PL-13-2722Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 205416
Scheduled Inspection Date: January 29, 2014
Inspector: Diaz, Osvaldo
Owner: COLLAZOS, ALEXANDRA
Job Address: 1110 NE 100 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor:
EH WHITSON PLUMBING
duiming Department comments
Permit Number: PL -12 -13 -2722
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Gas
Phone Number
Parcel Number
1132050190460
Phone: 954 - 929 -3599
RUN NEW NATURAL GAS LINES TO HWH, RANGE AND Infractio Passed Comments
DRYER I INSPECTOR COMMENTS False
Inspector Comments
Passed REATED AS REINSPECTION FOR INSP- 203945. provide drop test for
EQ�
gas final
Failed
Eir 0 le-
Correction ❑
Needed
Re- Inspection ❑
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
January 28, 2014 For Inspections please call: (305)762 -4949 Page 20 of 39
E.H. WHITSON PLUMBING
421 S 21 AVENUE
HOLLYWOOD, FL 33020
(954)929-3599
STATE LICENSE #CFC1425799
DROP TEST CERTIFICATION
OWNERS INFORMATION:
NAME: lot "igi4 el11'pf 1`
ADDRESS:
CITY: /P,' lam/ ` g4 .or ~ STATE: ,
TYPE OF INSTALLATION: NEW UPGRADE_
OF WORK:
SYSTEM PRESSURE FROM METER: 40.1 Ke ZA 9 0 �
IF YBRID SYSTEM, BRANCH PRESSURE:
WATER COLUMN: rem' "
TEST DURATION: Igor l% %
DATE OF TEST: ,�'' ,� R' /44
PRINT NAME JOA4
DATE /// �lllq
State of florida ���
Coun
sworn to and subscribed before me this 4da3
&sonally know
identification— type of identification
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: (3057 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
JOB ADDRESS:
0 4 2013
syeom ---- --- ---
FBC 20 1A
Permit No.
Master Permit No. 19L 13 a 1;n Da
-Coll
City: Miami Shores County: Miami Dade Zig:
Foho/Parcel #: 11-003205 • 6tq • 0 00
Is the Building Historically Designated: Yes NO >'ft Flom Zong o L
TenanW.essee Name: Phone#:
Email:
Address: ''rAJ
City: T W111.
Qualifier Name: —d
State Certification or
Contact Phone#-YM
Address:
of Competency #:
DESIGNER: ArchitecdEngineer. Phone#:
Value of Work for this Permit: $ 44M Square/Linear Footage of Work:
Type of Work: ❑Addr�ss N, atio ❑Ne • ❑Rair/R
Descrinlion of York& fur), fm) &M �7pY� G
I�Yej
25'
���e�����������+ �u�ex����x����u�ae������x�����Fees���e�a�����ee�m���e������x���e�����������x�n •a����
Submittal Fee $ Permit Fee $ 1�2 7,5*- CCF $ CO /CC $
Sunning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
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 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 constriction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
CONIlVIENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
LVIPROVEMENTS 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 co ence ust be pos d at jo ite
for the first inspection which occurs seven (7) days after the building permit is iss In he enc s pas n , the
inspection wi of be approved and a reinspe 'on fee will be charged
MIA I
Signature Signature s
Owner or Agent on for
The foregoing ms meat ''//was
day of 20�b
me this -b%
My Commission Expires:
The foregoing instrument was acknowledged before e this
day of , 20, by KA
who is rsonall �enntification who has od
Pe �-N1f 1
and, jM an .
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY 2''P -r.7 Plans Examiner
Structural Review
(Revised3 /12/2012)(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 311.5/09)
Zoning
Clerk
r
CERTIFICATE OF LIABILITY INSURANCE
DA-M `mont"M
F12/2/2013
TYPE OF INSURANCE
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
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: N 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
Keyes Coverage Insurance
5900 Hiatus Road
W.crSuzie B.
PHONE
No Est 954-724-7000 AIC No:
RES3:suzieb@keyescoverage.com
Tamarac FL 33321
rKODUCER
2193
INSURER(S)AFFORDING COVERAGE
NAIC 0
3/7/2013
INSURED
E. H. Whitson Plumbing
Al &John Enterprises Inc dJb /a
INSURERA:Alli d Provertv & Casualtv Ins Co
42579
INSURERS: Brid efield Casualty Ins Co
10335
INSURER C:Brid efield Enmloyers Ins Co
10701
423 S. 21st Avenue
Hollywood FL 33020
IpSUREItD:
INSURER E:
GENERAL AGGREGATE
$2,000,000
GERL AGGREGATE LIMIT APPLIES PER:
7X POLICY PR4 LOC
PRODUCTS - COMPIOPAGO
$2,000,000
VVVCr%Al7C0 GCKIIrIGA IL-- NUm13tK•11 nASnnaal RGVICInnI Ll"11/12co
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.
LLTTRR
TYPE OF INSURANCE
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
POLICY 'NUMBER NUMBER
POLICY
EXP
LINOTS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fx-� OCCUR
Y
Y
ACP GLPO 5924902956
3/7/2013
3/7/2014
EACH OCCURRENCE
$1,00D,000
°
PREMISES a rrenc
$ 100, 000
MED EXP (Arty one person)
$Excluded
PERSONAL BADVINJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GERL AGGREGATE LIMIT APPLIES PER:
7X POLICY PR4 LOC
PRODUCTS - COMPIOPAGO
$2,000,000
$
A
AUTOMOSILE'UABILIIY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
ACV
Y
ACP BAPC 5924902956
/7/2013
/7/2014
COMBINED SINGLE LWT
(Es accident)
$1,000,000
X
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
X
(P Par DAMAGE
$
X
COMP DED
$500
C01,L DED
$1,000
A
X
UMBRELLA LRB
EXCESS LIAB
g
OCCUR
CLAIMS -MADE
ACPCAP5924902956
3/7/2013
3/7/2014
EACH OCCURRENCE
$1,000,000
AGGREGATE
$1,000,000
DEDUCTIBLE
RETENTION so
$
X
g I
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIErORdPARTNERIECUTIVE
OFFICERIMEMBER EXCLUDED? ❑
(Mandatory In NH)
Ii Eyam, rclbs under
DSCRIPTION OF OPERATIONS below
NIA
Y
196 -26105
0830 -31592
4/12/2013
3/5/2013
4/12/2014
3/5/2014
X M&A% I OTH-
E.L. EACH ACCIDENT
$SOII. 000
E.L. DISEASE -EA EMPLOYEE
$500,000
E.L. DISEASE - POLICY LIMIT
$500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N more space is required)
I.CK 1 IrmaA 1 C MULUtK f`AI►If_CI I ATInAI
W 1V5t1 -aUUV AGORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
TOWN. OF MIAMI SHORES
10050 N.E. 2ND AVENUE
MIAMI SHORES FL 33138
AUTHORIZED REPRF.SENYATITIIVE
I
W 1V5t1 -aUUV AGORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
f 115 S. Andrews Ave., Rm. A -100, Ft. rvVMIM&A7%7 IIAA
Lauderdale,
L 33301 -1895 — 954- $31..rt00Q
VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30 2014
i D:
BUSieg Name: g H WHITSON PLUMBING Receipt #:
Business j ,PLUN8� LT1 SPRN;t(L /t
Owner Name: JOHN S LIPIak (PLUMBING CONTRACTOR)
Business Location: S 21 AVE Business Opened:01 /07/2005
• HOLLYWOOD CouMY 1CertjReg:CFC1425789
i
Business Phone: 954- 929 -3599 Exemption Code:
Rooms seats
Number of Machlnw
Tax Amount Transfer Fee NSF Fee
54.00 0.00
0.00
Employees IIIWchin�
Ending susin�s ONy
i Prior Years
0 -00 0.00
Professionals
Coffedfon Cwt Total POW
0.00 54.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT
WHEN VALIDATED
Mailing Address:
JOHN S LIPKA
421 S 21 AVENUg
HOLLYWOOD, FL 33020
This tax is levied for the privaege of doing business within Broward County and is
non-regulatory in nature. You must meet all
and zoning requirements. This Business Tax CR near MenidpaIlty planning
the business is sold, business name has changed pt must be transferred when
business location. This receipt does not indicate th th b yousinesss s legal moved fiat
it is in compliance with State or local laws and or that
regulations.
Receipt #3.ss -12- 00004250
Paid 07/25/203.3 54.00
a
SEQ L12080702055
KEN LAWSON
SECRETARY
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WITH P,,-EoF-B44o
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Survey Sheets / Plans
Customer Name:
Address: /O% /�® '��
City, State, Zip:
1 .
Phone #:
All Work to Comply With N.F.P.A. Code #:
Estimated lob Cost:
Description of Work:
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