V Phone#:
Address: t' - 01 06
City:wp'b f /91LIM l Bath State:_F),ori t, Zip:
Qualifier Name: Phone#:
State Certification or Registration#: C i—(. �~j(�(a,f%J Certificate of Competency#:
��rC
DESIGNER:Architect/Engineer:�r��,,1�e(;'k��e �„ �'rVjP►j;�✓4 � ' Phone#:3sigr 1541S6
Address:qq D "7
City:R, f„AutJedG,)rr,State:PF -1—Zip:
Value of Work for this Permit:$ -35L)d �� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
Repair/Replace El Demolition
Description of Work: Htll rVC'_W ivc4neyE"Llvej l e'CNJ' AA"'CF4j, 3.'•,i1C '�i>>{� GzN�
Specify color of color thru tile:
Submittal Fee$ D Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ h�
(Revised02/24/701 41 `
i
}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
G 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 bn estimated value exceeding$2500, the applicant must
I 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 Signature
42AOWNER or AGENT CONTRA R
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
fD day o 26 _ 20 / ,by /I �-day of P�h .20 / ,by
Oy C��dr�uC�who is personally known to A) ,oNS�J 40e _who is personally known to
i me or who has produced .( sDL,
as me or who has produced ' {7�� as
identification and wh d take an oath. identification and who di take an oath.
NOTARY PL BLI NOTARY PUBLI ' R
Sign: Sign
Print: A Print v
`= M C MMISSION#FF974952 Seal
Seal: MY C M ISSION#FF974952
EXP S April 05,2020
' EXPIRES April O5,2020 .`r' „
1407)39fl-0153 PlaidallotaryServiCe.com C�fly9®0151 FlptideNotatyService.com
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APPROVED BY / Plans Examiner Zoning
Structpral Review Clerk
i
(Revised02/24/2014)
t
gttOREs G
s� Miami shores Village
oal
Building Department
10050 N.E.2nd Avenue
�l0R1Dp' Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
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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:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of ,20a.
By_ A nl)G�rF�i�p���h who is personally known to me or has produced
as identification.
Notary: /
1
MELIZA ALVAREZ� t
SEAL: � �'=
'' MY COMMISSION#FF974962
•. EXPIRES April 05,2020
407 1 Floridallota rviee.COm
/1
Company Letter Head
Date:
State of a-
County of
Before me this day personally appeared A140r& tq% who, being duly sworn,deposes and
says:
r,
That he or she will be the only person w rkingon the project located at
G72y z C,
Sworn to or(affirmed)and subscribed before me this h day of P� ,2 0 IiLy
o Sb L+y
Personally known
Or Produced Identification
Type of Identification Produced
MELIZA ALVAREZ�
MY COMMISSION#FF97496
EXPIRES Ap'd 05,2020
(407)398-0153 FioridsNouryServiee.com
P 4- ITypoo Stamp of Notary
i
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t
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�.-.1 Fax: (305)756-8972
'4�" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
02/14/2017
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 INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 CONTACT
NAME: Sasha Aristy
Horizon Insurance.Inc. PHONE 941-755-9500 FAX
c No)-941-753 9472
7347 52nd Place E
E-MAIL info@horizonins.net
Bradenton, FL 34203 INSURERS AFFORDING COVERAGE NAIC#
INSURER A: International Insurance Company of Hanover SE
INSURED
Copper Stone Construction&Designing Corp. INSURER 8:
Alfonso Lopez INSURER C:
4839 Badger Rd INSURER D:
West Palm Beach, FL 33417-2915 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00000000-1625579 REVISION NUMBER: 2
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.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE iNqn wvn POLICY NUMBER MM D MM D LIMITS
A X COMMERCIAL GENERAL LIABILITY 1 G06AO1 1051-01 01/15/2017 01/15/2018 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE rx]OCCUR IDAPREM SES E ToEa occur ence $ 100,000
MED EXP Anyone person) $ 5,000
PERSONAL&ADV INJURY $ 11000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY❑PRO-- LOC
JECT PRODUCTS_COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY P
AUTOS ONLY AUTOS (Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $
J $
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
Ii yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Contractor ID#CFC1427669
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 N.E.2nd Avenue
AUTHOR IZED REPRESENTATIVE '
Miami Shores, FL 33138 l�H/\O
SSA
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Printed by SSA on February 14,2017 at 11:11 AM