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PL-16-189Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit No. PL-1-16-189 Per Permit Type: Plumbing - Residential ll Work Classification: Gas Permit Status: APPROVED Parcel Number Issue Date: 1/27/2016 1 Expiration: 07/25/2016 Applicant 9730 NE 5 Avenue Road 1132060171470 Miami Shores, FL Block: Lot: JOHN & MARIE PERIKLES Owner Information Address Phone Cell JOHN & MARIE PERIKLES 9730 NE 5 Avenue Road (786)236-0254 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone SUPREME PLUMBING, CORP (305)316-1164 Type of Work: INSTALLATION OF A NEW TANKLESS WATE Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF $1.80 DBPR Fee $2.25 DCA Fee $2.25 Education Surcharge $0.60 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $2.40 Total: $162.30 Valuation: $ 2,500.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # PL-1-16-58428 01/27/2016 Credit Card $ 112.30 $ 50.00 01/22/2016 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 OOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the fore oing inf rmation is acc(rate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authoriz the ab a -named contrto do the wolk stated. January 27, 2016 Authorized Signature: Owner / Applicani / Contractor / Agent Date Building Department Copy January 27, 2016 1 Miami Shores Village b Building Department N 2 2OJ6 y 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 201%-4 BUILDING Master Permit No.(-( ( 3 `I`rJ PERMIT APPLICATION Sub Permit No-F LVo -189 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL 2/pLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 1' I� CONTRACTOR JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: l J 2'0 (0 C) 1 G) Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: _ OWNER: Name (Fee Simple Titleholder): Jo 4 PW -i Ir I Phone#: -7 Address:030 /� City: VA % ct � 4* S L v State: � Zip: Tenant/Lessee Name: Email: Phone#: DRAWINGS NO FFE: CONTRACTOR: Company Name: d Phone#: 305— 3/6 f I16v Address: !2 T O �5- c7 1 City: �1 j Qualifier Name: Zip: 33 0/0 Phone#: 305— 316 0 State Certification or Registration #: C K_ Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 4 goo. Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: A-"TALLA7/L)Al) OF & NW yE, 1 t Is t �9 Vie MID/l - Specify color of color thru tile: Submittal Fee $ • Permit Fee $ j ,66 �1'` y CCF $ 'CO/CC $ Scanning Fee $ (� Radon Fee $ ' CT DBPRR $� Notary $ Technology Fee $_ Training/Education Fee $ _ • ���1✓ Double Fee $ Structural Reviews $_ Bond $ TOTAL FEE NOW DUE $ 2 ' 0 (Revised02/24/2014) 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 at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In #bbsof such posted notice, the inspection will t be proved an reinspe ion fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrum rt was acknowledged before me this aay of 20 by (1 Ot3 who s personally kno to me or who has produced The foregoing instrurrKrit was acknowledged before me this day of Y-' 20, by who is per nally known as me or who has produced idenEvtn nd who did take an oath. identific ion nd who did take an oath. NOTIC: NOTAR PUB IC: L C;rt Pri Print: as Seal: COMES Seal: LORETMA COMES who MY CMMISSION #EE181658 W COMMISSION #EEE181658 CrEXPIRES: MAR 21, 2016 EXPIRES: MAR 21, 2016 *********** * *�RI�tJgjJq I�*ems ***************a***a****** 9130NMPM�fl*st I F **************** APPROVED BY ( �� ) 'ZC �6 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1428027 'he PLUMBING CONTRACTOR Named below IS CERTIFIED ^ Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 CUE, HECTOR EDUARDO �;,,:. SUPREME PLUMBIING,COa.P� f-,7 840 EAST 5 STREET HIALEAH FL 33040 ISSUED: 080/2014 DISPLAY AS REQUIRED BY LAW KEN LAWSON, SEdRETARY SEQ # L1408210001429 001411 Local Business Miami —Dade County, -THIS IS NOTA BILL 6857628 BUSINESS NAME/LOCATION SUPREME PLUMBING CORP 840 E 5 ST HIALEAH FL 33010 Tax Receipt State of Florida - DO NOT PAY LBT RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2016 7132251 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED SUPREME PLUMBING CORP 196 PLUMBING CONTRACTOR By TAX COLLECTOR Worker(s) 1 CFC1428027 $45.00 07/08/2015 CREDITCARD-15-034743 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, Ora 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 Ba-276. For more information, visit y gxarra+lemR9 4QvRaxcollactor ACORO0 �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 01/22/2016 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 CONTACT NAME: arays garcia Okay Insurance Exchange Of America ac"N Ell: (305) 267-7232 FANo: (786) 388-0492 E-MAIL ADDRESS: g@ ieaunderwritin bestrate-insurance.com 7293 W Flag ler Street INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: GRANADAINSURANCE Miami FL 33144 INSURED INSURER B INSURER C : Supreme Plumbing Corp INSURER D : 840 E 5th St INSURER E : INSURER F : Hialeah FL 33010 COVERAGES CERTIFICATE NUMBER: RFVISII7N Nt1MRFR: 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 SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE El OCCUR 0185FL00073796 08/19/2015 08/19/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY ❑ JET LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS L AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR EXCESS LIAB - OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I 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 below NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS f LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) plumbing work CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF MIAMI SHORES VILLAGE BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVENUE AUTHORIZED REPRESENTATIVE MIAMI SHORES, FL 33138 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE Date 1/25/2016 Producer: Plymouth Insurance Agency This Certificate is issued as a matter of information only and confers no 2739 U.S. Highway 19 N. Holiday, FL 34691 rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. Insurers Affording Coverage NAIC # (727) 938-5562 Insured: South East Personnel Leasing, Inc. & Subsidiaries 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Lion Insurance Company 11075 InsurerB: insurer C: Insurer D: Insurer E: Coverages The policies of insurance listed below have been issued to the insured named above for the policy period indicated. Notwithstanding any requirement, tens 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 have been reduced by paid claims. INSR LTR ADDL INSRD Type of Insurance YP Policy Number Y Policy Effective Date Policy Expiration Date Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence Commercial General Liability Claims Made Occur Damage to rented premises (EA occurrence) Mad Exp Personal Adv Injury General aggregate limit applies per: General Aggregate Policy ❑ Project ❑ LOC Products - Comp/Op Agg AUTOMOBILE LIABILITY Combined Single Limit Any Auto (EA Accident) Bodily Injury All Owned Autos Scheduled Autos (Per Person) Bodily Injury Hired Autos Non -Owned Autos (Per Accident) Property Damage (Per Accident) EXCESS/UMBRELLA LIABILITY Each occurrence Occur ❑ Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2016 01/01/2017 x I WC Statu- OTH- Employers' Liability tory Limits ER E.L. Each Accident $1,000,000 Any proprietor/partner/executive officer/member E.L. Disease - Ea Employee $1,000,000 excluded? NO If Yes, describe under special provisions below. E.L. Disease - Policy Limits 1 $1.000-000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations/Locations/Vehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 92-69-393 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company": Supreme Plumbiing, Corp. Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s), while working in: FL. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name: ISSUE 01-25-16 (TLD) Beqin Date 4 27 2015 CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES VILLAGE Should any of the above described policies be cancelled before the expiration date thereof, the issuing BUILDING DEPARTMENT insurer will endeavor to mail 30 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. 10050 NE 2ND AVE MIAMI SHORES, FL 33138 S I JEFF ATWATER CHIEF FINANCIAL 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: 8/22/2015 EXPIRATION DATE: 8/21/2017 PERSON: CUE HECTOR E FEIN: 275301441 BUSINESS NAME AND ADDRESS: SUPREME PLUMBIING CORP 840E5ST HIALEAH FL 33010 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR 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 it, 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609