PL-14-0222PV
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 206723 Permit Number: PL -2 -14 -222
Scheduled Inspection Date: February 12, 2014 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: MICHAEL & CYNTHIA KOVENSKY, Work Classification: Repair
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Job Address: 534 NE 92 Street
Miami Shores, FL
Project: <NONE>
Contractor:
BERGERON PLUMBING INC
tiunamg uepartment Comments
PLUMBING GAS VENT INSPECTION
Phone Number
Parcel Number
INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction .,, A
Needed ❑
Re- Inspection ❑
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
M
ILX i s ')/ I—
1132060141180
Phone: (561)445 -2115
February 11, 2014 For Inspections please call: (305)762.4949 Page 25 of 39
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Miami Shores Village
Building Department
90050 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
r- cEC�rv�;ra
FEB 02014
BY:
FBC 20 10
Permit No. P L, 1 4
�.
Master Permit No. 1 S °Za i ` Q1
JOB ADDRESS: `''� Y y4 E cl 2 aal. CT
City: Miami Shores County: Miami Dade Zip: 3 313 S
Folio/Parcel #: 9-3266-0111-1186
is the Building Historically Designated: Yes
NO 9 Flood Zone:
OWNER: Name (Fee Simple Titleholder): /.y/ /e#.RzL- 21 Vj rX Phone#: / 7LYA 511
Address: 5614 N C1 Z 'j' 5-r
City: � AM; �5kl o Statue: C—
TenantUsseee jName:
Email:J1'Ol%�/%s�'®"�/J!> cor%
CONTRACTOR: Company Name: bergeron plumbing inc Phone#: 561- 445 -2115
Address: 5562 aspen ridge cir
City: delray beach State: florida 33484
Qualifier Name: david bergeron Phone#:
State Certification or Registration #: cfc1427568 Certificate of Competency #:
Contactphone#: 51- 445 -2115 Ema;lAddress: bergeronplumbing @hotmail.com
DESIGNER: Architect/Engineer. Phone#:
Value of Work for this Permit: $ 5 120, ®6 Square/I.ffiear Footage of Work:
Type of Work: OAddress ❑Alteration ONew ORepair/Replace ODemolition
Description of Work: i°lvMB//i%�Y (T -.49
Submittal Fee $ Permit Fee $ f Uv s -'- CCF $ CO /CC $
Scanning Fee $
Radon Fee $
Notary $ TraininglEducation Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
IJ 1.9 .,
Bonding Company's Name (if applicable) Al
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
zip
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 appyoved and a reinspection fee will be charged.
Signature l°® Signs
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this
day of , 20t, by &jdd'NM
who is personally known to me or who has produced —r—j—, L>L
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission
APPROVED BY
JILL S. TULLY
MY COHMISSION #EE43885
EXPIRES: NOV 21, 2014
Bonded through 1 st State Insurance
The foregoing instrument was acknowledged before me this*
day of QI) , 20 �, by �Av��alef�' n
who is personally known to me or who has produced-Ea DL
as identification and who did take an oath.
ex)? /i i
NOTARY PUS:
(61 y Plans Examiner
Structural Review
(Revised311=012)(Revised 07 /10/On(Revised 06/10=W)(Revised 3115/09)
Sign:
Print
r "Ime, Notary Pub - State of Florida
My Commission �� My Comm. �m Mar 25, 2016
� Commission #F EE 182713
Zoning
Clerk
DAVIDDI OP ID: MN
,4% °'- CERTIFICATE OF LIABILITY INSURANCE
01r
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 pollcypes) 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 Hsu of such endorsement (s).
PRODUCER Phone: 561-27"221
The Plashidge Agency -DSO Fax: 561 276 -5244
820 N.E. 6th Avenue
Delray Beach, FL 33483
CA0,N,TA:CT
P Fff
No:
Mr.
Michael Bottcher
INSURER( AFFORDING COVERAGE
NAIC /
EACH OCCURRENCE
INS1atERA:Old Dominion Ins.
40231
$ sue,
INSURED Bergeron Plumbing Inc.
5562 Aspen Ridge Circle
Delray Beach, FL MINI
muRERs:Progressive Express Ins. CO.
10193
INSURER C:
GENERAL AGGREGATE
$ Z,000,
INSURER D :
PRODUCTS - COMPIOP AGG
INSURER E:
$
INSURER F :
AUTOMOBILE LIABILM
ANY AUTO
ALL X AUUTTOS
X HIREDAUTOS X AUTNOOWNED
COVERAGES CERTIFICATE NUMBER, RF -QlnM IJIIMRCD-
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 BY PAID CLAIMS.
L
TYPE OF INSURANCE
POLICY NUMBER
pREDpULCED
M10
kW4M
LIMITS
A
Geaum LIABILITY
X COMMERCIAL GENERAL LIABLITY
CLAIMS -MADE a OCCUR
MPGM96
0//2212014
01122/2015
EACH OCCURRENCE
$ 1,000,00
PREMISES (Ell oaurrence )
$ sue,
MED EXP (Any one person)
$ 10,00
PERSONAL & ADV INJURY
$ 11000,
GENERAL AGGREGATE
$ Z,000,
GEN1. AGGREGATE LIMIT APPLIES PER:
POLICY PRO- LOC
PRODUCTS - COMPIOP AGG
$ 2,000,
$
B
AUTOMOBILE LIABILM
ANY AUTO
ALL X AUUTTOS
X HIREDAUTOS X AUTNOOWNED
021116180
04/011 2013
0410112014
COMBINED NGL MT
(Es accident)
$ 1
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
P1�e �MD AG
$
$
UMBRELLALIAS
LUIS
OCCUR
CLAIMSMADE
EACH OCCURRENCE
$
REXCESS
AGGREGATE
$
IDED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIEfOR1PARTNERIEXECUTIVE
OFRCERIMEMBEREXCLUDED? El
(MandalwyInt)
It yyes describe under
DESCRIPTION OF OPERATIONS bslmv
NIA
W STA U- OTH-
TO LI ITS ER
E.L. EACH ACCIDENT
$
E.L. DISEASE -EA EMPLOY
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddiHornd Remarks Schedule, K more space Is required)
AX: 305 - 756 -8972
MUIMISI
Miami Shores Village
Building Department
10050 NE 2nd Avenue
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORS REPRESENTATIVE
- 13 �
rinhta raaarvad
ACORD 25 (2010005) The ACORD name and logo are registered marks of ACORD
ANNE M. G A N N O N P.O. Box 3353, West Palm Beach, FL 33402 -3353 "LOCATED AT*
CONSTITUTIONAL TAX COLLECTOR www.pl CWX -COm Tel: (561) 355-2264 5562 ASPENRIDGE CIRCLE
Serving Palm Beach County DELRAY BEACH, FL 33484
Serving you.
TYPE OF awpa S OWNER CERTIFICATm # I RECEIPr # IDATE PAID AMT PAID I BILL #
I .,- Cb^M nA%An Utf34AF{ CFC1427M I 813 .1344719 -07MM3 $27.50 I B4017QOa5
This docwmed IS valid Only when receipted by the Tax Collector's Office.
BERGERON PLUMBING INC
BERGERON PLUMBING INC
5582 ASPEN RIDGE CIR
DELRAY BEACH, FL 33484 -2582
STATE OF FLORIDA
PALM BEACH COUNTY
2013/2014 LOCAL BUSINESS TAX RECEIPT
LBTR Number. 200819386
EXPIRES: SEPTEMBER 30, 2014
This receipt VIM the privIlege Of er>gaging In or
managing any bteiress profession or occupation
within its jurisdiclion and MUST be conspicuously
displayed at Ute place of bushtess arid In such a
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Mi
- - IMPORTAW '
STATE CFF.%ORDA... Ir patVand to Chapter 440.05(14), F•S., In officer of a MPoratlon who
O alaW ex on from tads by filing a to tificete of auction
tp t botef� s or cmVmsffdcn under Ill
Comm-trio TRY L wmW this section n" not recover
T t 0 B APT FROIti OI�O/►
CMMFrA IRATIf DATE: 03/30/20'14 Forsuett to Chapter 440.05(13), F.S., Cardito tes of elacdon to be
�Tivt 03/30/2012 EV H exempt- "Ply Way within to scope of the bushusce or trade listed
PERS; DAVID M BERGERM E the nofm of alwdon to be exonPL
FEft 261941395 R 41!0.05(13), FS. N of ekwdaa to he exam-
E Fu sulfft.. Cif stodi be s�slact to revo+ i
ASS NAME AND ADDRESS: toed CmttftMW of eied1m to be exempt
BMW OM Rum= 91c if, at any tans after the fiiW of the notice or the issuance of *8
asaz Affi�7 C6tC1E certificate, do polo teemed on tto notice or certifinette no I014W
oaw,v WAM FL 33"4 the r� Of ibis SOCI for is�ance of a cartifu�a The
delovont shall revoke a cardfICOto at MW tam for failure of the
`
person noted on the cmtiflcm to nasal the requkententit of this
SCOPE OF BUSINESS OR TRADE won M*STOW (850) 413-
t- PLtad M KOC AM ORWM