PL-12-114I
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 169094 Permit Number: PL -1 -12 -114
Scheduled Inspection Date: February 01, 2012
Inspector: Hernandez, Rafael
Owner: HUNDERVADT, ROBIN
Job Address: 9100 N BAYSHORE Drive
Miami Shores, FL 33138-
Project: <NONE>
Contractor: PLUMBTECH INC
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)751 -7624
Parcel Number 1132050010560
Phone: (305)234 -9003
Building Department Comments
INSTALL NEW SUBMETER FOR IRRIGATION
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
January 31, 2012
For Inspections please call: (305)762 -4949
Page 25 of 39
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
permit No.
BUILDING
PERMIt APPLICATION
FBC 20
• �� 'J rL
r, ^ n
PIY
JAN 232iii2
Master Permit No.
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): if le %HI rtb//. t 1'54-0 / Phone#: 6 ` 29 57- 32 G 6
Address: 9/40 /'CR 74 6. JWo3 O:!_
City:' 1/4,;4,7A e J/z State: C-1-4 Zip: 71 i3,.?
z -°
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: 910 n 1 L 4 js #v a..,E t
City: Miami Shores County: Miami Dade Zip: 37 3 3'
Folio/Parcel #:
Is the Building Historically Designated: Yes NO "'- Flood Zone:
CONTRACTOR: Company Name: 1414'4.1A1 2-64 0/ /' ' C Phone*. 3 6 S- Z Y cf— 9003
Address: / 2 2 ? S exic / 3/ /1-yK
City: 0`71-7; State: "4-4- Zip: '3 3 /
Qualifier Name: C i ` Phone#: t-®S 23'1' f
State Certification or Registration #: _ Certificate of Competency #: Oc°J 00/6 4 9e)
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ /2 5. 0 "I Square/Linear Footage of Work:
Type of Work: °Address °Alteration °New °Repair/Replace °Demolition
Description of Work: /' 7-11-1-(- . f�fl /'' A .f gec ®6-S NA/
******> ****> *>,a **+t ****>a **** **** * *aa>a**** Fees****> a************ ******** * ********a*aea+*****
Submittal Fee $ Permit Fee $ / t, 6 CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FFE NOW DUE $
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 CONDmONERS, 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.
41641*/e%1
Owner or Agent
The foregoing instrument was acknowledged before me this 2 The foregoing instrument was acknowledged before me this Z �'
day of ,.fa') , 20 12, by _ f[ c T )i CI G , day of ..I G ii , 20 �, by C n � (C�Ir)C'�
who is personally known to me or who has produced who is personally known to me or who has produced
h' > -060 -/, 04-23 identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Contractor
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
Sign:
Print: 3Citfl c omc -
My Commission
**,x******* *** * * *** ******* ***a * * * ** ** ***** ** ** ** ** * * * * **
49 Of P`4 Notary Public State of Florida
Susan Coloma
4, My Commission * 1! ' *'L lttmaitiiiefo'a * * * **a*
/-2<r---1z,- Plans Examiner Zoning
Structural Review
(Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk
Ay
cr CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
01/24/2012
PRODUCER
ECONOMY INSURANCE
1800 WEST 68 ST SUITE 139
HIALEAH, FL 33014
THIS CERTIFICATE IS 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.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
PLUMBTECH , INC.
12274 SW 131 Ave
MIAMI, FL 33186
INSURER k NATIONAL INSURANCE
Enter NAIC#
INSURER B: GUARANTEE INSURANCE
Enter NAIC#
INSURER C: UN1"1'ED AUTOMOBILE
Enter NAIC#
INSURER D:
Enter NAIC#
INSURER E:
Enter NAIC#
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
LTR
ADM.
INSRD
TYPE OF INSURANCE
POLICY NUMBER
POUCY EFFECTIVE
DATE (MM/DD/YY)
POUCY EXPIRATION
DATE (MM/DD/YY)
UMITS
A
❑
GENERAL LIABILITY
COMMERICAL GENERAL LIABILITY
02L- 0000484-00
09/03/2011
09/03/2012
EACH OCCURENCE
$1,000,000
DAMAGE SET REoccurrence)
$1,000,000
❑❑ CLAIMS MADE ❑ OCCUR
MED EXP (Any one person)
$5,000
PERSONAL & ADV INJURY
$1,000,000
❑
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
❑ POLICY ❑ PROJECT ❑ LOC
PRODUCTS - COMP/OP AGG
$1,000,000
C
❑AUTOMOBILE
LIABILITY
❑ ANY AUTO
061047501
01/06/2011
12/22/2011
COMBINED SINGLE LIMIT
(Each Occurrence)
$20,000.00
. ALL OWNED AUTOS
BODILY INJURY
(Per person)
$10,000.00
❑ SCHEDULED AUTOS
❑ HIRED AUTOS
❑ NON -OWNED AUTOS
❑
BODILY INJURY
(Per accident)
$10,000.00
PROPERTY DAMAGE
(Per accident)
$10,000.00
❑
❑
GARAGE LIABILITY
❑ ANY AUTO
❑
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
AUTO ONLY: AGG
$
❑
EXCESS/UMBRELLA LIABILITY
❑ OCCUR ❑ CLAIMS MADE
❑ DEDUCTIBLE
❑ RETENTION $Enter Amount
EACH OCCURRENCE
$
AGGREGATE
$
$
$
$
li
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECU-
TIVE OFFICER/MEMBER EXCLUDED?
If yes, descnbe under
SPECIAL PROVISIONS below
30100502562109
09/11/2011
09/11 /2012
❑ WC STATU- ❑ OTH-
TORY LIMITS ER
E.L EACH ACCIDENT
$100,000
E.L DISEASE - EA EMPLOYEE
$100,000
E.L DISEASE - POLICY LIMIT
$500,000
❑
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
VGt\ t tt t I" 1 1.. „VVVV•∎
MIAMI SHORES VILLAGE BUILDING DEPARTMENT
10050 N. E. 2ND AVENUE
MIAMI SHORES, FL. 33138
----- _ --- - - - -''
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE 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 UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
a_. Awwwe, ATtA\t 4 410
ACORD 25 (2001/08)