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PL-16-2478r .N, BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC 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 ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS I\ECE`VEL MAR 0 S 2018 C"4_1 BC 20 y Master Permit No.� Sub Permit No .�__) � ❑ REVISION EXTENSION RENEWAL XCHANGE OF ❑ CANCELLATION ❑ SHOP ��/""" CONTRACTOR DRAWINGS JOB ADDRESS: 1-7 AW IC)z; 57Wt7— City: Miami Shores County: Miami Dade Zip: 3_:�'I Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: c OWNER: Name (Fee Simple Titleholder): OU L&C 252V (A&T Phone#:305-K1 03%_..)6" 1 Address: 1-7 1VE IDS City: A-4141M, j 5klIQkEs State: Zip: 7!!aL 38 Tenant/Lessee Name: Email: CONTRACTOR: Company Name: j4 Bcro S pl u rn b1 Phone#: S6 3SG Z! Address: g q C-gA% U) . Z y City: l n 1 aml' State: Ir Zip: 3 3 1 L17 Qualifier Name: Phone#: 91;6 3 (,.V 11.61'. State Certification or Registration #: C.1 q Z,413 74 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: Value of Work for this Permit: $ Type of Work: ❑ Addition Description of Work: City: State Square/Linear Footage of Work: ❑ Alteration ❑ New ❑ Repair/Re Zip: o❑ Demolition Specify color, of color thru tile: a Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ r,' Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted ai the job site for the first inspection pkch occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection wilJ,aet=be a and a reinspection fee will be charged. or AGENT The foregoing instrument was acknowledged before me this day of VAC�l2U4 20 NO by ___,who is personally known to me or who has produced and who did take an oath. as Signatur TOR The foregoing instrument was acknowledged before me this _ day of aaYCh 20 J 8 by �f'j1jQleZ who is personally known to me or who has produced N / as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: 14L Print: -F=W �. , .. Y Print: Seal: Notary Public State of Flor da Sindia Alvarez eal: t ,p MyComm.ssvonFFISC750 1s �� ViLMA SANCHEZ flo� Expires030312018 MYCOMMISStON#GGI73087 EXPIRES. Janus 7 ***********************************.*,*/*Q********************************* *****4Y*ski ********* APPROVED BY 3 W Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N.? -l6 -247$ Owner's Name (Fee Simple Title Holder): OLI EDL Phone #: -305 RK) 915/ Owner's Address: N>_ City: M.1 AA3 5 State : 1 Zip Code: Job Address (Of where work is being done): 17 )JF— 10S S'`r T City: Miami Shores State:_Florida Zip Code: 33l3$ Contractor's Company Name: Address: Phone City: 1?2) State: rL Lip Qualifier's Name • (8S Lic. Number: Architect/ Engineer of Record Name: Address: City: — State: Phone #: Zip Code: 1 hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the 'ami Shores harmless of all legal inv vemen . Signatur Signature Cwvne r Contractor or Architect The foregoing ins umen was a ledged before me The foregoing instrument was aknowledged before me this 5 day of 20 PJ ULA \j it- e-, �L � this day of m4lze-&, 2019y L-," c-s Who is personally known to me or who has produced who is personally known to me or who has produced as indentification. r)L- I rV I as indentification. Notary P ! ic: Notary Public: Sign: Sign: Seal: <—\ (�� , �/�-� Seal: MARTA AWSTA zoo"R Pkye No?arY?nnsicState ofFloriaa stElf.PI =�• :o MYCOMMISSIONiFF971450 EXPIRES: May 1,2020 .�IVaraZ v h, `oe My Commission FF 156756 '%Fo; €gip' WxledTInNd"PulftUnIwAilem o�Loc' Expire_ 09/03/2018 �: ? a ,4 R. 4 ... a ,n. t. .e. � n. n. • . Miami Shores Village 7BY TI 0 Building Department 2018 10050 N.E.2nd Avenue, Miami Shores, Florida 33138Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ) {� FBC 201ys BUILDING Master Permit No. T.C- ( (o " 1 t I PERMIT APPLICATION Sub Permit No. ` c.11( ^ `aLOI�) ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL 'PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 5 City: Miami Shores County Miami Dade Zip: 331 38 ( Folio/Parcel#:� 1' 9L 13 (9- C)O�_ p (D O Is the Building Historically Designated: Yes NO Occupancy Type: -5 FF Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): O ).l e-X -5,i52 (/gT Phone#: J�'O✓'- a �%-�/(i/ Address: 1 -4 S S f City: _ M ArA t State: Fc— Zip: 3 1 3g Tenant/Lessee Name: Phone#: Email CONTRACTOR: Company Name: Pc. PLu m e' i n &-1 G �Z� Phone#: W 6 1 V Address: 9� Zo �`' ' '-1" O sT City: / 09mf //State: L Zip: Qualifier Name: AL +C4 oS Phone#: 3AZAP V- 2 V- State Certification or Registration #: C FG O S4"% S `'I Certificate of Competency #: DESIGNER: Architect/Engineer: one#: Square/Linear Footage of Work: State Zip: Type of Wor c: Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: •45 Od')'t P�'!✓S —' Av6W 4*6k g!?2� AAlb P/141 Specify color of color thru tile: Submittal Fee $ ` D • C)�3 Permit Fee $ 223�— CCF $ 1 • 2-0 CO/CC $ Scanning Fee $ 'E3 - 6 Radon Fee $ 3 ` 2 t& DBPR $ 3' 39J Notary $ Technology Fee $ I VV Training/Education Fee $ G . TQ Double Fee $ Structural Reviews $ Bond $ 10 TOTAL FEE NOW DUE $ U 7 1 !C (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lenders 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 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 anAa reinspection fee will be charged. OWNER o The foregoing instrumer was acknowledged before me this q _ s day of 20 4� {P by r i { 6 ( 0 ' who is personally known to me or who has produced it. Adas identification and who did take an oath. NOTARY PUBLIC: Sign Print: W COMMISSION # FF 971460 EXPIRES: May 1, 202D Wrded Tbru Nobly Pubic UWwoltm Signature 4 CONTRACTOR The foregoing instrument was acknowledged before me this day of rntt{�,�- 20 1(o by -65 u- F V,4.Lh-GI pS who is personally known to me or who has produced ��, Tom_ as identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal: Y ►i MAR M AC06TA .L MY COMMISSION i FF 971460 EXPOM May 1 202D `" Bonded llru Notary Pubic Ihde► tM APPROVED BY ' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village " 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 LOit Phone: (305)795-2204 Permit NO. PL-9-16-2478 Pe Permit Type., Plumbing - Residential rtill't Work Ciassifrcation: Addition/Alteration Permit Status. APPROVED Issue Date: 9/12/2016 1 Expiration: 03/11/2017 Project Address Parcel Number Applicant 17 NE 105 Street 1121360060100 Miami Shores, FL 33138- Block: Lot: OLIVER & ANDREE STEPHANIE Owner Information Address Phone Cell OLIVER & ANDREE STEPHANIE 17 NE 105 Street --- - - -- MIAMI SHORES FL 33138- 17 NE 105 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone PC PLUMBING GROUP INC (305)640-5690 (305)219-6500 Type of Work: AS PER PLANS NEW BATHROOM AND WASHI Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF $1.20 DBPR Fee $3.38 DCA Fee $3.38 Education Surcharge $0.40 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $237.96 Valuation: $ 1,800.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # PL-9-16-61253 09/12/2016 Check #: 647 $ 187.96 $ 50.00 09/07/2016 Credit Card $ 50.00 $ 0.00 Avaname 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, MFGKANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AF5PAVIT: I certify at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction Anp zoning. Futher or authorize the above -named contractor to do the work stated. September 12, 2016 AuWd-rized nattjfe:OvYner / Applicant / Contractor / Agent uate Building apartment Copy September 12, 2016 1 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD TKe-PLUMBING:CONTRACTOR - '`- Named -below IS CERTIFIED= -Unger,LH, provisions`of•Chapter 489 FS. - — -- �' •' - - '> .Expiation date:: AU_G 31; 2018 - PALACIOS JOSE;F .. P,C PLIFMBING'GRQUP__ING�....; ��,.—a� )520,9.W 40-ST��O'1,: _ �" 4 ' zIx IgNfl rFL 331,6.,...5+-:=-~1 y+ , f,,. r.. � _,•,.4^•r.,►..' ` fir..._ '�'�� 7-� ,� ' �� , ,.�, `. � rlilk- ISSUED: 06/09/2016 DISPLAYAS REQUIRED BY LAW SECI# L1606090000969 010683 Local _Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 6415624 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES PC PLUMBING GROUP INC RENEWAL SEPTEMBER 30, 2017 9520 SW 40 ST 201 6683792 Must be displayed at place of business MIAMI FL 33165 Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED PC PLUMBING GROUP INC 196 PLUMBING CONTRACTOR BY TAX COLLECTOR C/O PALACIOS, JOSE F CFC057684 $45.00 07/09/2016 Worker(s) 3 CREDITCARD-16-037591 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visit www.miamidade.gov/taxcollector CERTIFICATE OF LIABILITY INSURANCE DAM (OMAWM ft"" THIS CERTIFICATE IS ISSUED AS A MATTER OF iNFOR"TION ONLY AND CONraRS No R(aHTs UPON THE CERTIFICATE HO ER1 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED ISY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSYITM A CONTRACT BETWEEN THE RBPRENENTAIM OR PRODUCER, AND THE CI RTIFICATE HOLDER ISSUING INSURER(s), AUTHORIZED the tanne an if bat111111111 I'll,, th holder Is an ADDmONAL INSURED, the Pollcy(tes) must be endorsed. If SUSROGAITON is WANED, subject eo the tents and Conditionsr InIIQ S the nd policy c In poll@I— maY require an endorsement. A statement on this � rertfllcate holder M lieu of such •ndorsom►erat(a). rtttTcate does trot confer rights to the Ample Insurance Company PO Box 929 Molina FL 34780 PC PLUmawa GROUP INC 9520 SW 40 St #201 FL rwutcy VF 11031JRANCE LISTED sELOW IiAAVe `w�v,vn ryVIriDC� INtxCATEp. NOTwrnIST3NawG ANY REQUIREMENT, TERM OR CONDITION OF 8 co�ntTTRAAC OR once Doc pNT WITH RESPECT Tq vvxtCPi� °9 CERTIFICATE MAY 6E ISSUED OR MAY PERTAmi. 7}IE INSURANCE AFFORDED BY 7HE POLICtF8 13ESCRIBEp HEREIN (S SUBJECT TO ALL THE TERMS, ExClUBtON$ AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE eEEN THFPREDUCED BY Pate CLAIMS TYPE OF WaURANCE PO axI ieCOMMMICIAL6ExveALUAsIurY UMFM C�MAN � OC M EACMGGc�RENCE 3 1,000,000 A PEW A00REGATE LN T APPLIES PER; ct.Ia0000slaao•oo Mwsw are •�� 10/91201 s 10J31/a018 PERSONAL & ADV UuuRY : a 3 1 ¢¢ x PoUCY ❑ ACT Ej LOC GENERAL AGGREGATE S 2 /ROOUCTe-COMPY9PA00 s Z, 'Ok"TClicalE gym' S ANYAWO 91 lEt s u osO1 vwEO Aoutr:o eDD4 v u+/LgtY <Per P.yO,t) i NIIIED pUrOe ..Q M AUTOS 9001LV I►+�UQiY jP�taa7ape,a) 3 ROP ti UMBRA LIM OCCUR S i ftia s P�rWE rIN aC1UDED7 N f AJ EL- FAGf �M=WstWWPAnrtue._..... E.L DI2EA - - ---.. -- •••••.� Ma i c+7ewilU7�R I YaNEClEB tACORD 1e1, Addtllaoq R�IOr14 ACINI�.++yY pA rya q elve ape�o b pltllr my ommerciai a residentadal 10� 14utamd Shores VKIage. Building Dept. THE ACC 10090 NE 2nd Ave MIwTd Shores, A 33138 AutKal ACORD 25 (2014/pt) The ACORD name and logo are 09 feI!!s ABOVE DESCRIBED PCLICWS BE CANCELLED BEFORE ATE TkFIMF. NOTICE: VNLL Ige DGW6RED IN HE POLICY PROVI9IONa. marks of ACORD •.`�iaLrt- A STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION R Y CERTIFICATE OF ELECTION TQ BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAyy R . CONSTRUCTION INDUSTRY EXEMPTION This Certfies that tile, individual listed bralow has elected to be exempt from Florida Workers' C EFFECTIVE DATE 3/112015 ompenstatlon law. PERSON: FAIgCIOS EXPIRATION DATE: 3/10/2017 VEIN: JOSE 2639 7523 F BUSINESS NAME aND ADDRESS: PC PLUMBING GROUP INC 9521) SW 40 ST #2, )1 MIAIM FL 33165 SCOPES OF Bt'ISI"ESS OR TRADE: LICENSED PLUMB NG CONTRACTOR Imyflunf Io Chapter 40.01041. F C '��nor rpCover henOfita 0 - [orroeneatlnn i.na.., �.,. �oratlon who ete= exenwUon rmm .r.:...w. y"'WPe of me bue Hass of trade rr den ". rurauant b Ch r• " -r mfig a oe,Ufioata of era exempt air? cerw the nottoe or etestion to be exg r 440.06(12), F,S., Certjryogtea at ai°n under thte aeotion �tBB of . -160@on to be axempt shelf be mpL Pursuant to Cha Ter eterAon to be axempL.. QPPb only the pp pn nanteQ a1 the F Ace or cgrocate no Ion SUCteCt to rgy00aiion if, at an D 440.0.5(13), F.S., Nolicos of elootion to be 9 meets th $ ttma ekar the Brv,g o f the notice or the o rewUemente of this section for issuance et Issuance of me certifiCato. DFS_P2_pyAG252 CEFTtFICATE a `a �fe• The department shalt revok9 a OF ELECTION TO BE EXEMPT Rt:1/13E0 DS-13 QUESTIONS? (850)413.1608 ORE ♦ SAIRC. Gi logo �IORiDp` Notice to Owner - Workers' Corn Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 nsation 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: 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; The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 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 allewoe, to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insui-ince coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BEi.OW_Y12JJ ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. L__ - A, J Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this �2, day of 2001 By ('L- I V1 &-a A who is personally known to me or has produced --A-& Si/ -to Y-ZZI -[A identification. Notary: woo, MARTAAC08TA SEAL: =*; ;* WCOMMISSION 11FF97141R) EIy�IRE3. maay1,21va •isOf Fl gQ �, p oN1 N TIVU io�y Putile %mi ;vs I V'! PC PLUMBING GROUP INC. 9520 SW 40 ST #201 MIAMI, FL 33165 PH: (305)4847814 _ PLUMBING CONTRACTORS CFC057684 Miami Shores Village Building Department Sept 06 2016 10050 NE 2Ave Miami F133138 State of Florida County of Miami -Dade Before me this day personally appeared Jose F Palacios. Who being duly sworn, deposes And that he will be the only person working on the project located at 17 NE 105 ST Sworn to and subscribed before me this 06 day of September 2016 CY/ �G^�G Jose F PZlacios