PL-13-2373Miami 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: pos) 762.4949
BUILDING
PERAUT APPLICATION
Permit Type: PLUMBING
OCT 2®13 l
FBC 20 LO
Permit No. �
Master Permit No. -I
JOB ADDRESS: 2
City: Miami Shores County: Miami Dade Zip: 33 ! (o r
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone: A/
OWNER: Name (Fee Simple Titleholder): ��b��"r �b a k� •°. Phone#: LY/S) 97 7 r
Address:_ 5 i S C -�gA e. -(7(VJ 41L
City: � 6� & State. FL Zip: ,?(3 r
Tenant/L,essee Name: Phone#:
Email: 0— cLS a1 -ceM
CONTRACTOR: Company Name: 1 hone #: ®—
A d d r e s s : 9rA y � ( , u 1 i i A,/
City: _r(
Qualifier Name:
-- rf Zip:
State Certification or Registtntion #: C IL C_ e"
Contact Phone#• Email Address:
DESIGNER: ArclunWringmeer: Phone #:
Value of Work for this Permit. $ �� 0 0;j " � Square/Linear Footage of Work: 1 2-5 58 '4
Type of Work: OAddress UAlteration ONew �cpair/Replace ODemolition
Description of Work: c�_ k-!
Submittal Fee $ Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Traintng/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ J,21 la
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
/l/
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
EAPROVEMENTS 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 ab ence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Owner or Agent ontractor
The foregoing instrument was acknowledged before me this The foregoing instrument acknowled ed before me this
day of L.1 .20 by day of U�1 .20 by '� 67- G (1Ti ri-
who is personally known to me or who has produced who is personally known to me or who hat produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: 1111► ►►►►,► /
Arl
Sign: A a
NOTARY PUBLIC:
Sign:
Print ' -�' `�� yid O� �' '
Print:
My Commission Expires: My C
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APPROVED BY Plans Examiner
Structural Review
(ReAsed3 /12012)(Revised 07 /10 /07XRevised 06 /10/2009)(RvAsed 3/15/09)
Zoning
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. , OPY 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 jETTHER 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: Lk C k f<��iL—T- W v -v`
BUSINESS ADDRESS: Li)
STATE ZIP CODE
BUSINESS PHONE: L36 ) FAX NUMBER L) 2-S y i -I S 6
CELL PHONE L2 04 QUALIFIER'S NAME: —f � alflcV`
QUALIFIER'S LIC NUMBER: (o f c- C � L �S- 10
E -MAIL ADDRESS (IF APPLICABLE):
Created on 3119109 BY MLDV / RV 3126W MLDV 1 RV 6127111 AS
i l ' A
L ClIM r
v L_ %41r Jj.LCU r-3 lU -L!1 d3
DATE BATCH NUMBER LICENSE NBR
07 31 2012 128024845 CFC1427510
me YLUMB.LNG CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2014
002846
GUTIERREZ, WALTER A
WALTER PLUMBING CORPORATION
4054 SW 113TH AVE
MIAMI FL 33165
DISPLAY AS REQUIRED BY LAW
RICK SCOTT
GOVERNOR
Local Business Tax Receipt
Miami -Dade County, State of Florida
—THIS IS NOT A BILL — DO NOT PAY
6121131
BUSINESS NAME /LOCATION
WALTER PLUMBING CORPORATION
4054 SW 113 AVE
MIAMI FL 33165
OWNER
WALTER PLUMBING CORPORATION
Worker(s) 1
j 11
RECEIPT NO. EXPIRES
RENEWAL SEPTEMBER 30, 2014
6384093 Must be displayed at place of business
Pursuant to County Code
Chapter 8A — Art. 9 & 10
SEC. TYPE OF BUSINESS
196 SPECIALTY PLUMBING CONTRACTOR PAYMENT RECEIVED
CFC1427510 BY TAX COLLECTOR
$75.00 08/16/2013
ECHECK -13- 005960
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license,
permit or a certification of the holders qualifications, to do business. Holder must comply with any governmental or
nongovernmental regulatory laws and requirements which applyto the business.
The RECEIPT N0. above must be displayed on all commercial vehicles Miami —Dade Code Sec 8a -276.
For more information, visit www.miamidade.aov/taxcollecter
KEN LAWSON
SECRETARY
THIS DOCUMENT HAS A COLORED BACKGROUND - MICROPRINTING s PAPER
i AC # 623.7276 STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD SEQ# L12073102554
DATE - LICENSE NBR
07/31/20121128024845 CUC1224638
The UNDERGROUND UTILITY & EXCAVATION CO
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2014
GUTIERREZ, WALTER _A
WALTER PLUMBING CORPORATION
4054 SW 113TH AVE
MIAMI FL 33165
RICK SCOTT
GOVERNOR
DISPLAY AS REQUIRED BY LAW
KEN LAWSON
SECRETARY
A C J:Y® CERTIFICATE OF LIABILITY INSURANCE
�..i -'"
DATE 10 /1 I/201 YY)
10/18/2013
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
REPRESENTATNE 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 endomement(s).
PRODUCER
A&A Underwriters, Inc.
8796 SW 8 St
CONTACT
NAME: PABLO M CONDE
PHON 305 -220 -7447 FNC Ne ; 305 - 220 -4821
@aaunderwdters.com
ADDRESS: pmc@aaunderwdters.com
"ct:.
INSURER(S) AFFORDING COVERAGE
NAICO
Miami, FI 33174
INSURERA: Arch Specialty Insurance Company
21199
$ 1,000,000
INSURED
INSURER 13: Bridgefield Employers Ins Co
10701
Walter Plumbing Corp
INSURER C:
$ 10,000
INSURER 0:
4054 Sw 113 Ave
Miami FL 33165
INSURER E:
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY 1:1 PRO- ❑
JECT LOC
OTHER:
INSURER F:
$ 2,000,000
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
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MM/DD
POLICY EXP
MMID
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
2013 -8325
10/25/13
10/25/14
EACH OCCURRENCE
$ 1,000,000
PREMMAGE TO RENTED
ISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY 1:1 PRO- ❑
JECT LOC
OTHER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP /OPAGG
$ 2,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS AUTOS NON -OWNED
COciMBINED SINGLE LIMIT
Ea acdent
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
D I I RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE Y /"
OFFICER/MEMBER EXCLUDED? F—YI
(Mandatory in NH)
If yes, desaibe under
DESCRIPTION OF OPERATIONS below
N / A
830 -38516
10/26/13
10/26/14
PER OTH-
X STATUTE ER
E.L. EACH ACCIDENT
$ 100,000
E.L. DISEASE - EA EMPLOYEE
$ 100,000
E.L. DISEASE - POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allachad K more space Is required)
GCK7II IGA 1 It MULUCK GAIVGtLLA I IUN
MIAMI SHORES VILLAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI SHORES, FL. 33138 AUTHORIZED REPRESENTATIVE
n 1988 -2013 ACORD CORPORATION. All rights reserved.
ACORD 25 (2013104) The ACORD name and logo are registered marks of ACORD