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PL-18-1209yHORes y` Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 tonrvA Project Address 10007 NE 4 Avenue Miami Shores, FL Information JOHN & CRISTINA BUTLER Permit NO. PL -5-18-1209 Permit Type: Plumbing - ResidentialPenWorkClassification: Gas Permit Status: APPROVED Parcel Number 1132060170490 Block: Lot: 10007 NE 4 Avenue MIAMI SHORES FL 33138- 500 NE 102 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone ENERGY MULTISERVICES CORP (305)796-2270 Type of Work: INSTALLATION OF 1-1000 GALLON TANK Type of Piping: Additional Info: INSTALLATION OF 1-1000 GALLON TANK Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF 2.40 DBPR Fee 2.25 DCA Fee 2.00 Education Surcharge 0.80 Permit Fee 150.00 Scanning Fee 3.00 Technology Fee 3.20 Total: 163.65 Issue Date: 6!6/2018 I Expiration: 12/03/2018 Applicant JOHN & CRISTINA BUTLER Phone Cell Valuation: $ 4,000.00 Total Sq Feet: p Pay Date Pay Type Amt Paid Amt Due Invoice # PL -5-18-67454 06/06/2018 Credit Card $ 113.65 $ 50.00 05/07/2018 Credit Card $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Press Test 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 AFFIDAVIT: I certify that all the foregoing inform construction and zoning. Futhermore, I authorize the above -n Authorized Signature: Owner / Applicant / Building Department Copy June is accurateand that all work will be done in compliance with all applicable laws regulating coritractgAo do the work stated. Agent June 06, 2018 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 FBC 20\ 01-6 BUILDING Master Permit No. O PERMIT APPLICATION Sub Permit No. t' L I j QcP I BUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL PLUMBING MECHANICAL [:]PUBLICWORKS CHANGE OF CANCELLATION SHOP CONTRACTOR JOB ADDRESS: 10C7O---v N E W"\ AI}f DRAWINGS Folio/Parcel#:_ `11 _ 390 It — 0 l9 O y C%0 Is the Building Historically Designated: Yes NO ( Occupancy Type: Load: Construction Type: _Flood Zone: QBFE: FFE: 1 0 . 9 , OWNER: Name (Fee Simple Titleholder)76AV\ + &00A r,P, 61k lLO . Phone#: —4 C)' Address:_ A L Q(I•LQ, City: /tiClM l 1 cS C{-S State: Zip: 3 p313b Tenant/Lessee Name: Email: Lt CONTRACTOR: Company Name: Address: one#: one#: ?A to — 2 a —40 City: A Cll State: F(- Zip: 3 3 l Qualifier Name: -5 lYV\IfVw_ l,(,l.`&x0-n Phone#: )" / l i State Certification or Registration #: 15CACertificate of Competency #: \ DESIGNER: Architect/Engineer: p ' UG,4 \ 0U-) .[VS Phone#:COSI ( (0 ` 2 90 a--4C')()Address: F M Q/l6 R City: State: zip: 331a Value of Work for this Permit: $ 000 - C") Square/Linear Footage of Work: Type of Work: Addition Alteration EdNew Repair/Replace Demolition Specify color of color thru tile: ^ Submittal Fee $ f Permit Fee $ V CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ Revised02/24/2014) Bonding Company's Name (I Bonding Company's Addres! City Mortgage Lender's Name (if 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 i pection which occurs seven (7) days after the building permi is issued. In the absence of such posted notice, the inspection ill n t b approved n a reinspection fee will be charged. Signature_A( Signature OWNER or AGENT The foregoing instrument was acknowledged before me this day of 41 120 by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: t4me Print: 4 rT ,,.P Seal: 2 r APPROVED BY Revised02/24/2014) CONTRACTOR The foregoing ins"mmen/t was acknowledged before me this MCI(,( AL day of CC 20 18 by T/ ti."tf A) 14 A, OA % Jelpty who is personally known to as me or who has produced (v +41 71 313 as LtC, Q.4 identification and who did take an oath. I o - .z ( 9- ad 3-a NOTARY PUBLIC: Sign: Print: c'r 1\ Seal: ,,,.,. CATHERINE A. DUFFIN N r r.;'•.,, CATHERINE A. DUFFIN Notary Public - State of Florida•• I Notary Public - State of Florida Commission p GG 104296 m• v Commission # GG 104296 r t r s G My Comm. Expirei May 14, 2021 N*"# Iiontlrd throughoughNational Notary Assn, o Plans Examiner Structural Review Zoning Clerk Miami shores Village Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 D. // COPY OF WORKERS COMPENSATION INSURANCE* Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. 0 0 M X 0 M 0 0 a a 0 M ...... 0 0 0 0 0 0 0 0 0 0 BUSINESSNAME: BUSINESS ADDRESS: 32- 77 ki V-) 100 ` 1 CITY iq A tiff 9 STATE ' ZIP BUSINESS PHONE: (J ) E Zf t"' FAX NUMBER CELL PHONE() QUALIFIER'S NAME: (jb,:'2 ck1 QUALIFIER'S LIC NUMBER: 0 % ' Tallahassee, Florida 32399-6500 Master Qualifier Mailing Address JIMMY A. CALDERON ENERGY MULTISERVICES CORP 7880 W 20TH AVE STE 42 HIALEAH, FL 33016-1848 Certificate Number 14852 Licensed Location Address ENERGY MULTISERVICES CORP 3277 NW 100TH ST MIAMI, FL 33147-1944 License Number 28607 This Master Qualifier Certificate is issued pursuant to Chapter 527, Florida Statutes. This certificate is valid only for the person and licensed holder listed. Any changes to the Master Qualifier status such as transfer or termination of employment) must be reported to the Bureau of Compliance at (850) 921-1600 immediately. The Master Qualifier Certificate is valid only through the date noted on the Certificate. A notice of renewal will be sent to you in advance of your expiration date. A Master Qualifier Certificate may be renewed if certification of a minimum of 16 (sixteen) hours continuing education is provided along with the renewal form. If training cannot be documented, an examination must be taken. If there are any errors on the certificate, please submit all changes in writing to: ppSMENT pF.q oP o ,o SUPER 5 Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apalachee Parkway Tallahassee, Florida 32399-6500 Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services Bureau of Compliance 850) 921-1600 Tallahassee, Florida Certificate No: 14852 Exam Date: October 12, 2001 Issue Date: July 24, 2016 Expiration Date: July 23, 2019 Exam: 0601 MASTER QUALIFIER CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes, to: JIMMY A. CALDERON Valid For License Number: 28607 ENERGY MULTISERVICES CORP 3277 NW 100TH ST AAM H. PUTN M MIAMI, FL 33147-1944 COMMISSIONER OF AGRICULTURE License Number: 28607 Business Mailing Address ENERGY MULTISERVICES CORP 3277 NW 100TH ST MIAMI, FL 33147-1944 Licensed Location Address ENERGY MULTISERVICES CORP 3277 NW 100TH ST MIAMI, FL 33147-1944 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LP Gas licenses must be renewed annually. Any license allowed to expire shell become -inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person, firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the departmen-E—All licensing requirements must be met by the transferee and a transfer fee of $50 will apply. To apply for a transfer, contact the Bureau of LP Gas Inspections at (850) 921-1600. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner, or end user upon request when engaged in the business of servicing, testing, repairing, maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number: 28607 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31, 2018 850 921-1600 Date of Issue: September 1, 2017 License Fee: $200.00 Tallahassee, Florida Type and Class: 0803 Liquefied Petroleum Gas License LP GAS INSTALLER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is Issued under authority of Section 527.02, Florida Statutes, to: ENERGY MULTISERVICES CORP 3277 NW 100TH ST MIAMI, FL 33147-1944 ADAM H. PUTNAM COMMISSIONER OF AGRICULTURE ACOCERTIFICATE OF LIABILITY INSURANCE DATE ) i 0413RbF 113/I0182018 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 Yeni LinaresNAME: iSure Insurance Brokers, Inc. PHONE (305)223-2533F (305)220-0765AICNoExt), A/C, No 8700 W. Flagler St MAIL Yeni@iSureBrokers.comADDRESS: Ste 270 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 INSURER(S) AFFORDING COVERAGE NAIC # Miami FL 33174 INSURER A: Scottsdale Insurance Company INSURED INSURER B Energy Multiservices, Corp. INSURER C: 7880 W 20th Ave , unit 42 INSURER D: Hialeah FL 33016 INSURER E : INSURER F: CPS2725674 COVERAGES CERTIFICATE NUMBER: 2017-2018 COI 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 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. INSRLTR TYPE OF INSURANCE ADDLISUBR INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR EACH OCCURRENCE $ 1,000'000 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1'000,000ACPS272567407/09/2017 07/09/2018 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLYN PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAWSWADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE $ Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Propane Gas contractor license # LTG28607 1- W"WV m Miami Shore Village Building Department 10050 NE 2nd ave Miami Shores 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 FL 33138 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CDD WEZ 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: 8/30/2017 PERSON: CALDERON FEIN: 270239884 BUSINESS NAME AND ADDRESS: ENERGY MULTISERVICES CORP 3277 NW 100 STREET MIAMI FL 33147 SCOPE OF BUSINESS OR TRADE: Plumbing NOC and Drivers EXPIRATION DATE: 8/30/2019 JIMMY A 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 benefits 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 if, 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 shall 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 ENERGY MULTISERVICES Date: S / 7 / 1 3 State Of i 12 County Of iu I p4 K -t < O 4-t E Before me this day personally appeared 4 CA- ( 1:1z-o M who,being duly sworn,deposes and says: That he or she will be the only person working on this project located at: r Signature Sworn to (or affirmed)and subscribe before me this , t* day of 2018 All rl 1 by Personally Know Or Produced Identification ` I/ Type of Identification Prod Print type or Stamp Name of Notary YANADYPRIETO MY COMMISSION # FF 214031 EXPIRES: March 25, 2019 oc,44• Bonded Thtu Notary Public Underwriters Office: 305 796 2270 Email: jimmycalderon2006@@yahoo.com License # 28607 3277 NW 100 St Miami, FL 33147 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner —Workers' Compensation Insurance Exemation 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 SIGNI BELOW Y CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTEN S. Signature: , Owner State of Florida County of Miami -Dade ) The foregoing was acknowledge before me this day of 20 By_ (2-4r)'Sl h Gt U i' who is personally known to me or has produced as identification. Notary: SEAL: — — — — — — — — — — CATHERINE A. DUFFIN Wary public - State of Florida My Comm. Expires May 14, 2021 domded through National Notary Assn.