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PL-10-23 ! Miami Shores Village 10050 N.E. 2nd Avenue �e&M, - O ate# Miami Shores, FL 33138-0000 F 3 e�,` Phone: (305)795 -2204 Fltflt b ti J r r Expiration: 07107/201 ,T Project Address Parcel Number Applicant 166 93 Street 1132060133090 Miami Shores, FL 33138- Block: Lot: CAMILA & RYAN PENDLETON Owner Information Address Phone Cell CAMILA & RYAN PENDLETON 166 NE 93 ST MIAMI SHORES FL 33138 -2818 Contractor(s) Phone Cell Phone Valuation: $ 7,000.00 DOUGLAS ORR PLUMBING INC 305/887 -1687 _..:.. Total Sq Feet: 0 Type of Work: PLUMBING For Inspections please call: Type of Piping: WATER SERVICE PIPE CHANGE OUT (305)762 -4949 Additional Info: Available Inspections: Bond Return: Inspection Type: Classification: Residential Top Out Re Pipe Main Drain Heater Water Service Final Water Main Lavatory Underground Fees Due Amount Invoice # Total Amt Paid Amt Due CCF $4.20 PL -1 -10 -36753 $ 204.20 $ 154.20 Education Surcharge $1.40 Permit Fee - Additions/Alterations $190.00 PL -1 -10 -36753 $ 204.20 $ 204.20 $ 0.00 Scanning Fee $3.00 Check #: 059375 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Technology Fee $5.60 Total: $204.20 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. January 11, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy January 11, 2010 1 Miami Shores Village M 'M Building Department JAN 0 6 2010 10050 N.E.2nd Avenue Miami Shores, Florida 3313$ y ' B Y. isormmree�lrra ® ®q ®er® Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING Per No. 10 PERMIT APPLICATION Master Permit No. FBC 2001 Permit Type (circle): Building Electrical Plumbing Mechanical Roofing Owner's Name (Fee Simple Titleholder) 9,YAJ 1 q 5 rJ1)L,5 - rJ Phone # Jas-- 7.5$"" O S S °7 Owner's Address /66v ,u,c- 1 ?3 sT City State L cl- Zip 2-3/ . 3 8 Tenant/Lessee Name Phone # Job Address (where the work is being done) 1(ra AA 93 ST City Nflami Shores Village County Miami -Dade Zip _33432' Is Building Historically Designated YES NO Contractor's Company Name 6,po & tq-S 0'Y2 ��i�//�i1J6 �lc_ . Phone # Contractor's Address _3 lq4 (&�__ �� c/ City !% i6lr+; State / Zip .3,8 I (� Qualifier /Y. 10A State Certificate or Registration No. (p V' Certificate of Competency No: Architect/Engineer's Name (if applicable), Phone # S Value of Work For this Permit ��� Q. 00 Square Footage Of Work: Type of Work: ❑Addition ❑Alteration ❑ N _.� ir/Replaoe },- El Demoolition Dgscnbe Work;: (lp *:;W, �,nw_ i ec P F t ti7 i T4 ,;. o �kf`eC.� 5''n - i�. , -tk y '� 4 ;;. - Wl:..�t+�Y. ^' *9e 4c �t f49cnt Ytk aY s@4t��tsY sYlF 9t 't Pe9e 9t ek 4t �t 9e9t '[ 4i it F a49&inY4e s't 9t9tdt 9t Y9t Rc9a 8c3r dt �fc 8c4eFe Ae t s4 aY Submittal Fee $ Permit Fee $ CCF $ 4''' CO /CC Notary S Training(Education Fee S • `' 0 Technology Fee $ Scanning $ ' Radon,$ Zonin _ Bond S Code Enforcement $ Structural Plan Review. $ Total Fee Now Due $ 1547-2L (Continued on opposite 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 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) ways after the building permit is issued In the absence of such posted notice, the inspection will not be.406roved and a re' spection fee will be charged. t Signature Signature �-- Owner or Agent Contractor The foregoing instrument was acknowledged before me this .S The foregoing instniment was acknowledged before me this day of 6k j - /Aax , 20 ..(o , by �- -Na L. Pr�,p ws�, day of .!,✓✓„ve-, . , by _WA -?wry �1 � who is personally known tome or who has produced P4 1- dk es who is persona known to me r who has produced 7 3 a— ' -3 Re- -;) As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: �L � e� Sign: a, .Print: L WN wi.... a tw+lES l�.srr. Print: N d" Of rwwavw My Commission Expires: , : Fe1;28,201 My Commission No" Pub • Sm of FWda 3 fi taqftsFab26 201 Its K1 .1I Om dPA7hrw0Nv1"#4ftyA=L APPLICATION APPRO BY: f Plans Examiner Engineer Zoning Chc 05/13/03 1 ' MIAMI -DARE COUNTY mm LOCAL BUSINESS TAX RECEIPT me FIRST -CLA81 TAX CO MM"A COUN - STATE OF FLORIDA U.S. POSTAGE 1a WOOR�R ST. EVIRES N� 38130 MUST BE DISPLAY® ATT PIAACK OF MUUA FL PURSUANT TO COUNTY CON CHAPTER SA - ARE Y A 10 PERMIT NO. M ta 445228- 0 THIS IS NOT A BILL - DO NOT PAY RENEWAL. B ORR NMMBIMB INC STATO i 82664 464791 -4 301 FLAGLER DR 33166 MIAMI SPRINGS Ow DOUGLAS PLUMBING INC WORKERS nW �� IMM9 CONTRACTOR 1 DO NOT FORWARD LAS ORR DOUGLAS PLUMBING INC ORR WAYNE 301 FLAGLER DR ►fTAx MIAMI SPRINGS FL 33166 1 19 , SEE OTHER SIDE o y 3 ACORA CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYY1f) 07/31/2009 PRODUCER (30S)822 -7800 FAX (305) 822 -1621 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Collinsworth, Alter, Fowler, Dowling & French ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P P. Box 9315 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 0. . kes, FL 33014 -9315 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # I as Orr Plumbing, Inc INSURERA: Amerisure Insurance Co 19488 301 Flagler Drive INSURERS: Amerisure Mutual Ins Co 23396 Miami, FL 33166 INSURER C: INSURER D: "s INSURER E: C OVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADWL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CPP2063609 08/02/2009 08/02/2010 EACH OCCURRENCE $ 1,000,00 n X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300.0 CLAIMS MADE X� OCCUR KET ADDITIONAL INSD MED EXP (Any one person) $ 10 1 A X CONTRACTUAL LIAR PER ENDT CG7048 0304 PERSONAL & ADV INJURY $ 1,000,0 WAIVER OF SUBROGATION GENERAL AGGREGATE $ 2,000,00 GEN L AGGREGATE LIMIT APPLIES PER PER ENDT CG7049 0905 PRODUCTS - COMP /OP AGG $ 2 000 00 POLICY X jE LOC AUTOMOBILE BI LIABILITY CA2063607 08/02/2009 08/02/2010 COMBINED SINGLE LIMIT $ 1,000 ALL OWNED AUTOS BROAD FORM AUTO ENDT BODILY INJURY B SCHEDULED AUTOS CA7171 0508 (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per aoddent) PROPERTY DAMAGE $ F (Per aoddent) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ ExcE88/UMBRELIJI LIABILITY CU206363 S 08/02/2009 08/02/2010 EACH OCCURRENCE $ 5 ,000,0 ()( 3 X OCCUR F CLAIMS MADE AGGREGATE $ 5 A U BRELLA IS EXCESS OVER $ DEDUCTIBLE GL, AUTO & WC $ RETENT $ FOLLOW FORM APPLIES $ WORKERS COMPENSATION AND WC2063608 08/02/2009. 08/02/2010 X WC 3TATU- OTH- EEL EMPLOYERB' LIABILITY WAIVER OF SUBROGATION E.L. ACH ACCIDENT $ 1 000 00 ANY PROPRIETORIPARTNERIEXECUTNE , A tt FF eFIICdE � BBEdReEXCLUDED? ER ENDT WCON313 0484 E.L. DISEASE - EA EMPLOYE $ 1, 000, 00 SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 1 000 A E(T05MENT FLOATER _ . '- CPP2063609 08/02/2009 08/02/2010 RENTED OR LEASED EQUIPMENT $100,000 PER ITEM $2,SOO DEDUCTIBLE DESCRIPTION OF OP RATIONS / LOCATIO 8 / VEHICLES I EXCLUSIONS ADDED BY E DORSEMENT / SPECIAL PROVISIONS Except 10 days notice Ar Nan - Payment of Prey =um E: Plumbing Contractor No. CFCO214S2 CERTIFICATE HOL CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Village of Miami Shores 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ` Building & Zoning BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 100 SO N.E. 2nd Avenue OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Miami Shores, FL 33154 AUTHORIZED REPRESENTATIVE Richard French ROSIEG f ACORD 25 (2001108) © ACORD CORPORATION 1888 F � -fit ••A_: :w• •�. .- ,� ...- -- - ,�� ; tzar �I� „ el � � ' � ` ..: !I• MW B OARD 4 _ -A: 4;'. t ..di;� ,•� Ii i . , .: -.. � y P` yi x s t G , 4 � 'fi ` ,,,/ �•� r ♦. { t :� " Y `7�.. �*� .. _ ''� .' I I �� r a: 1� s l- i � z + `-g, Y }. 43.°.•i����",.l i.��.,',�k} f7 ���#t� r� ,• : � J i �y M . � _ � a�, ty a§s`'� 'tlt' yi��yt* f,Attit�:Yq�(yt,�A `:,r__g;. ,� 3AM,. �,4 4 . I���wi���d��'ei� ,� ♦ y � . Ii � �� fS� .'�? t c�`"', � t • i•'J - J � § I LAW lLAW ��,• �• I I Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 132726 Permit Number: PL 1 -10 -23 Scheduled Inspection Date: February 17, 2010 Permit Type: - Residential Inspector: Hernandez, Rafael . Inspection Type: Final Owner: PENDLETON, CAMILA & RYAN Work Classification: Addition /Alteration Job Address: 166 NE 93 Street Miami Shores, FL 33138 - Phone Number Parcel Number 113206013309 Project: <NONE> Contractor: DOUGLAS ORR PLUMBING INC Phone: 305/887 -1687 Building Department Comments REPALCE APPROXIMATELY 160FT OF GALVANIZED PIPE WIIRV CO PPER PIPE INSTALL NEW 1 COPPER WATER Inspector Comments Passed I n Failed rq Correction ❑ Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. February 16, 2010 For Inspections please call: (305)762 -4949 Page 11 of 28