PL-9-16-2433, 812 NE 92nd StLiLfNi
F[OR�DA
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit NO. PL-9-16-2433
Permit Type: Plumbing - Residential
Per m Work Classification: Pool - Private
Permit Status: APPROVED
Issue Date: 12/16/2016 1 Expiration: 0 114/2017
Project Address Parcel Number Applicant
812 NE 92 Street 1132060050190
Miami Shores, FL 33138- Block: Lot: GERALD & ANABEL DE BRUIJN
Owner Information Address Phone Cell
GERALD & ANABEL DE BRUIJN 812 NE 92 Street (305)299-7252
MIAMI SHORES FL 33138-
812 NE 92 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone
DECONEX INC (305)817-8777
Type of Work: POOL PIPING
Type of Piping:
Additional Info:
Bond Return :
Classification: Residential Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
JAn
Permit Fee
Scanning Fee
Technology Fee
Total:
Valuation:
Total Sq Feet:
Pay Date Pay Type Amt Paid Amt Due
Invoice # PL-9-16-61173
09/01/2016 Credit Card S 50.00 $ 186.36
12/16/2016 Credit Card $ 186.36 $ 0.00
$ 1,000.00
0
Available Inspections:
Inspection Type:
Main Drain
Final
Rough
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-eFF-the fgr�oing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and ning. Futhermore, I a ize the above -named contractor to do the work stated.
December 16, 2016
Authorized Signature: Owner / Applicant / Contractor / Agent Date
Building Department Copy
December 16, 2016 1
Local Business Tax Fbi Pt
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1
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
.1 l�t�.LWNRA
S4
FBC 201 14-
B U I LD I N G Master Permit Noel 6- 2 q 32
PERMIT APPLICATION Sub Permit No.—'L-( G - 2,(-t33
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
215'LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: 9/Z �2 t
DRAWINGS
City: Miami Shores County: Miami.Dade Zip:
Folio/Parcel#: Is the Building. Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): // C '/W_ �_Pho4-
Address:
City: ��1-�`���—f Stater Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: G�C()/U C Phone#: 7jes`/
Address: 2% L3 Z/412 F7� 0 /)- Q
City: C o 12 n L State: L— Zip:
r-U L`
Qualifier Name: . + V l o; J +�, l A. Phone#:
State Certification or Registration #: C EC i 41? V2 3) Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Z�� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ u� Permit Fee $ _ � CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ I
(Revised02/24/2014)
Bondirig 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrumen as acknowledged before me this day of 20 1l, by
�� Xl i$;j7. who i personally known -to
me or who has produced as
identification ad-d who did take
BLIC:
Sign: s�
Print:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of AV & ✓5 7— 20 1 (✓ , by
(1 oh N ho is personally knowtas
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: .1y FIZZ C C-' 11710 VJ s /{
�:q• �,g�bh Ur t.r1i
Seal: =* t p- "ommiWon # FF 06E936 Seal:
6,01res January 23, 2018
. JORGE ROBBEAU
1 j,`i;:�•eond"d Rom rtrovFma ineWbma Pq.fJ•38fr1M9
1NY CODII1'IIS10>V N1►F119WN
EXPUM (bil�4so�s� Mg4.2018
s***s* fthen*s ss***s*s**ssss
APPROVED BY f �[!• _ Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
DECONEX INC
CERTIFIED PLUMBING CONTRACTOR
LICENSE NUMBER CFC1428231
247 BIRD ROAD CORAL GABLES FL 33146
PHONE 786-443-9590
Augest 30 2016.
State of: Rip -
County of 'AgDE
Before me this day personally appeared �V who
being duly sworn, depose and say:
That he or she will be the only person working on the proyect
located at: �� Z ! '` �2 a
Sworn to ( or confirmed) andsubscribedbefore me this 3 d day of
201S , by DAWO •
Personally Know
Or Produced Identification
Type of identification Produced
Print , Type or Stamp
Name of Notary
JORGE ROSSEAU
MY COMMISION NFF119045
EXPIRES May 4, 2018
(s0'n 398-m5� Floridallotw7Service.eom
Notice to Owner — Workers'
Miami shores Village
Building Department
10050 N.E2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax:(305)756.8972
insurance
Florida Law requires Workers' Compeumdon itlsulance coverage under
allows corporate officers in the conshuctian Ind toe OMPW 440 of the Florida Statutes. Fla Stat § 440.05
obtaining a bw7digg Pamir Pursuant to the Divisim exempt
Workers' Cow that moment F br any oottshr/cQon p%)ect prior to
Compensation Employe Facts Brochure:
All emPloycr in the con5rinction industry who emPloys one or more part-time or Call -time
employees, including the owner, must obtain workers' compensation coverage. Corporate office
Or bets of a limited lialyi ity company (j_q in the suction
exempt it-estiY may elect to be
1. The officer owns at least I0 pement of the stock of the corporation, or in the case of
an I LC, a statement ammting to the minimum 10 percent ownership;
2. The officer is fisted as an officer of the corporation in the records of the Florida
Departmemt.of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporatiom
No mom: than three corporate officers Per corporation or limited liability company members are
allowed to be exempt Consmrctim exemptions are valid for a period of two years or until a
voluntary revocation is Sled or the exemption is revoked by the Division -
Your contractor is requesting a permit under this workers' compensation exemption and has acknowledp Part-time he or she will not use
be the
day labor. Part-time employtxs or subcontractors for your Project The connector has provided a staring that he or she earl!
�Y Pin allowed to work on your project In these ci _mstacees, Miami Sham Village does not require verification of
workers' compensm011 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 1TS
CONTENTS.
Owaer
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me d is day of
who is Personally
Commission # F 0659 6
Expires January 0 v
i 20 .
krro to tut pmxq��
u l
_ JORCtl~ROSSEAU
`.. MY COM USION UP119045
EXPIRES May 4, 2019
(407)398.0153 FloridallotaryServieaeom