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PL-15-3184Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit I8sue Day Permit NO. P L-12-15-3184 Permit Type: Plumbing - Residential Work Classification: Drainfield Permit Status: APPROVED :12/30/2015 Expiration: 06/27/2016 Parcel Number Applicant 1316 NE 105 Street Miami Shores, FL 33138- 1122320270150 Block: Lot: Owner Information FLUS LLC Address 1316 NE 105 Street MIAMI SHORES FL 33138- 5210 SW Terrace SOUTH WEST RANCHES FL Contractor(s) JASON'S SEPTIC INC Phone 305-252-1080 CeII Phone FLUS LLC Phone (305)609-2522 Type of Work: FIX DISCONNECTION BETWEEN EXISTING Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due Bond Type - Contractors Bond CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Amount $500.00 $0.60 $4.50 $4.50 $0.20 $300.00 $3.00 $0.80 Total: $813.60 044/11,01 Pay Date Pay Type Invoice # PL-12-15-58163 12/30/2015 Check #: 95 12/28/2015 Cash Bond #: 2938 A Amt Pa,: mt Due $ 763.60 $ 50.00 $ 50.00 $ 0.00 Cell Available Inspections: Inspection Type: HRS Approval Final Review Plumbing 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 AFFID IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction anWing. Futher ore, I authorize the above -named contractor to do the work stated. December 30, 2015 horize• Signature: Owner / Applicant / Contractor / Agent Date Buil • ing Department Copy December 30, 2015 1 Miami Shores Village BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC ELUMBING ❑ MECHANICAL 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 ❑ ROOFING ❑ REVISION RECEIVED DEC 28 2015 FBC 201(1 Master Permit No. 5-9:. Sub Permit No. ?L 6- 31 J 1 ❑ EXTENSION RENEWAL PUBLIC WORKS ❑ CHANGE OF CONTRACTOR JOB ADDRESS: / 1 / (9 /V E / (% 5 S-K-QP -)- j,t City: Folio/Parcel#: Miami Shores ❑ CANCELLATION ❑ SHOP DRAWINGS County: Miami Dade Zip: 3513 Is the Building Historically De: J e • : Yes NO X.- 1 OQpang TypQ: Load: — Construction Type: Sp `h C' Flood Zone: - ' ,: ;,. .4 OWNER: Name (Fee Simple Titleholder): 19 VS i LC -"KV( iN`Nnone#: Address: 53) l" S l� '1--2,f f C( LSL. -FL • I� _ 2 Tenant/Lessee Name: Phone#: 31-� FFE: STh City:y^1-1cA). t>Qt3161Ci\PS State: Email: Zip: 333�r- CONTRACTOR: Company Name: Ac.or Sip % C Address: City: 1 State: Qualifier Name: State Certification or Registration #: \--A LA Certificate o DESIGNER: Architect/Engineer: Address: City: State: Value of Work for this Permit: $ 9S(T - CO Phone g ) 9S(30 Zip: 33 I .9-(f) Phone#: 3n a )2r 10a1 Square/Linear Footage of Work: l 7 Type of Work: ❑ Addition n Alteration ❑ New Zip: 71 Repair/Replace ❑ Demolition Description of Work: Pvi x (T is C c-, r , 1\-E' kr'P -Q )c( Si,try-- -k-Gc\e(1ra\n i-e9c • Specify color of color thru tile:. Submittal Fee $ ``Permit Fee $ $3OU ) 7 CCF $ Scanning Fee $ Radon Fee $ DBPR $ Technology Fee $ Training/Education Fee $ Structural Reviews $ F . `CO/CC $, .. Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ a-63 • o (Revised02/24/2014) V 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 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 PAYINGITWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND 41. TO OBTAIN FINANCING, ®CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE,OF'COMMENCEMENT." w. 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 for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such po - • notice, the inspection will not be approved and a reinspection fee will be charged. Signature'-1 OWNER or AGENT The foregoing instrument was acknowledged day of Gea1i/(Loe- i s , 20 -p04 1 A. ; who,is personally kno *,,,. I Ime or who has produced 4" r ( identification and who did take an oath 1 NOTARY PUBLIC: 1 i Sign: I I Print: Seal: A ! ti Si this TRACTOR ing instrument was acknowledged before me this by , 3 day of 1�PGedN\`YF- , 20 3 , by cicjrtn_' SP.mc, who is personally known to as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Notary Public State of Florida Catherine E Nylund My Commission EE 216211 orw Expires 07/15/2016 *************** * * APPROVED BY * * Sign: f^ Print: 0G—�C\►' leX-`Y.) Seal: Notary Public State of Florida Catherine E Nylund My Commission EE 216211 or a Expires 07/15/2016 **************************************** ** * ************ 75 Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk REGISTERED SEPTIC TANK CONTRACTOR JASON A. NESENMAN 13341 SW 88 AVENUE MIAMI, FL 33176- JASON'S SEPTIC, INC. SR0031444 Registration Expires on September 30. 2016 Business Authorization: SA0031157 000165 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NO T A BILL - DO NOT PAY 5175567 BUSINESS NAME/LOCATION JASONS SEPTIC INC 13341 SW 88 AVE MIAMI FL 33176 OWNER JASONS SEPTIC INC Worker(s) 3 RECEIPT NO. RENEWAL 6409677 LBT, EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter BA - Art. 9 & 10 SEC. TYPE OF BUSINESS PAYMENT RECEIVED 196 SPECIALTY PLUMBING CONTRACTOR BY TAX COLLECTOR SEP031444 $82.50 10/06/2015 ECHECK-16-000644 This Local Business Tax Receipt poly coah.nns payment of the Local Business Tax. The Receipt is not a license,governmental permit, or a certification of the holder's alificatioas, to do business. Holder must comply with any or nongovernmental regulatory laws an requirements which apply to the busbies*. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Cods Sec Ba-276. For more information, visit y niamidade aovRaxg0II for Dec. 23. 2015 12:44PM No. 3970 2/2 Aca'RLf CERTIFICATE OF LIABILITY INSURANCE L....I DATE(MMIDDIYYYY) 12/23/2015 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 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 LRA Insurance 498 S Lake Destiny Dr Orlando FL 32810 CO TACT Elizabeth Rivera NA PHONE (407) 838-3445 FAX (407)838-3460 (AIC, No Ext): (A/C, No): E-MAIL ADDRESS erivera@lrainsurance.com INSURER(S) AFFORDING COVERAGE NAIC 2 INSURERA:E. U B A Workers' Comp. (United INSURED Jason's Septic, Inc 13341 SW 88th Ave Miami FL 33176 INSURER B : INSURER C : INSURER D: INSURER E : INSURER F: CERTIFICATE NUMBER-2015/2016 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 LTR TYPE OF INSURANCE ADDL INSD SUBR MD POLICY NUMBER POLICY EFF (MMIDDlYYYY) POLICY EXP (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY OCCUR EACH OCCURRENCE $ CLAIMS -MACE DAMAGE T P NTED PREM SES (Ea occurrence) $ MED EXP (Any one $ GENT person) PFRSONAI RADV IN.II IRV $ ACCrECATE LIMIT APPLIES CER LOC GENERAL AGGREGATE $ PRO- POLICY JECT OTHER: )'RUUUCIS-CUMPiUI'HG:i $ $ AUTOMOBILE LIABILITY ANY Al .TO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS CCMBINEJ SINGLE LIMIT (Ea accident) $ BODILY INJURY rPer person) $ HODII Y IN.II IRY (Par accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLA MS -MADE EACH OCCURRENCE AGGREGATE $ $ DED RETCNTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRO'RIETOR/PAR-NER/EXECUTIVE OFPICERE.L. /MEMBER EXCLUDED" (MandatorylnNH) P yyes, describe under Y / N N/A 106-57177 10/26/2015 10/26/2016 PER X CTH- ERH }( - below EACH ACCIDENT $ 500,000 E.L. DISEASE - EAEMPLOYEE $ $ 500,000 500,000 E L DISEASE- POLICY LIM T DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) LIC #SR00031444 rrDTl rl r Al", 11I1i rs r•,-• (305) 756-8972 CANCELLATION Miami Shores Village Building Department 10050 NE 2 Miami Shores Villag, FL 33138 ACORD 25 (2014/01) INS025 (201401 ) 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 B Tomlinson/COHLER @ 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12/23/2015 11:56 7862067066 ofsiC7C1Ft PD. STATEWIDE INSURANCE PAGE 01 DATE (MM/DD/YY) CERTIFICATE OF LIABILITY INSURANCE 12/23/15 PRODUCER Galloway Insurance 17840 South Dixie Highway Miami, F'L 33157 Phone (305)255.1661 Fax (786)206-7066 THIS CERTIFICATE 1S ISSUED AS A MATT OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTCR TI IC COVERAGE APFORDE D BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Jason's Septic, Inc. 13341 SW 88th Avenue Miami, Florida 33176 Vendor # 254564 INSURER A: Scottsdale Insurance Company INSURER B; Scottsdale Insurance Company INSURER C; INSURER D. INSURER E; COVERAGES THE POLICIES OF INSURANCE LISTED 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. AGGREGATE LIMITS SHOWN MAY HAvt BEEN RtUUCkU BY YAIU CLAIM, INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD DATE (MM/DDrrYYY DATE (MMIDD/YYYY) GCNCRAL LIABILITY LJ © COMMERCIAL GENERAL LIABILITY ❑❑ CLAIMS MADE n OCCUR PD: Ded: $1,000/Claim GEN'L AGGREGATE LIMIT APPLIES PER: ! . POLICY © PROJECT ❑ LOC AUTOMOBILE LIABILITY El LJ ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS GARAGE LIABILITY ❑ ANY AUTO CPS2337507 EXCESS / UMBRELLA LIABILITY 0 OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYER$' 1. LAIRD ITV YIN ANY PROPRIETOR / PARTNER / EXECUTIVE. OFFICER / MEMBER EXCLUDED? (Mandatory In NH) If yPR, drecrlbe under SPECIAL PROVISIONS below OTHER XBS0008143 12/04/2015 12/04/2015 12/04/2016 12/04/2010 LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence)_ MED EXP (Any one person) PERSONAL & ADV INJURY $1,000,000 $100, 000 $5,000 $1,000,000 GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $2,000, 000 $2,000.000 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY • EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG EACH OCCURRENCE 1,000,000 AGGREGATE 1,000,000 Excess Liability Form 1,000,000 ❑ Tf1RY NITS ❑ gH E.L EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE C.L. DIF,LAEC - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Installation, Service, Repair, Excavation, Maintenance, Drain Fills, Grease Traps and Cleaning of Septic Tanks **Please note that any changes to this policy must be submitted to the Insurance Company for approval`" CERTIFICATE HOLDER Miami Shores Village 10050 NE 2nd Avenue Miami Shores, Florida 33138 Attn: Building Dept Fax # 305-756-8972 ACORD 25 (2009/01) QF CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THertE0r, THE ISSUING INSURER WILL ENDEAVOR TO MAIL N/A DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ®1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD