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PL-13-2218Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 200209 Permit Number: PL -10 -13 -2218 Scheduled Inspection Date: October 10, 2013 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Typ , _ Owner: Work Classification: Addition /Alteration Job Address: 186 NE 109 Street Miami Shores, FL 33161- Project: <NONE> Phone Number Parcel Number 1121360090090 Contractor: R&I PLUMBING SERVICES CORP Phone: 305 -823 -6911 comments NEW SINK AND DRAIN INSPECTOR COMMENTS False Inspector Comments Passed Ef- Failed Correction ❑ Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. October 09, 2013 For Inspections please call: (305)762-4949 Page 11 of 22 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 11111JI11 1 1 PERMIT APPLICATION Permit Type: PLUMBING OCT 01 2W FBC 20 Permit No. I� Master Permit No 13 ::: 16 JOB ADDRESS: 1 k � l) -e o QI 51 City: Miami Shores County. Miami Dade Zip: Foho/Parcel#: Is the Building Historically Designated: Yes NO Y Flood Zone: OWNER: Name (Fee Simple Titleholder): Phone #: Address: / 41-4!! I City: /yol! ys..yb4. State: zip: Tenant/Lessee Name: Phone #: Email: CONTRACTOR: Company Name: 9. J' -Z P7 ut'j �✓ 74 Phone #: 3 0 _S , .5;L 12 Address: /.W � w 17q 7'e d./& -- /-- City: f -c /0 %+ State: 1� Zip: 33 Qualifier Name: 2 -el t 6-v7z -)I y1 Phone #: State Certification or Registration #: D 3)9 -- b h 6 b 7 41 Certificate of Competency #: Contact Phone #: 325 Sits �l'7 Email Address: DESIGNER: Architect /Engineer. Phone #: Value of Work for this Permit: $ W , c` Square/Linear Footage of Work: Type of Work:. DAddress OAlteration ONew JlRepair/Replace ODemolition Description of World: Submittal Fee $ Permit Fee $� ® S cj' ® CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) _ Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Zip Application is hereby made to obtain a permit to do the work and installations as indicated I cer* 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 EMPROVEMENTS 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 g Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this____ day of C-20 L*, by !Z>1 day of 20 , b, It el e J�uz?-tyq who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. NO Y PUBLIC: Sign :,_.,�_ Lk Print. 1 a My Commission Expires: APPROVED BY as identification and who did take an oath. NOTARY PUBLIC: Print: JANICE AIMEE MATOS My MY COMMISSION #FF011193 EXPIRES April 23, 2017 ® @­2_­1,') Plans Examiner Structural Review (Revised3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) COMMISSION # EE 105391 EXPIRES:JUNE21,2015 WWW,AARON NOTARY com Zoning Clerk Miami shores Village Building Department CONTRACTORS' REGISTRATION 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION JEITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: BUSINESS ADDRESS: 21106 Al at 1 74 14—w; CITY 14 t & [e-0-44 STATE I—' f ZIP CODE UP r BUSINESS PHONE: ( 1'�) ' gZf - T 17 FAX NUMBER (_—) CELL PHONE ( ) QUALIFIER'S NAME: &0_ 4, 4,) QUALIFIER'S LIC NUMBER: 05P 7 2)0M_7 E -MAIL ADDRESS (IF APPLICABLE): %� �� ,�''ht f L a Created on 3119109 BY MLDV 1 RV 3126109 MLDV 1 RV 6127111 AS 5.? �,;rPS I- - - GUZMAN,RENE INDIVIDUAL 7898 NW. 174TH TERR. MIAMI LAKES FL 33015 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.myfloridallcense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn 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! �ftt Fl9Bl1� ^D ?? (850) 487 -1395 The Department of State is leading the commemoration of Florida's 500th anniversary in 2013. For more information, please go to www.VivaFlorida.org. DETACH HERE STATE OF FLORIDA LENT OF BUSINESS AND PROFESSIONAL REGULATION :ONSTRUCTION INDUSTRY LICENSING BOARD 0 RICK SCOTT ISSUED: 09/08!2013 SEQ # L1309080002688 KEN LAWSON RF0067119 The PLUMBING CONTRACTOR - Named below HAS REGISTERED e Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2015 (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANYAREA) GUZMAN,RENE INDIVIDUAL 7898 NW ' 174TH TERFL MIAMI LAKES FL 3301.E VIVA RORIPA', RICK SCOTT ISSUED: 09/08!2013 SEQ # L1309080002688 KEN LAWSON im", 500765 -3 THIS IS NOT A 6u _L - 130 NOT PAY BUSINESS NAME / LOCATION R & I PLUMBING SERVICES CORP 7898 NW 174 TERR 33015 UNIN DADE COUNTY OWNER R & I PLUMBING SERVICES CORP X196 PLUMBING CONTRACTOR THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IY DOES NOT PERMT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONWO LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE RENEWAL NO. 522894-5 CC * 03P000074 WORKER /S 1 HOLDER FROM MY R & I PLUMBING SERVICES CORP PERMIT Oft LICEM REQUIRED BY LAW. THIS IS RENE GUZMAN PRES NOT A THE HOLDERS QUALIRCA-A- 7898 NW 174 TERR TIOP1& MIAMI LAKES FL 33015 PAYMENT RECEIVED M" -OADE COUNTY TAX COLLECTOR: ' 09/11/2012 09010251001 000075.00 214 SEE OTHER SIDE {u I f t tf it s iat i feel LL sit f a tsseit t itt at 00 '10020o0 ' 1009000IZz0 nozrtz�('sTw Xv.LM m 5102£ IA S3XVI IWVIN SH31 bLI MN 868L S321d NVWttll3 3N321 eq W st + d2103 S33IA83S 9NIBWf11d I v N kP n14 �PlOal amvma0:I tON Oa S311Iltldl3lHnw in iCTI N 174 TER FL =IS-3 6r .� w. JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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. EFFECTIVE DATE: 3/28/2013 EXPIRATION DATE: 342842015 PERSON: GUZMAN RENE FEIN: 611433275 BUSINESS NAME AND ADDRESS: R & 1 PLUMBING SERVICE COI 7898 NW 174 TERRACE HIALEAH FL 33015 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pursuant to Chapter 440.05(14), F.S., an of er of a corporation who elects exemption from this chapter by fling a tie of election undertlris section may not recover benettis or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., CaVicates of dectfort to be exempt... apply only within the scope of the business or trade Bled 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 shall to subject to revocation ff. at anytime after the fffM of the notice orthe isstarice of the carlillcate, the person named on the notice or ce Plicate no longermeets the requ[rements of this sec SorrforTssuartce of a cmMicate. The department shall revokee certillicate at anytime forfai ure of me person named on the certificate to meet the requirements of this section. DFS- F2 -DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07 -12 QUESTIONS? (850)413 -1609 CERTIFICATE OF LIABILITY INSURANCE DAT 09 /21/13YYY) 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 certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WANED, 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 World Of Insurance Agency 18600 NW 87 Ave Unit 113 CONTACT NAME: PHONE Ext: (305) 231 -1111 F c No: (305) 231 -0711 MAIL worldofinsuran@att.net INSURERS AFFORDING COVERAGE NAIC # Miami Lakes, FL 33015 INSURER A: SECURITY INSURANCE Phone (305) 231 -1111 Fax (305) 231 -0711 INSURED INSURER B: INSURER C: $ R & I PLUMBING SERVICE CORP INSURER D: 7898 NW 174 TARRACE INSURER E: Miami Lakes, FI 33015 305 INSURER F: $ 1,000,000.00 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 BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AODL INSR UBR WVD POLICY NUMBER POLICY EFF MM1D POLICY EXP MMID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO PREMISES (RENTED occurrence) $ 1,000,000.00 © COMMERCIAL GENERAL LIABILITY MED EXP (Anyone person $ 1,000,000.00 A F] ❑ CLAIMS -MADE © OCCUR ❑ GL- 37683 -1 08/0712012 08/07/2014 PERSONAL & ADV INJURY $ 5,000.00 El GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP)OP AGG $ 2,000,000.00 $ ❑ POLICY ❑ PROT- ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMB a accident BODILY INJURY (Per person) $ ❑ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS NON-OWNED ❑ HIRED AUTOS ❑ PRO r acExidenDAMAGE $ $ ❑ ❑ ❑ UMBRELLA LIAR ❑ OCCUR EACH OCCURRENCE $ AGGREGATE $ ❑ EXCESS LIAR ❑ CLAIMS -MADE ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) ❑ N 1 A WC STATU- OTH- RY LIMIT ❑ ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) BUILT BY DESIGN 5800 SW 84 STREET MIAMI ,FLORIDA 33143 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND MIAMI SHORES FLORIDA 33138 AUTHORIZED REPRESENTATIVE I_ JORGE CASTILLO C 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) QF The ACORD name and logo are registered marks of ACORD