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PLC-11-1770Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 164865 Permit Number: PLC -9 -11 -1770 Scheduled Inspection Date: January 18, 2012 Inspector: Hernandez, Rafael Owner: Job Address: 10500 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: A CAPITAL PLUMBING LLC Permit Type: Plumbing - Commercial Inspection Type: Final Work Classification: Gas Phone Number Parcel Number 1122300010500 Phone: (786)346 -5020 Building Department Comments EXTENDED EXISTING GAS LINE 30 FEET Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Ai° 64)ark C 11° ‘' Piefrnf �1. January 17, 2012 For Inspections please call: (305)762 -4949 Page 13 of 49 (441 \`)0V BUILDING 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. C 1 I Z° PERMIT APPLICATION FBC 20 FTE D SEP w7CO11 Master Permit No. Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): 3f'/ 1 C' 5 /9 f r,JC7ne rAlofc'l Phone #:� — li S `° 0 Address: j03O0 R /5CGyie R /LCD, City: , i vh: t $ b 0 P eJ State: FL Tenant/Lessee Name: AV 13)-L Email: Zip: 3 3/ -7$' Phone #: JOB ADDRESS: / G 5 O C e; 5 C City: Miami Shores County: Miami Dade zip: 3 3/ 3 3' Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: �Q ' fG � / /�/d'7 6���/ e� Phone #: 7 g w. -3 414 o 2 0 Address: ?'Z /(/ C ?I` b 5 f. City: ; Ot phi State: fC Qualifier Name: To'f erA Of ;fie State Certification or Registration #: t 2 7 �/ 3 1, S� Contact Phone #: .E Zip: 3 -7/7 Phone #: 7 ' - 34(6 -3-0 2 0 C , G Lf Certificate` of Competency #: Email Address: AG A/J /749/0 IC /11', 6i , �/ 47'044'6°' G G s� DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ //FC7(7° a 0 Square/Linear Footage of Work: 3 0 re e 74 Type of Work: ❑Address Ly'Alteration UNew ❑Repair/Repglace ❑Demolition Description of Work: r X - el') CJ` e 0/ F /^g S L I. i? e -f reef. ******** * * * * * * * * * * * * * * * * *** * * * * *** * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ ` Permit Fee $ /dd CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 546#0 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 will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contractor The fore oing instrument was acknowledged before me this 1'7-- The foregoing instrument was acknowledged before me this , day of c`; , 201 ‘ , by L• . v Po °Yr:0 $S z- who is personally known to me or who has produced `1` (--1 1 As identification and who did take an oath. as identification and who did take an oath. ���w11u/sroi�® NOTARY PUBLIC: NOTARY PUBLIC: `\�\\����, c, S i I ye", 'i,,,,/ ', ' own to me or who has produced 0, , t lnf S3a1dXa �> !„ . : oII�a' �'NOISStWVVOa ooNnr 0/10008 "' APPROVED BY •.� (Revised 07 /10 /07XRevised 06 /10/2009XRevised 3/15/09) Sign: Print: 08\1, wot My Commission Expires: d;° COW pp165901 ..... O via 4IE OF /„,' Plans Examiner Zoning Structural Review Clerk • 'L' CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 09/26!11 rvTHIS C RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ,CERTIF)CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ?BELO THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. —IMPORTANT: If the certificate holder is an ADDITIONAL. INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER nsurance Masters Agency, Inc. 14610 NE 6th Avenge Suite 4 vorth Miami, FL 33161 'hone (305)949 -0099 Fax (306)944 -9933 p MGT PHONN Ext): (305)949 -0099 (A . No); (305)9449933 ADO ESS: insurancemasters@bellsouth.net INSURER(S) AFFORDING COVERAGE NAIL it INSURER A: ASCENDANT INSURANCE CO NSURED 4 Capital Plumbing LIc )2 NE 49 Street MIAMI, FL 33167- 305 INSURER B : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER C • MED EXP (Any one person) INSURER D: PERSONAL & ADV INJURY INSURER E: I INSURER F : $ 300,000.00 E NUMBER: REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1 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 BY PAID CLAIMS. IN R' TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF (MM/DO/YYYY) 06/02/2011 POLICY EXP (MM/DD/YYYY 06/02/2012 LIMITS EACH OCCURRENCE $ 300,000.00 I A ' GENERAL LIABILITY !—, k • ,/' OOMMERCIAL GENERAL LIABILITY ,_ A CLAIMS -MADE V OCCUR TTT GL- 37418 -0 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 300,000.00 I GENERAL AGGREGATE $ 300,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: — POLICY ❑ JEU ❑ LOC PRODUCTS - COMP /OP AGG $ 300,000.00 ; $ AUTOMOBILE LIABILITY J ANY AUTO --1 ALL OWNED ggCHEDULED AUTOS ❑ AUTOS NON -OWNED -7 HIRED AUTOS AUTOS ❑ I 1 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ j UMBRELLA LIAB ❑ OCCUR _� EXCESS LIAB ❑ CLAIMS-MADE I EACH OCCURRENCE $ AGGREGATE $ J DED ❑ RETENTION $ $ -1— WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PRQPRIETOR/PARTNER/EXECUTIVE N / A r-� WC STATU- OTH- ❑TORY LIMITS ❑ ER E L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ SCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) P UMBIN RTIFICATE HOLDER MIAMI SHORES 10050 NE 2ND AVE MIAMI SHORES, FL 33138 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIO AUTHOR PRESENTATIVE ACORD 26 (2010/06) OF -1 © 1988-2010 ACORD CORPORATIOIVvAII rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. 02 -22 -2011 EFFECTIVE DATE: PERSON: FEIN: 02/22/2011 EXPIRATION DATE: 02/21/2013 MORISSEAU JOSEPH 262624054 BUSINESS NAME AND ADDRESS: A CAPITAL PLUMBING LLC 82 N E 49TH ST MIAMI FL 33137 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED PLUMBING CONTRACTOR * IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shell be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 02/22/2011 EXPIRATION DATE: 02/21/2013 PERSON: JOSEPH MORISSEAU FEIN: 282624054 BUSINESS NAME AND ADDRESS: A CAPITAL PLUMBING LLC 92 N E 49TH ST MIAMI, FL 33137 SCOPE OF BUSINESS OR TRADE 1- CERTIFIED PLUMBING CONTRACTOR IMPORTANT O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt. R E Pursuant to Chapter 440.05(13r F.gt, Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. CUT HERE QUESTIONS? (850) 413 -1609 * Carry bottom portion on the job, keep upper portion for your records. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 MORISSEAU, JOSEPH A CAPITAL PLUMBING LLC 92 NE 49TH ST MIAMI FL 33137 Congratulations) With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE STATE Of FLORIDA AC# 5330222 EPOTMENT ifteolUSUitst AND PR•PESSI.ONAL REGt ;ATXON CFC1427913` 11/0 10 loft) 2912 2 } CE TIF.IED PLDI 'INGrP CONTRACTOR MCRIS'SEAU, : r7OSEPH A:: CAR 'IVAL PLUMBING LLC IS CERTIFIED under the pro idiom of Ch.489 Fs iaeiok-4 44 AIIG` 3 JA01.2 ' a,01 ,$'4010 -17' L CEN E :NB The ,PLUM'BIN6 N RACTOR Uamed be :ow i . `,( ERTIFIED nder the ptebiasiona at Chap; Expiration dates AUG 31, 2012; ONAL .eREG JLATION .. IN Q: BOA'( Lyj,114010*t