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PL-10-409Inspection Number: INSP- 137840 Permit Number: PL- 3- 10-409 Scheduled Inspection Date: April 23, 2010 Inspector: Hernandez, Rafael Owner: GARRETT, SUSAN Job Address: 91 NE 91 Street Miami Shores, FL Project: <NONE> Contractor: SUBURBAN PROPANE Building Department Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments April 22, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Gas Phone Number Parcel Number 1132060130140 Phone: 305 -891 -8393 Page 2 of 6 Project Address 91 91 Street Miami Shores, FL Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number 1132060130140 Block: Lot: SUSAN GARRETT 91 NE 91 ST Miami Shores FL 33138 Valuation: Total Sq Feet: Contractor(s) SUBURBAN PROPANE Phone 305 -891 -8393 Cell Phone Fees Due CCF Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Submittal Fee Submittal Reversal Fee Technology Fee Total: Amount $0.60 $0.20 $150.00 $3.00 $50.00 ($50.00) $0.80 $154.60 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Phone Type of Work: SET TANK RUN GAS LINE Type of Piping: GAS Additional Info: PLUMBING Bond Retum : Classification: Residential Pay Date Pay Type Invoice # PL -3-10 -37281 03/12/2010 Cash 03/22/2010 Cash Amt Paid Amt Due $ 50.00 $ 104.60 $ 104.60 $ 0.00 March 22, 2010 Date Expiration: 09/13/2010 Applicant SUSAN GARRETT CeII Available Inspections: Inspection Type: Final Press Test ROW 1 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 all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. March 22, 2010 1 BUILDING PERMIT APPLICATION FBC 2004 Permit Type: Piumbing Owner's Name (Fee Simple Titleholder) ® NS ( 'f cd1A/ l d el+ Phone # go S' ‘O6 ` 3 Owner's Address 9/ A/ L� / / S f City my/ //f/Yli 444 State Tenant/Lessee NameL Phone # E -MAIL: Job Address (where the work is being done) f/ 4/6 '9 / 5 I City Miamt Shores Village County Miami -Dade " Zip /3' Y FOLIO / PARCEL # Is Building Historically Designated YES NO Contractor's Company Name 3 0 64/V6 ,2rc, - #4 e Contractor's Address / 9. C/ A/G /3e f City A.l' ,'74.7V ( State c' Qualifier Name $)L4 l' y926 State Certificate or R4gistration No. Certificate of Competency No. e/:6 ©oiy ? E -MAIL: Architect/Engineer's Name (if applicable) Value of Work For this Permit $ Miami Shores Village TOEVEZUM Building Department KKR 1 2 2010 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BY: Permit No. 171-1©'401 Master Permit No. Zip 33 /3 e Phone # F5 k 3C3 Zip 3 / 6 1 . Phone # SOS Phone # Square / Linear Footage Of Work: Type of Work: ['Addition ['Alteration DNew D Repair /Replace ['Demolition Describe Work: . frnif.)Ar fziocr 6,95 L/. . '' ******* * ** * ** * *** * * * * * ** *** ** ** ** * **** F ees *x *x * * * * * * * * ** * ** ** ** ** * * *w ** *x�xxxxx * * * ** ?PSub mittal Fee $ 50 Permit Fee $ 2 CCF $ '( i O CO /CC Notary $ Training /Education Fee $ 0'626 Technology Fee $ a . Scanning $ V `0D Radon $ DPBR $ Zoning $ Bond $ Code Enforcement $ Double Fee $ Structural Review. $ Total Fee Now Due $ 4 •(l See Reverse side -* Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 taws 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 The foregoing instrument was acknowledged before me this 6 My Commission Expires: wner or Agent Sign: Prin My Comm, **** 4 t xxxxxx *********' ka' eittie k& oY4coe**** oc****dexe4******** **** *** 4*** APPLICATION APPROVED BY: (Revised 02/08/06) Signature 1,1 4/./*" Contractor The foregoing instrument was acknowledged before e this day of j , 20 10 , by Sv 111 van who is personally known to me or who has produced as identification and who did take an NOTARY P C: c� a C �"•'e 4 INEZ s:Notary Public . State of Florlda MY Commissl�t► � ,� -.9,� � .o. ommtsslon � # DD 667494 � :°�'� Bonded Through National Noisy Assn. Plans Examiner Engineer Zoning M011 LTR AMYL INSRC TYPE OF INSURANCE GENERAL LIABILITY POLICY NUMBER .. .__ .__ _ ...... ._. _.._ POLICY EFFECTIJE DATE IMMUDD YTYY) POLICY E 1tPIRATION DATE(MINDDNYYY) ... ....__ ...... ._ .. .. LIMITS A X - _ GENERAL COMMERCIAL GENERAL AL LIAI IILITY �. _ _ CLAIMS MADE I. X I C CUR AGGREGATE LIMIT APF JES PER - I JE o- I - • I LOC POLICY TB2- 631- 507975 -030 03/01/2010 03/01/2011 011 EACH OCCURRENCE 2,000,000 $ 250,000 $ 10,000 $ 2,000,000 $ 2,000,000 $ 2,000,000 D TO RENTED DAMAGE occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE - PRODUCTS - C:O RODMP /OP AG A AUTOMOBILE X X_ X X X LABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS AS2- 631 - 507975 -040 03/01/2010 I 03/01/2011 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) _ "' ' ` BODILY INJURY (Per accident) $ 2,000,000 $ $ $ PROPERTY DAMAGE (Per accident) GARAGE - LIABILITY ANY AUTO AUTO ONLY -EEA ACCIDENT $ $ OTHER THAN EA ACC AUTO ONLY: AGG EXCESS F UMBRELLA UABILITY EACH OCCURRENCE AGGREGATE $ $ $ $ OCCUR I__ —I CLAD IS MADE DEDUCTIBLE RETENTION $ B B WORKERS EMPLOYERS' ANY PROPRIETOR/PARTNERIEXECUTIVI: OFFICER/MEMBER (M P a ECIA ndat L PR Sow COMPENSATION AND LIABILITY Y IN EXCLUDED? I N 1 WA7 -63D- 507975 -010 (AOS) WC7 -631- 507975 -020 (OR) 03/01/2010 03/01/2010 03/01/2011 03/01/2011 x WC STATU- I IOTH- L1 xonY_Mn'.S' . __ _ ER E.L EACH ACCIDENT $ 1,000,000 $ 1,000,000 $ 1,000,000 ' DISEASE - EA EMPLOYEE In OVISIONS NH) If ye9, bel describe under F.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPE RATInmen Arl nucldeuln . __.._.. ..--------- ___ _ -____ ACRD. CERT'FICATE OF LIABILITY INSURANCE PRODUCER MARSH USA, INC. 44 WHIPPANY ROAD PO BOX 1966 MORRISTOWN, NJ 07962 Attn: Morristown.Certreque: it @Marsh.com Fax 212- 948 -0979 J08990- ALL - CAS -10 -11 CLIE INSURED SUBURBAN PROPANE PARTNERS, L.P. 1 SUBURBAN PLAZA P.O. BOX 206 WHIPPANY, NJ 07981 COVERAGES THE POLICIES OF INSURANCE NOTWITHSTANDING ANY REQUIR MAY BE ISSUED OR MAY PERTAIt CONDITIONS OF SUCH POLICIES. , RE: SUBURBAN PROPANE LIC #01196 CERTIFICATE HOLDER ACORD 25 (2009101) MIAMI SHORES VILU.GE BLDG DEPT 10050 NE 2nd AVE MIAMI SHORES, FL. 3138 NYC - 003848064 -12 CANCELLATION INSURERS AFFORDING COVERAGE INSURER A: Liberty Mutual Fire Insurance Company INSURER B: Liberty Insurance Corporation INSURER C: INSURER D: INSURER E: DATE (MMIDDIYYYY) –THIS—CERTIFICATION-1S _ 02/22/2010 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NAIC # 23035 42404 LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. liMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE I, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND IGGREGATE LIMITS SHOWN MAY HAVE BEEN RFDI1CFn RY PAID CLAIM'' 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING 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 p�' U p PO � N �p THE INSURER, ITS AGENTS OR REPRESENTATIVES. Or Marpsh Qp USA lita aNTAnve Mary Radaszewski © 1998-2009 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD 1 From Date Sender's Name company SUBURBAN Addre=S 1491 NE 130TH ST City NORTH MIAMI 2 Your Internal Billing . Reference Wet24dmra40uewa appear on 3 To /J,, / //J® �►5^ Q /d NaeipieLas /���av ,s C� / I• + -� / Name P ?� l Phoney ) Company Address Express Address . , 1'® #G We cannot delver to P.O. bens or P.0. 21P codes. Dco lab 6 17q- 5 LI 57 USAirbill Tilt 8 715 4798 16 6 7 Senders FedEx FEE t EE: Account Number fil/e/A-•-c.) PROPANE DeldaboriSubflioam State FL zip 33161 -4410 NOTemilable ter (Ed Et HOED Weekday ❑ Magee:slat:Won address Fod That ur L� ©! O Ifi1'A�y:.�,{1SG f�PJ 'i:.t f' , Phone 1 305) 891 -8392 HOLD Feda Saturday addrmsbdwx Available and 2J�ymseiect Overnight Dept rrouitaiROOm location Print Feria n U here selected CitY 0 State / ZIP. 3367 0416030710 on -at tef ex. e your account, Aar Package Service ex Priority Overnight business de rnentng..Friday Marday ❑ SA YDe el bedstead SOImmd. ZDay SY4 4b Express Freight Service »Tonmmk= FedEx 1Da dtyy�nFy F . rai ht ❑ Crea u SATURDAY FeI�rl�yadgldBmkhlgNa FedEx2DayFreight ❑ Second tuskless dab rined&Gvered enMoMaymdeae ..,, ,.,, f selected. 5 Packag . " =`l >,• oar ❑ FedEx PS ❑ FedEX Box ❑ FedEx Tube ❑ Other Enve 6 Special Han r ! and Delivery Signature Options ❑ to aaaDebm Sm idard Overnight, Fed& Post Ovendght,Fred Es Express Saved aFedEc30ayFtefght No Signature Required ❑ Package be WIailmnt obodn&ga m ootordagver: Does this shipment contain dungarees geode? One bet omot be checked. I ❑ NO- - ❑ ha_ . arched aieratton, ❑ Y ,mt,e9,�ad oacimedm' m1meFed & agaa�d lrootbe*dopedIn Feedpackegfip I BIBta Includes I- Smell Pak Feats Large .: Fee=SeadyPek •waa»moa6mm. FedEx Standard Overnight Nextussetmnmcn. Saturday Debrwy Nor evabable. FedEx Express Sever Tbrd buss day Sabuday DeliveryNOTaaallable. ❑ DrectSignature Sameu®a wesenrsoddmas maysentordomve. w. Paclogos over 150ths. ❑ I1Dd business des Freight eyDeliveryNOTavelahht. Indract na ture ❑ Dworeia atroc rga dpmyI d Ft residential fao appllaa ❑ D Ice thylotauN,Be kg ❑ Cargo Aircraft Only blur FedrodZet Na. va Zed Cud No. below. -- u ❑ Recipient ❑ Third Party ❑ GraditCard ❑ Cash/Check NI Date Total Pa es TotLWeight To Declared Velvet og $ ter ehkh •sebn.See beater Wails. Byidlest* Maim � t wadi=andnbckd add M lathe lathe amnstFedEc Send. Wade, hmbdlvgtm� Rev. Dee =Wad #1532rt@1W4 -20811FedE PNNIID IN USA RS Packages up to 15J ❑ FedEx First Overnight Earliest nmdb amming datvarytoadeQ .• on Staudey Delivery NOT udable. 553 Name: Mail Address: Employee #: Co. #: Signatures: Date: Suburban Propane, Its Subsidiaries and Affiliates 2010 Employee Expense Statement For use of January 1, 2010 thru December 31, 2010 Cost Center#: Cost Center or Department Name: Headquarters: Position: of Date: To: Employee Manager (Director if Central Support) Page: Period Covered: From: / Totals: 1 See Instruction in Policy & Procedures for Reimbursement: * ndicate Business Purpose & Code of each trip: A ** Code for Transportation - Auto Expense: B A - Air C - Car O - Gas/Oil R - Railroad C B - Bus T - Tolls P - Parking M- Maint/Repairs D Miles * .50 ***Attach all Receipts: E **** Entertainment Explained on Back of Expense Rpt: F Total Expenses: A - Total Exp: B - Less Adv: C - Bal Due Co: D - Bal Due Emp: Payee #: Invoice #: Fill in purpose of trip and cross -ref expense in column #2 Account: CSC: Amount: Reference: Revised 12/09 ac / g9 / y s� �- 5 el ®Ale too L P C A'A A-, Q J2t)sd 6, L 4462 coma' 1jd`C 6e ' 2# ' Ca des c v ®oq °C /7/16°'-' r M e cri CV Qualifier Job Address Longest Run Total BTU's Suburban Propane 1491 N. E. 130th Street N. Miami, FL 33161 305 - 9 93 >- co N 9/6 1': /,q ii g /iexos 6 rir - 15 ° 01' P fr N' Suburban Propane 1491 N. E. 130th Street N. Miami, FL 33161 05 i 3X7 Qualifier Job Address y / 9VG' j/ sloes / on est Run , eie 7 oiLii BTU's /3 o ooz 4 4 /V 1s� ASME ORDER NO. OL II D TW WC B C L 200# ASME SILVER METALLIC 5763 42.48 34.06 24 172 476 18 14 NO 200# ASME WHITE 5763.1 42.48 34.06 24 172 476 18 14 NO 420# ASME (QUADRWITT) SILVER METALLIC 6762 5325 45.62 30 326 1000 23.1 16 LIFT LUG (QOADRII}T T) WHITE 6762.1 5325 45 30 326 1000 23 16 LIFT 420# AND 200# CYLINDER SPECIFICATIONS OL 4 D D.O.T. AND A. S. M. E. BASIC COMPARISONS 000 USS TANK (800- 877 -8265) D.O.T. A.S.M.E. DIA. 30" 30" O.L. 53.3" 53.3" WT. 275# 326# RETEST PERIOD 12 YEARS NONE MATERIAL THICKNESS 13% HEAVIER MORE CORROSION PROTECTION NAMEPLATE STAMPED IN COLLAR STAINLESS STEEL RIVETED INSIDE COLLAR FINISH POWDER COATED MASTIC DIP POWDER COATED MASTIC DIP T/L 99 99 TRANSPORTATION WITH PROPANE YES - 80% YES -80% 420# AND 200# CYLINDER SPECIFICATIONS OL 4 D D.O.T. AND A. S. M. E. BASIC COMPARISONS 000 USS TANK (800- 877 -8265) NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED O THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. I®P (1l FOLIO NO. LL-3205.On - Ono STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be mad property, and in accordance with Chapter 713, Florida Statutes, the followitiffii is provided in this Notice of Commencement. B 1. Legal description of property and streeVaddress: L 0 a J 106 2. S T 2. Description of improvement: L-4 fl �Y� 1J5 3. Owner(s) name and address: b 1 n i c l eA•a 3 n � . c = . O r) t (4 5 1. q?.. S'j El :,, A Lt io , Interest in property: bu.l r'' - Name and address of fee simple titleholder 4. Contractor's name, address and phone number. Florida Home - improvement Associates 4070 SW 30th Ave. Hollywood, Florida 33312 P one: 954 5. Surety: (Payment bond required by owner from contractor, if any) Name, address and phone number: Amount of bond $ 6. Lender's name and address: 7. Persons within the State of Florida designated by Owner upon whom notices or other docum is may be served as provided by Section 713.13(1)(a)7., Florida Statutes, Name, address and phone number: 8. In addition to himself, Owners designates the following person(s) to receive a copy of e Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Name, address and phone number. 9. Expiration date of this Notice of Commencement: (the expiration date is 1 year m the date of recording unless a different date Is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION r F THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDS OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. c'e pau'ee b Signatu of Owner(s) or Owner(s)' Authorized Officer/ Director /Partner/Manager CAM,' ' � i ,, t + re By By l .H Print Nam /ILL • (r V Title/Office Title/Office , (.5(A) 3 • - HD LerioStiOrs -c-L. 333 jZ Pri ,1Name corn STATE OF FLORIDA COUNTY OF MIAMI -DADE The foregoing instrument was acknowledged before me this 1 a day of By ❑ Igdividually, or • as for ersonally known, or ❑ produced the following type of identification: Signature of Notary Public: Print Name: (SEAL) VERIFICATION PURSUANT TO SECTION 92525. FLORIDA STATUTES Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. STATE OF FLOR I HEREBY CERTIF original file r this o 1 dr ‘7 ,// L to x-07 a N Le‘. T-i.r 3313? 11111111111111111 1111111111111111111111111111 CFN 2010R0179024 DR Bk 27217 Ps 1040; Ups) RECORDED 03/17/2010 13:34 :43 HARVEY RUVII'i r CLERK. OF COURT MIAMI —DADE COUNTYe FLORIDA LAST PACE A, COUNTY OF iADE t...:..• y of rte da of AD `/ Official Seal. ERK, oft aad 9qtrrxy Courts D.C. that this Space above reserved for use of recording office Owner(s) or OwAr(s)'s A horized Officer /Director/Partner/Manager who sign =• above: By ..f