PL-11-554Inspection Number: INSP - 157768 Permit Number: PL -3 -11 -554
Scheduled Inspection Date: April 08, 2011
Inspector: Hernandez, Rafael
Owner: FISHMAN, GEORGE
Job Address: 103 NE 99 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: Dale Plumbing
Building Department Comments
REPLACE WATER LINE
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
April 07, 2011
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: Addition /Alteration
Phone Number
Parcel Number 1132060132180
Phone: (786)663 -1804
Page 3 of 5
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder):
Address: 1 AJ
0 3 2— R
City:
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS:
City:
Folio/Parcel #:
Sce
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
Miami Shores County: Miami Dade Zip:
Is the Building Historically Designated: Yes NO / ic Flood Zone:
CONTRACTOR: Com a y Name: I�Q �' ' 1'( lU j-kiD Phone #: 7 ��c5 t� I C
Address: f c L 'IQ 63 S
City: / t l G..th/tC _ State: Zip: //- f '1
Qualifier Name: �'><1 �CYY\. )16 W <<X't Phone #: 7 L9� 3 I a V K
State Certification or Registration #: l LR 7 07 e
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ ` CTh Square/Linear Footage of Work: 1A1 �7 a-/ —
Type of Work: DAddress OAlteration DNew epair DDemolition
Description of Work: Q ( C C€ H �. s .-.l 7 4
at-Q-ki -A-ack -fru rv\
****+ x**** ***+x+x+x+x******* * * ******* u**** *m Fees** * *,u******* ** n**** ******* ******m******* ****
fio
Submittal Fee $ S LR ° - C)
Permit Fee $
CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
e-o
State:
M M :7713
LIAR 3 0 2011
Permit No. 1
Master Permit No.
3c7 7S�
1 S )-)NI CI..A. , ce I `i �� 17
� Phone #: :�_��I
Zip: 3°3 ("f
Certificate of Competency #:
TOTAL FEE NOW DUE $ ( . (D C>
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) days after the building permit is issued. In the absence of such posted notice, the
inspection wil . be approved and a spection fee will be charged.
Signature
The foreg $, g ins � ment was
day o� �' x;,20 4 ,b
NOTARY PUBLIC:
t OM 11 1 1
Sign:
Print:
My Commission Expires:
********* **** **** ** **** * * ****
APPROVED BY
Owner or Agent
owledged bef
s"'
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
e this 9q
`4 / Plans Examiner
Signature
Contractor ;;��
The foregoing instrument was acknowledged before me this SC)
day of m " , 20 l' , by Utn k-
who is personally known to me or who has produced -
w ho is personally own to me or who has produced -_
a s identification and who did take an oath. as identification and who did take an oath.
Sign:
Print:
NOTARY PUBLIC:
— ® rn in —O N
4 es
My Commission Expires:
Zoning
Clerk
APPROVED
ZONING DEPT
Miami Shores
L4 14 L0 1 I
0.10'
(.4
0'
LEGAL DESCRIPTION: Lots 15 and 16,B3.ock 16 of "AMENEED PLAT OF MIAMI SHORES,SRCTION ONE"
according to the Plat thereof as recorded in Plat Book 10,Pacle 70 of
the Public Records of Dade County, Florida.
103 N.E. 99th Street, Niiami Shores, Florida 33138
NANCY ANCRI 4
ADDRESS:
CERTIFY TO:
BLDG DEPT
DATE
SI111.1E O 1'I .` DERALL
( ;taro tC) fJD :K <�i- RflO OAM
Community Panel No. 125098 0093 F
F. I. R.14. Date: Novel 4,1987
Base Flood Elevation= N/A
Zone: " x ."
I HEREBY CERTIFY Chet the sketch shoat hereon and the survey on which It is Mimed was dons
of ay knomted s end belin and that It conforms to the *polfoabts requiryants of Ch
the Florida Adelnletretly Cods:
Note: This Document 1s not valid unless sealed nth an embossed Surveyor's Seal.
Date of Opaline:. _OcIt
1.) Rani
prowl
2.) Lands
P8110
3.) Bea
I8
4.) El
Bee
PO.
1 -0 . 1 -r 12
I ''
Fir), Y "lizooPrs.
Raw S•yrI I'
c L oc. fucg
o4& UQl3e_
M
.`..43. ,(Fa FT- I fs • V2 )N(.1.09-F.
�""
'1,
CORP, It's successors and/or assigns
MAR 3 0 2011
ES
Ann Description,
abatactsd for easements,
f record.
e to mold. Record plat,
sham hereon as the
u a ar �t letive to the Nation
der Si supervision mulls correct to the best
f the Florlds) tutepTand Chapter 2INH of
MAN H. VJ.iET
1 . vT 1 "1
IC,
IMPORTANT: lithe certificate holder Is en ADDITIONAL, INSURED. the n011000411 must be enlIOreed. If SUBROGATION 19 WAIVED. subject to
the terms and Conditions Of the Polley, Certain policies may require an endorsement A statement on thla certificate Hoeg not confer rights to the
• coMlflcete holder In lieu of such endorsement(s).
PRODUCER
Responsive: Insurance Agency Ina.
17845 NW. 271h Avenue Suite
M(amI; FL 33066
Phone (305) 821 -9111 Fax (305) 621 -9181
INSURED
Dales Plumbing Company
154 NW 97th Street
Miami, FL 3315D-
305
Int
Apr 05 2011 9:52AM RESPONSIVE INSURANCE 3058219181 p.1
CERTIFICATE OF LIABILITY INSURANCE 1 1; 1
THIS CERTIFICATE 18 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 BE1WEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
GENERAL LIABILITY
COMMERCIAL GENERAL UASIL
❑ ❑
GEML AGGREGATE UNIT APPLIES PEW
® POLICY ❑ W ❑ LOC
AUTOMOBILE LIABII-ITY
0
a
TYPE OP INSURANCE
0
CERTIFICATE HOLDER
ACORD 25 (2009/09) QF
CLAIMS -MADE ❑ OCCUR
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
❑ UMBRELLA LIAB
❑ EXCESS LIAB
❑ DEDUCTIBLE
❑ RETENTION S
❑ OCCUR
❑ DLAIMB -MADE
WORKERS COMPENSATION
AND NMPLCYaV 8 MAMMY
ANY PR E OR/PARTNERMECUTIVE
FF
+I ry In NMI
r EXCLUDED?
DE - dRI TI TI ' o p OPERATIONS MIOw
MIAMI SHORES VILLAGE
10050 NE 2 AVE
• MIAMI SHORES, FL 33138
1FAX ( 305)786 -8972
N /A
NPP 1274014 .
NsacT WESTERN WORLD INSURANCE COMPANY
PH !
FAX
INSURER A
INSURER B 1
INeuRER O 1
INSURER D
INBURtCt E
INSURER F I
INSURER($) AFFORDING COVERAGE
_ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: •
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 SY PAID CLAIMS. •
IADDL,SUER
JINNI 1 _.._ POLICY NUMBER
137/27/2010
CANCELLATION
07/2712011
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (MOM ACORD 10, Additional Remake Schedule, If mare swot Is required)
AUTMQRizED REPRESENTATIVE
EACH OOCURRENCE
D AMAGS s0 RhNI ED
PREMISES (Es ocwuunincol b
MED EXP Amine ine porn ¢
PERSONAL R ADV INJURY tl
GENERAL AGGREGATE
PRODUCTS - CQMPIOP AGO
COMB WED SINGLE LIMIT
(ifs eocidient)
BODILY INJURY (Per person)
B ODILY INJURY (Pere
PROPERTY DAMAGE
(Per ealdent)
EACH DCCURRENC
AGGREGATE
LIMITS
I I TtiRYI/IMIYF ❑ FER
El.�h ACCIDENT
E.L. DISEASE -EA EMPLOYE
E.L. DISEASE •POLICY LIMIT
s •
NAIL
8300.001
350.001
$300.00
S000.00
8300.00
a
a
8
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL IRE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
® 1998 -2009 ACORD CORPORATION. All rights reserved
The ACORD name end logo are r glatered marks of ACORI