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PL-19-1983Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: Location Address Parcel Number 9330 NE 12TH AVE, Miami Shores, FL 33138 1132050070160 Contacts Permit No.: PL-0849-1983 Permit Type: Plumbing - Residential Work Clossi ication: Alteration Permit Status: Applied Expiration: 02/23/2020 WEI CHEN Owner DONOVAN PLUMBING SERVICE INC Contractor 9330 NE 12 AVE, MIAMI SHORES, FL 33138 DONOVAN KANGAS 7771 NW 30 ST, HOLLYWOOD, FL 33024 Business: 9549317737 Description: PLUMBING FOR KITCHEN RELOCATION Valuation: $ 1,100.00 Inspection Requests: 5-762-4949 Total 5q feet: 380.00 Fees Amount Application Fee - Other $50.00 CCF $1.20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee $50.00 Scanning Fee $30.00 Technology Fee $2.50 Total: $138.10 PAN Payments Date Paid Amt Paid Total Fees $138.10 Credit Card 08/29/2019 $138.10 Amount Due: $0.00 Building Department Copy 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 AFFIDAVI certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constr nd zoning. FutUeLaaore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date August 29, 2019 Page 2 of 2 0 Miami Shores Village lac 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 LL BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING FBC 201-120 Master Permit No.��' Sub Permit No.r��—{ u ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING [:]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 'I -7 IU; City: Miami Shores County: Miami Dade Zip: :wadp Folio/Parcel#: Is the Building Historically Designated: Yes NO l occupancy Type: Load: , �1ConstructionjType: Flood Zone: BFE: ( 01 FFE: OWNER: Name (Fee SimpI Titleholder): U Ve l e� l � i?, V� Phone#: �%' " Address: City:~ Y,� ff Stater Zip: 133 W Tenant/Lessee Name: Email CONTRACTOR: Company Name: v /v l �j J l✓�� Phone#: 457-7 q3l 7737 Address: 7/ N141 City: Qualifier Name: UO/✓BVN%✓ 11(A W Phone#: /�1,,V11113)!%3% State Certification or Registration #: l? 104s W46 Certificate of Competency #: p 6 OOI R DESIGNER: Architect/Engineer: Phone#: Add Value of Work for this Permit: Type of Work: ❑ Addition 'LEI Alteration Description of Work: M o f LAuTe 64 1 i7 V i�, t �� ��3/• i e Specify color of color thru tile: Submittal Fee $ <=&— Permit Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Radon Fee $ City: State: Zip: e m caster \ Ule_ Squar Linear Footage of Work: ❑ New ❑ Repair/Replace 'UM fff bry Add With. CCF $ DBPR $ Training/Education Fee $ ❑ Demolition CO/CC $ . Notary $ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ (� U _.Jonding 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 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 OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of 20 by �i who is n•wn to me or who has produced f[ bLiV U�; �100 �a� identification and who did take an oath. NOTARY PUBLIC: The foregoing instru nt FS:who :Cpersonally before me this day of 20 by kn•wn • me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: r1l 1[ ' •. -,►" L A P NA Print: t CG/ - ,Vlfi v/AILEEN PENA MY COMMISSION S GG054738 '= MY COMMISSION * GG054738 Seal: Seal: -?�• EXPIRES December 13, 2020 Vie_,. •:,,, EXPIRES December 13, 2020 .w::;,�' APPROVED BY /l 1247' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami -Dade County - Building and neighborhood Compliance Office Page 1 of 1 Contractor License Information Contractor Number: 06P000399 Contractor name: DONOVAN PLUMBING SERVICE INC Address: 7771 NW 30TH ST City, St, Zip: DAVIE FL 33024 Phone: (954) 885-5666 Other Phone: Fax: Email: RSGISELL@HOTMAIL.COM D/B/A: Contractor Status: ACTIVE Class Category Category Description Expiration Date PLUM 1 1 PLUMBING 09/30/2019 CONTRACTOR INQUIRY COMPLETE BCCO Contractor inquiry and Complaint Search I BCCO Home Pace I State License Search Menu • Home I About I Phone Directory I Privacy I Disclaimer © 2001 Miami -Dade County. All rights reserved. http://egvsys.miamidade.gov:1608/WWWSERV/ggvt/BNZAW941.DIA?CNTR=06P000399 8/27/2019 000425 Local Business.4m, ` eel Miami-sDadeCountyr State of Florida --THIS S NOT A BILL DC %OT PAY 5906087 BUSINESS NAMfAOCATION RECEIPT NO. DONOVAN PLUMBING SERVICE INC RENEWAL. SEPTEMBER 30, 20 9 DOING BUS IN DADE CO 6160774 Mw.st be"dispiayedi at place er .,_ra,,.ess MIAMI FL 33000 Pursuant to Count, Cots: Chapter SA- Art. 9 & 10 OWNER SEC, TYPE OFBUSINESS . PAYMENTRECEIVEO DONOVAN PLUl6"BING SERVICE INC 196 PLUMBING CONTRACTOR. BY TAX COLLECTOR 06P000399 $82.50 10/27/2018.. Workers) 1 CREDITCARD-19=0d3568 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, ' I permit, or a certification oftheholder'squalifications, todobusioess. Holder must camp ly with any governmental at nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed an all commercial vehicles - Miami -Bade Cede Sec 8a-276. For more information, visit w miamidade;o4Laxcalfrr_tor I a ACORH CERTIFICATE OF LIABILITY INSURANCE 16._� DATE (MMIDD/YYYY) 1 08/20/2019 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 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 �Cj,ONTACT Dallana Olazabal Finney Insurance Corporation 5601 Sheridan Street Hollywood, FL 33021 PHONENo, 954-966-5533 FAX No: 954-989$208 ADDRESS, dallanao@finneyinsurancecorp.com INSURERS AFFORDING COVERAGE NAIC a INSURER A: Arch Specialty Insurance Co INSURED INSURER B : Donovan Plumbing Service Inc INSURER C: 7771 NW 30th St INSURER D : Hollywood, FL 33024 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 104 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 DDL SUBR POLICY NUMBER POLICY EFF MMID POLICY EXP MM/DDMlYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR AGLOO64913-01 07/13/2019 07/13/2020 EACH OCCURRENCE $ 1,000,000 NTED —15-AMAG—E TO occurrence)$ PREMISES (Ea 100,000 GEN'L MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ] JET LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITYCOMBINED ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON-OWNEO AUTOS ONLY AUTOS ONLY SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per acddent $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUC r (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Plumbing services 8r repair \.CK I Ir iL A 1 C rlULUCK GANGtLLA 1 IUN Miami Shores Building Department 10060 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENT r _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Printed by DOO on August 20, 2019 at 11:36AM 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: 4/25/2018 PERSON: DONOVAN KANGAS FEIN: 550860531 BUSINESS NAME AND ADDRESS: .DONOVAN PLUMBING SERVICE INC 7771 NW 30TH STEET HOLLYWOOD, FL 33024 SCOPE OF BUSINESS OR TRADE: Licensed Plumbing Contractor EXPIRATION DATE: 4/24/2020 EMAIL: DONOVANKANGAS@Hi'OTMAIL.COM tMPORTANT: 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 w cofnpensation under this chapter. Pursuant to Chapter 440Z5(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or traile 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 kx failure of the person named on the certif+Cate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 AA Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 otice to Owner — Workers' Compensation Insurance Exemption Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to ng 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: i. 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 officerr 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 tabor, part-time employees or subcontractors for your project, The contractor has provided an affidavit stating that he or she will be the onlyperson 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 daylabor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State County of Miami -Dade The foregoing was acluiow1cdge before me this day of i 20 By �)z Teti CAw who is personally known to nee or has produced _ as identification. Notary: A MY COMMISSION # G0009356 SEAL: EXPIRES February 03.2021 -D000vavr'FImwnbimg Service Dic. 7771 NW 30* street 44oll4wood, -FL 33021 T: q54-C131-7-737 of Fa County of iqM 1)Uu6 August 22, 2019 Before me this day personally appearezrm who, being duly sworn deposes and says: Md That he or she will be the only person working on the project located at: Signature to (or a ►ed) and subscribed before me this. ZP day of 41VA, 2019, by � �� S AILEEN PENA ,` MY COMMISSION S GG0547M p�n�" EXPIRES 09cember 13.2020 Personal Know Or Produced Identification Type of Identification w Print, T { t ' pN yp r amp Name of otary AILEEN PENA MY COMMISSION 8 GG054738 Rf EXPIRES Oftember 13, 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: 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: ` F Owner State of Florida County of Miami -Dade j �C/ The foregoing was acknowledge before me this3 day of / S [ , 20 By C2 pq C// 1 W who is personally known to me or has produced L-pt as identification. ,`vie,. CAYTEN CLARK Notary: MY COMMISSION # GGO(18356 SEAL: . ` EXPIRES Fabna" 03, 2021 r 'Poviovavi V(Av nbivlq Service Iv16, 7771 NW 30* S+re,& -} oll4wood, -FL 33021 T: 6154-CI31-7737 State ofDr—Ida County of l�'1'rl &616 August 22, 2019 Before me this day personally appeare n _ who, being duly sworn deposes and says: M KIT S That he or she will be the only person working on the project located at: 30 2 i ours M 1C4M byei, 3 31�Y Contractor Signature worn to (or aff'r led) and subscribed before me this -2�P day of V T 2019, by 9110 S �C4 ?'"""4;;•: AILEEN PENA MY COMMISSION # GG054738 EXPIRES December 13, 2020 Personal Know Or Produced Identification Type of Identification W Print, 7 Typ r Sta'mp ame of Notary AILEEN PENA r MY COMMISSION 8 GG054738 EXPIRES OeCember 13, 2020 �Tf,