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PL-19-2816Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit No.: PL-1 1 -19-2816 w Permit Type: Plumbing - Residential tv—�fly Work Classification: Addition/Alteration Permit Status: Approved Issue Date:12/09/2019 Expiration: 06/08/2020 Location Address Parcel Number 82 NW 100TH TER, Miami Shores, FL 33150 113101 01 80360 Contacts ASSI SILES Owner 82 100 TER JYP SERVICE & REPAIR CORP Contractor JOSE Y PENA 9915 W OKEECHOBEE RD 5-107, HIALEAH, FL 33016 Business: 3052167283 Description: INSTALL PLUMBING UNDERGROUND ROUGH, Valuation: $ 10,450.00 Inspection Requests: DRAINAGE PIPE, HOT & COLD WATER SUPPLY, INSTALL DRAIN 305-762-4949 & CLEAN OUTS, INSTALL UNDERGROUND GAS LINES, INSTALL Total Sq Feet: 913.00 NEW GAS HOT WATER HEATER, CONNECT GAS LINES TO APPLIANCES INSTALL PLUMBING FIXTURES Fees Amount Application Fee - Other $50.00 CCF $6.60 DBPR Fee $5.49 DCA Fee $3.66 Education Surcharge $2.20 Permit Fee $315.75 Scanning Fee $3.00 Technology Fee $9.14 Total: $395.84 Building Department Copy Payments Date Paid Amt Paid Total Fees $395.84 Credit Card 12/09/2019 $345.84 Cash 11/25/2019 $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, PLUM4NG, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all t ` kregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futher re, I authorize the above named contractor to do the work stated. Authorized Signatdre'�,L-� / Applicant / Contractor / Agent Date December 09, 2019 Page 2 of 2 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC Miami Shores Village ENTERE:I) Building Department NOV 2 5 2019 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BYt CL)� INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201---- Master Permit No. ?C-0 3 - 1 9 - &IC% Sub Permit No. 1PL-- ( I 1- .28 1�p ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 82 NW 100 Terrace City: Miami Shores County: Miami Dade Zip: 33150 Folio/Parcel#: 11-3101-018-0360 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Assi Siles Address:82 NW 100 Terrace City: Miami Shores State: FL_ Tenant/Lessee Name: N/A Email: hone#: 813-716-0675 hone#: 33150 CONTRACTOR: Company Name: Z . � &e-e e Phone#:3bs-01 Address: 1q[5- W • Q Vt_' ,9/,(e'er City: ,�/%S �/ d� �d,�-s State: ✓O `� O�� _ Zip: : 3en'<-- Qualifier Name: 36S Phone#: 30§ 'Z�(,'2' State Certification or Registration #: 1414F�Certificate of Competency #: DESIGNER: Architect/Engineer: Udl rdy Design Associates, Inc. Phone#: 786-656-8983 Address:2125 Biscayne Blvd. Ste. 200 Cc�: Miami State: FL Zip: 33137 Value of Work for this Permit: $ / i / 01 Square/Linear Footage of Work: Type of Work: Addition 0 Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: Install plumbing underground rough, drainage pipe, hot & cold water supply, install drains & cleanouts, install underground gas lines, install new gas hot water heater, connect lines gas. -to- a�p#iat�s�irll'� tubing fixtures Specify Jilok of color th u tile: /' '•� ��r` q,)/ . Permit Fee $ Submittal Feel$ �a� CCF $_ CO�/CC $ III Scanning Fee $" Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ Cl 1 TOTAL FEE NOW DUE $ -3 qG ' u L (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's'Address City State Zip _ t Mortgage Lender's 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 low 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) d ys after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspectiy�i fee will be charged. or AGENT The foregoing instrument was acknowledged before me this 13th day of November .20 19 by J personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as Signature ,.i R The foregoing instrument was acknowledged before me this 13th day of November 20 19 by -So P&4219, who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Printt T Seal: PAYPGj TAMMY L. MCNAIR Seal ,4i° =; Notary Public - State of Florida • Commission # GG 051781 VN My Comm. Expires Mar 23, 2021 APPROVED BY 2<2 (r �C /y Plans Examiner Structural Review (Revised02/24/2014) �iAµY PV6 TAMMY L. MCNAIR Notary Public - State of Florida • Commission # GG 051781 ops:� My Comm. Expires Mar 23, 2021 *1'*,R��,w�**gtl`nCt�tl`f�i'blfiirt`Id'dlSllfi`dl'Itldf�r'C1l!`�,* ****"**** Zoning Clerk Local Business Tax Receipt Miami-padeCounty, State, offlorida TtiiSIS NOT A WU —p0 NOT PAY 13USMWS NAME/LOCAT" JYP SERVICE $ REPAIRS,CORP 9915 W OKEECHOBEE RD 5107 MIAMI, FL 33016 ONYNER JYP SERVICE 8 REPA RS.0 OUP C/O JOSE Y PENA RECi1pT NO. RENEWAL 7518642 SEC. TYPE•ORBUSINE" 196 PLUMBING CONTRACTOR CFC1429883 EXPIRES SEPTEMBER 30, 2020 Must be displayed at place of business Pursuant to County Code Chapter SA — Art. 9'& 10 PAYM1W RECEIVED BY TAX COLLECTOR 45.00 09/24/2019 0226-19-006565 This Loral etiaesdt Tax FA W P W4 1, Deals ! , of the Local Business Tm The Receipt is not a license. penak or acatti6ad;arollmholdWs"I iradoas,todobasiommH*Wrmustcomplywithanygovernmental or na g, p o wieebJ ts9ablRtky burs and regnmtawue� which apply m the be riness The RECEIPT ND,sbore mm be displayed as all eonvowelal vehicles— Miami —Dade Code Sec U-276. Eoc aims latrarmtioa.ritkftXcQIkCtQr acev rrf CERTIFICATE OF UA►BJUTY INSURANCE I%ftIUl" 11172W9 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONTILE CERMCATE MOLDER. THIS. CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATI" OF INsuRANCE DOES NOT cCMNSTavm A CONTRACT BETWEEN THE ISSMINGr IFt3+IIRER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,. IMPORTANT: It ih* eaniHcata holder is an. ADOITIONAL INSURED, the polky(las) must be endortmL B SUBROGATION IS WAIVED, sublets. to The tame and condiUms of the policy, certain policies mW require an andoroenwit- A stotea* T on this ccnificaft does not confer rights to The evnaoucOt Blanco, Insurance Asw, Inc. 1462 E 4 Awe Itrscrosa 1w Servic" & Rem Corp;. 65VI a ST APT 3 216-72 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE, LISTED BELOW HAVE WEN WUfD TO THE INSURED NAMED ABOVE FOR IK POUCY PERM INDICATED. ?A"ITHSTANDIN?G ANY REOLARE ENT, TERM OR CONWnON OF MY CO" ACT OR OTHER OOCL VrE NT' SS"M RESPECT TO W K>J THIS Cl RTIFICATE MAY BE ISSUER OR MAY PERTAIN, T,* W SURAWE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB,ACT TO ALL THE 'TEPMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIE& UWTS SH01WN MAY,NAVE BEEN REDUCED BY PAID CLMAS, t'tl►e OR atslackxta town A OEMFJAAI tI✓Maalil' � i< CgYi�ElAI gENERAl LV6k9TY CLAIM! 1ADC Qocox Y C'STMft,4-01 0012WX19 0%2&2= :EACH QGCiIUCEIAC,E. 'f. 1,OOO,OXW ee,P1�Ea+zwre«jam i jUis.l.r} a 5.0oo.00 *AovxxMew % 1tofto00.Ot1 010a t&:Wiy ATVt>IAr14P"RIi4PER:. X VG.C, M A.Cc asl to 0",OAre s 2.,400,OOO,f10 -JRCptJ»TA•t.t?4rt's9t"rr+'+iCntS 4. .QQQ.Q Ii,iID C AlAre!lORRE WIatITY myALRC ALL€kA#" scoltout£q Rurtn �i�Ap�rr tfmoN1rts t uwsEttA U" 0=0HEAT tlAessis tLsa m*w!m! " IKETEW 1 50820032115-0!?I 1f 0:lii 02OTftO:tt1 1; >4QOAYarA,ta�a pexaa, f 10,000 60glY NtNTY(Wr+esi $ _O,d}00 3 10.QL10 Et 1 i Tle --Iml MKt141iAIClCtWMEakSwtlOM: A%V j!W L.4sVI" UA0IU" AIRY rwoolerMwltr>•AAlfW" OwIlve 71A1 N'AA: err CCtT :IEkffi!f R E tCitlgE31• Ap3i+�s,gw» b[3CNiPl3[7t[iKrJr4ifJtltgA:Sirsriaw - _ _ -°:� A "tl.. [Ulm.. OR I El.£-+.[N ACLW::W .—_....-w. . F,L. dS£AM-EA EA:fe"L4wEs; L t F.tpSE.•rK9tlGytrr S. oe><GMtIrhT,MA OF pYEaATMQheI A t4Cli"m A'hE4a US I "o" ese, *Awww fto* . a a" #0"** "W*04 PIUMBLIKO CONTRACTOR CERT ReATE HOLDER CANCELLATION 0IOt140 A W OF TNE.ABOVE DEED POLICIES ft CABLED BEFORE: MIAII11i Slmoros VIA M aE7 MATION DATE TIIERicAd NOT1 LL A49 DELIVERED at AWORDANC! TVITIT Im PWCY FROYIS"L Buldn0 tiopm9menl IOM NE 2nd Avo ReYIAZaapTTATtYIF F,9emi 'Os FL 33135 ACORO 25 (2(11*W) C 19W2010 ACORD CORPORATION. ;All OoMs reswed. The ACORCI nam and lop we rAaoaletad MUM of ,ACORO wig 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: 10/11/2019 PERSON: JOSE Y PENA FEIN: 271247181 BUSINESS NAME AND ADDRESS: JYP SERVICE & REPAIRS CORP 9915 W OKEECHOBEE RD APT 5107 HIALEAH. FL 330162128 SCOPE OF BUSINESS OR TRADE: Plumbing NOC and Drivers EXPIRATION DATE: 10/10/2021 EMAIL: YIMMY7@HOTMAIL.COM IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by fling a certificate of ern 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 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 fifrng of the notice or the issuance of the certificate, the person named on the notice or certificate no burger meets the requi ements 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 E01034594 QUESTIONS? (850) 413-1609 SERVICE & REPAIR CORP, C F C w 14 2 9 8 8 3 Date: State of��' 1� County of tJ { Before me this day personally appeared �� s �/�c�e( who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: ntractor Signa ure Sworn to (or affirmed) and subscribed before me this, day of %C' , 20� by �.r�/ ��l�u S Personally know l �,✓<< Or Produced Identification Type of Identification produced Print, Type or Stamp Name of Notary Notary Public Wale of Florida = David Silva Son Pedro N n Commission GO 246364 ?ar Expires 08/07/2022 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: 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 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 ACKNOWL DGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: caner State of Florida County of Miami -Dade q The foregoing was acknowledge before me this rC� day of20 B i 1 who is personally known to me or has produced ��0 SIO W,.. /�iV% Y, S ' S P Y P • VO�H 25, 20 %p, as identification. * ,.y #GG 287268 Notary: i20i�'�'d Bon �ti0 Rr `` SEAL: c, d /1/1/ .0&,el C � ��//11111111111\\\