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PL-12-2035Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 183348 Permit Number: PL -10 -12 -2035 Scheduled Inspection Date: December 27, 2012 Inspector: Hernandez, Rafael Owner: PEARSON, LEONARD Job Address: 246 NE 103 Street Miami Shores, FL 33138 -2431 Project: <NONE> Contractor: MG PLUMBING & SPRINKLER SERVICE Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060134880 Phone: (305)525 -9236 Building Department Comments REMOVE AND REPLACE KITCHEN SINK Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 180819. December 27, 2012 For Inspections please call: (305)762 -4949 Page 11 of 17 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 BUILDING PERMIT APPLICATION Permit Type: PLUMBING JOB ADDRESS: 2 4( 5-re- FBC 20 MD Permit No. 9 2. ®20 3 Master Permit No. r 12 — '263 3 City: Mi mi Shores County: Miami Dade Folio/Parcel #: NO Zip: Is the Building Historically Designated: Yes Flood Zone: OWNER: Name (Fee Simple Titleholder): 4Atati d Phone #: ° (9130 3 Address: C ceNN C , s, Rdev 6 City: / 4f cl e rdo State: Zip: 3330 Phone #: 155 lee 1 Tenant/Lessee Name: Keyi0" Email: ' •1 372 `(O l ° ( fe) 4 vI 1" ) a fan ctlyi elder, eq, e CONTRACTOR: Company Name: / y e / ' -£41 � ��.J�� ,Le c J one #: 1°57-61-2-r--72-34 Address: / 2- C.' S- U%. City: inr4,4 ' Avc B State: A-C„ , Qualifier Name: tJ zip: .33 /6 % Phone #: State Certification or Registration #: ar6 Certificate of Competency #: Contact Phone #:,, % f 2 Y �3J Email Address: f4-1-4•111$ ,ce' 4 / ®r te d- . DESIGNER: Architect/Engineer: Phone #: Value of Work for .this Permit: $ POO Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ONew 01' epair/Replace ❑Demolition Description ofWork: 12) 1 Vre_ia Si1 ******** * * * * * * * * * * * * * * * * * * * * * * * * * ** * * ** Fees************* ** * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ /00 ' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Sl Q/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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be ap roved and a reinspection fee will be charged. Signature /' % Signature ‘3"--etodifk 0 ' er or Agent The foregoing instrument was acknowledged before me this day ofOCTO J ,20 la,byL pEf 9)N , Contractor The foregoing instrument was acknowledged before me this day of Obi ,,2012-, by- lktMeS .l yct.t wl , who is personally known to me or who has produced who is personally known to me or who has produced C - As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Co as identification and who did take an oath. NOT!k$Y ' " IC Structural Review (Revised3 /12 /2012XRevised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09) Sign:, ithr ANIL CARLOS GVIENZEL otary Public - to of Florida Print:4 r4Th ' J ' n 0 978958 • My Commission Expires: Zoning Clerk 09/24/2012 18:04 9543820080 A oR °° CERTIFICATE OF LIABILI'T 1t' INSURANCE THIS CERTIFICATE IS IS ISSUED 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 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT': h pterms and condition certificate holder i, is n policies AINSURED, ii an endoesem nt, A statement on this certificate sate does not confer rights, to the • certificate holder in Ilea of such endorseent($). KEY KNOWLEDGE INS PAGE 01 Policy Number. CA -24753 Date Entered: 9 /21/2007 PATE (MMIDDIYYYY) 9/25/2012 PRODUCER REY KNOWLEDGE INSURANCE, me. 9101 -C S. W. 19TR. PLACE FORT LAUDERDALE, FL. 33324 1NSURPD M. G • gt t3MBZNG & SPRXN ! LERS SVCS . , INC , mew= TROY GORDON 1265 NW 203TH STREET NI .NI, FL 33169 jAC N MEI Pt+oN a►: (954) 392 -5259 TO,�__(95Ay 392 - 0080 .MMIL e7 sCdke3yYstowl+3dg Sias.cam _ INgUREp(S�AFFORDING COVERAdG ,_L, NAIL fl INSURERA;i,7+G7CES G6 LOIWON INSUREI? 6 : A Raend 3Cerci� —�nStu afC9 . 1110 . INSURER,CR__ _ INSURER 0 : 11�5,�7RER E 1 _ INSURER F t 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 SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANC CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �iiLl POLtZ°YRXF T TR TYPE OF INSURANCE IN 9 PODGY NUMBER __ tMMtDDt f____tMM1DDIYYYYI LIMITS GENERAL LIABIU tY EACH OCCURRENCE I a 1, 000 , 000 --7" ; COMMERCIJLGENERALUARILITY ALt21O659 9%23/2012 14/23/20.2 PREM}y^ES[ES,OCa+nbnCe} J $ _100,000 MED EXP SAnne person) S 5 , 000 CLAIMS-MADE ` ' OCCUR - t31rD10(}O AO]? PERSONAL &ADVINJURY S1 r 000, 000 '— GENBRALAGGREGATE s2, 000 r 500 • PRODUCTS - CQMPICPAGG 52,000, 000 GER L AGGREGATE LIMIT APPU E9 PER: — PRC• j� $ POLICY I I IN LE LiMI SN/A AuTOtaOBILELiABILITY CA-24753-11 A/23/2O12 9/23/2013 s50, 000 73 ANY AU BODILY INJURY (Per aCCldent) $100 , 000 PR TY OApTAnE .... L 50, 000 5 L:CCichairt) ya sI. 4Y INJURY (PM person} r' Y TO AALLOOYSNNE(I . SCHEDULED AUTOS FARED AUT )S AUTOS EX DED50q CO DED 50 0 UMDRELLA OAS I I OCCUR EXCESS LIAR CLAIMS -MADE DED I IRETENTION_S MAKERS CDMrrENSAT1 ©N AND EMPLOYEF S' UABILT Y Y1 N ANY PROPRIETC.FJPARTNERIEXECUTIVE ri (A FICER/NIEM NM} LUDE07 If yes, describe under DESCRIPTION CIF OPERATIONS below NIA N/A N/A EACH OCCURRENCE AGGREGATE s _ 5 WC $TATU- 071-1- _, ZO.5Y.41MItS I J. ER _.. E.L. EACH ACCIDENT S ,,, _ E.L. DISEASE- EA EMPLOYEE $ E•L DISEASE.. POLICY LIMIT $ DESCRIPTION OF OPI RATION; t 6QCAT10NS ! VEHICr•01 tAR1IeA ACORN 191, Adaltlenal Remarks SrheGUle, It mom epas• is rowing') RESIDENT'TAL AND COIiRCIAL PLt NBING CONTRACTOR CERTIFICATE I10 LDER y SHORES VT i,AGkt 10050 N.E. 2ND AVENUE MIAMI S)iCtE8, !:'L. 33138 3D5- 756 -a?972 ATP; VIV2AN CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTiOE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MARIA A. EctAL6, ,ADEN? 01988..2010 ACORD CORPORATION. All rights reserved. ACORP 25 (2010105) The ACORD name and logo ere registered marks of ACORD Produced uRing Forme Boss Pius sot were. ww4.FCnnaBo:.e.cont; Impmssi4e PLONIFt ing 800.2018.14177 NOV -02 -2012 11:55 From: 3056512429 To:1 800 685 7530 P.1/1 IHISDOCI MENT`HA. A! (_L{1HF,1[T.;lA' h'G:IiiOU{ U`t di1lCR t)PRINTI".•;,•LINI;';lARK" 'PATENTED PAPER :# ' .. 6.1.s . use 3:. s . 5.. . STA'TE.OF FLORIDA. DEAR OF• • 8 SXi S ' S � PRppF •. :'I�+UM TIS 4 r9I4 IISTRY .IAX: EATb7 wC LATION SEQS# L12070700184 The Puncersd robrricisturott f ' " warned be m' IS CE'RTIFIFIV • fl 'Odder the .provisiOne s •,Chapt Expiratign ,date: AUG. 31, 2014114,2:11r '. 1 1 • & G Pl ING . S'P O • 'LER SER. MIAMI FL 33169 .,� ' ' "- 1265 203' S T TTCRti .SCOT'; • QQOR DISPLAY AS REOLORED BY LAW Mt *Ism SS ARY r TAX UM !AL > LLOC/0 ' 1MUU% FL 33130 2012 LOCAI. BUSINESS TAX RECEIPT 3D13 FDADE COUNTY - STATE OF FLORIDA 13XPOIES SEM 30} 2013 Jlrusr S DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 3,10 587193 -5 TH:SSNoTADa.L- DONoTPAY RENEWAL g�LfW PRINKLER SERVICE STATE '6920 pW3 33169 MIA$X GARDENS IrIG PLUMBxte & SPRINKLER SER INC ser1WROAVING CONTRACTOR 1=14,111144CEEM Noma TO VICLATE WATING av�1O, v O" COUNTY OR aTIg . vw� 07/19/2012 60000000139 000045.00 SEE mum 5Io • WORKER /S • 1 DO NOT FORWARD MNC PLUMBING & SPRINKLER'SERVICE MERVIN GORDON PRES 1265 NW 203 ST MIAMI GERDENS DR FL 33169 FOIST•CLASS U.S. POSTAGE PAID Ft- P� O 1 612435 -0 J0 11F►if)1;11if1 114ll ��>� �l�r� i,��il�,l�l�ll���1�1 ,1 j JAIL, $A -re H NUMBER L CENSE NHIt,,°`- IM_ S `"'' + 07 07 203.2 1104 908 ..: CF Ds:692 :__ -_ -- E ► � • The Puncersd robrricisturott f ' " warned be m' IS CE'RTIFIFIV • fl 'Odder the .provisiOne s •,Chapt Expiratign ,date: AUG. 31, 2014114,2:11r '. 1 1 • & G Pl ING . S'P O • 'LER SER. MIAMI FL 33169 .,� ' ' "- 1265 203' S T TTCRti .SCOT'; • QQOR DISPLAY AS REOLORED BY LAW Mt *Ism SS ARY r TAX UM !AL > LLOC/0 ' 1MUU% FL 33130 2012 LOCAI. BUSINESS TAX RECEIPT 3D13 FDADE COUNTY - STATE OF FLORIDA 13XPOIES SEM 30} 2013 Jlrusr S DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 3,10 587193 -5 TH:SSNoTADa.L- DONoTPAY RENEWAL g�LfW PRINKLER SERVICE STATE '6920 pW3 33169 MIA$X GARDENS IrIG PLUMBxte & SPRINKLER SER INC ser1WROAVING CONTRACTOR 1=14,111144CEEM Noma TO VICLATE WATING av�1O, v O" COUNTY OR aTIg . vw� 07/19/2012 60000000139 000045.00 SEE mum 5Io • WORKER /S • 1 DO NOT FORWARD MNC PLUMBING & SPRINKLER'SERVICE MERVIN GORDON PRES 1265 NW 203 ST MIAMI GERDENS DR FL 33169 FOIST•CLASS U.S. POSTAGE PAID Ft- P� O 1 612435 -0 J0 11F►if)1;11if1 114ll ��>� �l�r� i,��il�,l�l�ll���1�1 ,1 j Nov. 2. 2012 2:18PM No, 4301 •LU -P. 1/1 OP ID: GC ddit 6 ibr CERTIFICATE OF LIABILITY INSURANCE 1 °ATE( "'� 11/02/1 2 THIS CERTIFICATE IS 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certlflcate holder Is an ADDITIONAL INSURED, the pollcy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the polity, certain policies may require an endorsement. A statement on this certlflcate does not confer rights to the certificate holder In lieu of such endor'ement(s). PRODUCER Workers Compensation Group P0 Box 410 Boca Raton, FL 33429 -0410 Workers Compensation Group INSURED M.G. Plumbing & Spri4ler Sery 1265 NW 203rd St Miami, FL 33169 Phone: 561 - 392 -3300 Fax: 561 - 361 -1132 NNAME CT Greg Carignan PHONE c No, Ertl: 5614924300 ADRESS: certs(wrorkerscompgroup.com I (FAac, No): 561361 -1132 INSURER(S) AFFORDING COVERAGE NAIC INSURERA: Castlepoint Florida Ins Co 13599 INSURER B : INSURER C : INSURER D : INSURER E : INSURFR F : COVERAGES • THIS IS TO CERTIFY THAT THE POLICI INDICATED. NOTWITHSTANDING ANY CERTIFICATE MAY BE ISSUED OR MA EXCLUSIONS AND CONDITIONS OF SUC S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD EQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, POLIC ES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL iNCR SUBR wvn POLICY NUMBER POLICYEFF (MMIDOIYYYYI POL)CYEXP (MM/DDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY $ 1 CLAIMS -MADE OCCUR $ $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: —I PRODUCTS - COMP /OP AGG $ POLICY I I ,PjFpOT 1-7 LOC $ AUTOMOBILE _ _ LIABILITY COMBINED SINGLE LIMI f (Ea accident) $ ANY AUTO ALL AUTOS HIRED AUTOS _ AUTOS NON-OWNED BODILY INJURY (Per person) $ BODILY BODILY INJURY (Per accident) $ TOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB 1 OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED 1 I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N / A WCP 760535402 10/12/12 10/12/13 WC STATU ( OTH x I TORY LIMITS I I ER OP ?ECUIIVE D OFFICER/MEMBER EXCLUD D (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below E.L. EACH ACCIDENT $ 100,00C E.L. DISEASE - EA EMPLOYEE $ 100,00C E.L. DISEASE - POLICY LIMIT $ 500,00C DESCRIPTION OF OPERATIONS / LOCATIONS I VEHI( LES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) •CDTICIf•ATC uni nrs MIAMIS3 Village of Miami Shores 10050 NE 2nd Ave. Miami Shores, FL 33138 LATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) @ 1 988 -201 0 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD