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PL-19-1471 (2)Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 06/26/2019 Location Address Parcel Number 79 NE 91ST ST, Miami Shores, FL 33138 1132060130130 Contacts Permit NO.: PL-06-19-1471 Permit Type: Plumbing - Residential Work Classification: Gas Permit Status: Approved Expiration: 12/23/2019 ROBBIE & KARLA SINGER Owner 79 NE 91 ST, MIAMI SHORES, FL 33138 ACCURATE GAS SERVICE CORP Contractor ALEJANDRO MOREJON Mobile: 7864998261 alex_morejon@yahoo.com Description: RUN GAS LINES TO KITCHEN Valuation: $ 500.0Inspection Requests: 0 1305-762-4949 Li TotalSq Feet: 370.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $110.30 Credit Card 06/26/2019 $60.30 Credit Card 06/26/2019 $50.00 Amount Due: $0.00 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 information is accurate and that all work will be done in compliance with II applicable laws regulating construction and zoning. Futhermore, I authorize the above named contrac�r to do the wo9/9 stated. L— L 0 / / Authorized Signature: Owner / Applicant / Contractor / Agent Date June 26, 2019 Page 2 of 2 BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 (l� 10 Tel: (305) 795-2204 Fax: (305) 756-8972 % All, INSPECTION LINE PHONE NUMBER: (305) 762-4949 6 FBC 20 )q Master Permit No. RC-03-19-518 Sub Permit NoPL---o(oo "i i— i%-n ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL OPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 79 NE 91st Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-013-0130 Is the Building Historically Designated: Yes NO X Occupancy Type: R Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Robbie & Karla Singer Address:79 NE 91st Street City: Miami Shores state: FL Tenant/Lessee Name: Email: Phone#:786-564-5925 Zip: 33138 Phone#: CONTRACTOR: Company Name: �C..[ L.V[ Ull't=. `i�-k7 ����� Phone#: �(�^� C Address: City: k State: -'�r Zi Qualifier Name: Phone#: ' State Certification or Registration #: :3s Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: _ Address: City: State: Value of Work for this Permit: $ 500 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑■ Alteration ❑ New ❑ Repair/Replace Description of Work: Run gas lines to kitchen ' 1 Specify color of color thru tile: Submittal Fee $ �' b� Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $_ DBPR $ Zip: ❑ Demolition CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ OL.� (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lgnder's Name (if applicable) Mortgage LenVer's Address City State Z.: Zip t � • i Y 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. /n the absent of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature , Signature OWNER or AGENT CONTRACT R The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before ^me this 24th ' day of June 20 by4 day o 19 f 20 'v, . ' by Karla Singer who is personally known to � who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: Sign NOTARY PUBLIC: Sign: No atr�"r DAYAMY PENAp�s4;-"Seal: 5"� MY COMMISSION # GG006365 ie � EXPIRES June 27.2020 44oa (407) 39"153 FlorideNoterySorvic..com APPROVED BY 4:: -� I';' Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk t State of Florida - Department of Agriculture and Consumer Services ' Division of Consumer Services Certificate No: 31216 Bureau of Compliance Exam Date: February 2a, 2015 '+o (850) 92171600 Issue Date: April 22, 2018 Tallahassee, Florida Expiration Onto: OM 2021 MASTER QQALIFIER' CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes, to: ALEJANDRO MOREJON Valid For License Number. 35908 ACCURATE GAS SERVICE CORP.16480 SW ADAM H. PU N AM MIAMI, FL FL 331 TH 77-2023 13CT COMMISSIONER OF AGRICULTURE IAMI State of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number. L135908 Bureau of Liquefied Petroleum Gas Inspection Effective Date: September 1, 2018 (850) 921-1600 Expiration Date: August 31, 2019 ...:... POST LICENSETallahassee, Florida CONSPICUOUSLY 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: ACCURATE GAS SERVICE CORP. 16480 SW 139TH CT ADAM H. PUTNAM COMMISSIONER OF AGRICULTURE MIAMI, FL 33177-2023 A 005626 Local Business Tax Itceipt Miami —Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7192126 LBT- BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES ACCUMSCASsERvICE COW RENEWAL . SEPTEMBER 30,2019 16480SW 13 ' ICT ,. 7473931 Must be displayed at place of business MIAMrr-L33177... t Pursuant to County Code 1 Chapter BA - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS ACCURATE GAS MMCE CORP 205 LPG INSTALLER PAYMENT RECEIVED C/O ALMORO J MOREION PRE . LPG35908 BY TAX COLLECTOR $100.00 07/23/2018 1 CREDITCARD-18-056320 This Local Bmsiness Tax Recai oNy confirms payment of the Local Business Tax. The Receipt is not a license, portaft, or sdie lardrta to dytHolder dttcomply with n/ Barnoeal o ew wbuddehopplytobos'nas The RECEIPT NO. above meat be displayed an all eomeiarcial vehicles - Mimi -Dade Cede See da-27.6. For mm iafomodoa, visit a ACtMt7► CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/19/2019 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 Claudia's Insurance CONTACT CLAUDIA M DE LA ROSA NAME: aIc°NNo E ; (786) 293-9141 FA No ; (786) 293-9142 E-MAIL claudia@claudiasinsurance.com 18901 SW 106th Ave 132 INSURE S AFFORDING COVERAGE NAIC # Miami, FL 33157 INSURER A : ARCH SPECIALTY INSURANCE COMPANY 21199 Phone (786) 293-9141 Fax (786) 293-9142 INSURED INSURER B : INFINTY 22268 INSURER C : COMMERCE & INDUSTRY INS CO 19410 Accurate Gas Service Corp INSURER D : 16480 SW 139 CT Miami FL 33177 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 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. ILTR TYPE OF INSURANCE ADD UBR POLICY NUMBER MM/LDDYIYYYY MMIDDYIYYYY LIMITS A © COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE❑ OCCUR N N AGL0031674-03 11/23/2018 11/23/2019 EACH OCCURRENCE $ 1,000,000.00 PREM SESOEa oRE EO ccu ence $ 100,000.00 MED EXP (Any one person $ 10,000.00 ❑ PERSONAL 8 ADV INJURY $ 1,,0000,,0000 00.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ JECT ❑ LOC ❑ OTHER GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS © AUTOS NON -OWNED ❑ HIRED AUTOS ❑ AUTOS N N 509820022691001 07/07/2018 07/07/2019 Ea accident)COMBINED SINGLE LIMIT $ 1,000,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident, $ PROPERTY DAMAGE Per accident $ $ C 0 UMBRELLA LIAB ❑ OCCUR EXCESS LIAR ❑ CLAIMS -MADE N N EBU 013494631 10/21/2018 10/21/2019 EACH OCCURRENCE $ 1,000,000.00 AGGREGATE $ 1,000,000.00 ❑ DIED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE[:] OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS belay N / A PERTUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) LP GAS APPLIANCE INSTALL, SERVICE AND REPAIR RESIDENTIAL AND COMMERCIAL LICENSE LPG35908 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF MIAMI SHORES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) OF The ACORD name and logo are registered marks of ACORD 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: 8/27/2017 EXPIRATION DATE: 8/27/2019 PERSON: MOREJON ALEJANDRO J FEIN: 473485283 BUSINESS NAME AND ADDRESS: ACCURATE GAS SERVICE CORP 16480 SW 139 CT , MIAMI FL 33177 SCOPE OF BUSINESS OR TRADE: Plumbing NOC and Drivers IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from tltis chapter by fibM a cute 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 bade fisted 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 icing of the notice or tho 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 arty time for failure of the person named on the certificate to meet the requirements of this sedan. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)4,113-1609 AC W-UR�TE SERVlGE 16480 SW 139 CT MIAMI.FL,33177 786-499-8261 Alex_morejon@yahooxom FDTTt—WJAI- MKiUlrM State of� County of " q�—t Before me this day personally appearedl, being duly Sworn deposes and says: That he will be the only person working on the project located at 79 NE 91 St. Miami Shore FL.33138 and subscribed before me this g�day o#---�c..1�, 20_C!5, V), Personally know Prod Signature of Notary (SEAL) —�" :4`''° L DAYAMY PENA MY COMMISSION # GG006368 EXPIRES June 27, 2020 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 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. l . 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 j The foregoing was acknowledge before me this !-b day of Jffl�_ 201. By KAkLA S IN6GP— who i Enally know to me or has produced as identification. Notary: 14, CHRISTOPHER BARAT BLOCK io :..... SEAL: t Commission # GG 109M �a� Expires May 30, 2021 OsiLOp` 8W4W 4uB0*N0WJSV4W