The URL can be used to link to this page

PL-11-584Miami 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 APPLICATI N Permit Type: PLUMBING JOB ADDRESS: �/--= -4 JAN 8 2014 FBC 20 Permit No. P 6 I/ -Jcy Master Permit No. e ,111 10 '�T_ City: Miami Shores County: Miami Dade Zip: - C5 5B a Folio/Parcel #: �/� 3 � L Is the Building Historically Designated: Yes Zone: OWNER: Name (Fee Simple City::./ b"110 State: Tenantdxssee Name: Phone #: Email: CONTRACTOR: Company Name:. 1c/ / t-=Ol1 x-a" !_1/ / y"y _z e Phone#: Address: �v?Ur (5At% L'Zfpy � City: Ct�/ Qualifier Name: c ala State Certification or Registration #: 4 /' c Certificate of Competency #: Contact Phone #: 1345 - ;MB c l�� Email Address: g/%d�es e le -OVGLS G Xjmwl , ga/" DESIGNER: Architect/Engineer. Phone #• Value of Work for this Permit: $ Square/Linear Footage of work: Type of Work: ❑Address OAlteration e ODemolition Submittal Fee $ Permit Fee $_ 1-50. QC� CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ 6 • c7 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 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; Asa 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�e / g ence of su¢fi-�osted notice, the inspection will not be approved and a reinspection fee will be charged. Signature ZE j (a, z Owner or Agent The foregoing ins ent was acknowledged before me this gy day o 20 � by WY g�i 0pA-40- , who is personally known to me or who has produced l-)fl� S Qi ofmcmd, As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: Y aasl'r APPROVED BY The for'egom' g instrument was acknowledged before me this day of k 517NVY? 20 4K by who is personally known to me or who has oduced & I� Y Pi' T Plans Examiner Structural Review I, ` -C (Revised3 /12/2012XRevised 07 /10 /07XRevised 06/10/2009XRmised 3/15/09) Zoning Clerk Miami shores V 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. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* 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* D. COPY OF WORKERS COMPENSATION INSURANCE* *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: I-Q � CITYY 1C.l�r►,�� STATE ZIP CODE 3 �Jl � /Z - e S ��,�r +�' BUSINESS PHONE: �) FAX NUMBER () O CELL PHONE D ) 1S �7 / QUALIFIER'S NAME:, (��✓�� _ t-J QUALIFIER'S LIC NUMBER: ( !,J— Created on 3119109 BY MLDV / RV 3126109 MLDV I RV 6127111 AS e - LICENSE NBR.. � J - 07 10 20`i2 128 05702 CK1427.635 The'. PLUM �INC3 CONTRACTOR Naludd. below .IS CERTIFIED Under the provisions of Chapter Expiration dat e: AUG 31, 2014 00 Local Business Tax Receipt Miami —Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY 6220164 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES ACA CONSTRUCnON INC RENEWAL SEPTEMBER 30, 2014 10725 SW 55 TERR 6484746 Must be displayed at place of business MIAMI FL 33165 Pursuant to County Code Chapter SA - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED ACA CONSTRUCTION INC 196 PLUMBING CONTRACTOR BY TAX COLLECTOR Worker(s) 1 CFC1427635 $75.00 09/07/2013 CREDITCARD -13- 007616 This Local Business Tax Recohrt only confirms payment of we local Business Tax. no Receipt Is note license, permit. era certification of tha7mlder s qualifications to do business. Holder must comply with any governmental or nongovernmental rellulatory laws and requirements which apply to the business. The RECE PT N0. above must be displayed on all commercial vehicles - Miami -Dade Cola Sec 8a4a For more information, visit www.mismideda amducalloeror 07 -20 -2012 MEW JEFF ATWATER STATE OF FLORIDA CHIEF FiNAICIALOFFICER 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 06/19/2012 PERSON: LEMUS FEIN: 204524410 BUSINESS NAME AND ADDRESS: ACA CONSTRUCTION INC 10725 SW 55 TER MIAMI FL 33185 EXPIRATION DATE: 06/19/2014 ANDRES SCOPES OF BUSINESS OR TRADE: 1— LICENSED GENERAL CONTRACTOR 2— REPAIR SERVICE 3— CERTIFIED PLUMBING CONTRACTOR 4— CERTIFIED ROOFING CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 06114). F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may net recover benefits or compensation under this chapter. Pursuant to Chapter 440.06x12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed as the notice of election to be exempt. Pursuant to Chapter 440.06{13), F.S., Notices of election to be exempt and .certificates of election to be exempt shall be subject to revocation ii, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate so looser masts the requirements of this section lot Issuance of a Certificate. The department shall revoke a cq lIficate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 CORt)r CERTIFICATE OF LIABILITY INSURANCE DATE (M=DIYYYYI 01/2312014 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 pollcy(les) must be endorsed. If SUBROGATION 13 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A Statement on this cerdflcate does not confer rights to the certificate holder In lieu of such endorsemen B . PRODUCER DELTA INSURANCE UN DERWRITERS, INC. 777 N.W. 72nd AVENUE, SURE 3133 MIAMI, FLORIDA 33128 {:¢NT. CT LUIS DE LA LLERA Page EC NL Etst. 305- 269 -1107 .305- 289 1108 ADDRESS: DELTAINSUND@AOL. COM INSURER(S)AFFORDINGCOVEIZAGE NAIL ar INSURERA: ARCH SPECIALTY INSURANCE COMPANY 21199 INSURED ACA CONSTRUC TION, INC. dba ACA PLUMBING 10725 SW 55 TERRACE MIAMI, FLORIDA 33165 INSURER B: EACH OCCURRENCE INSURER C: INSURER D• COMMERCIAL GENERAL LIABILITY CIAIMS MADE OCCUR INNIRER I- INSURER F. COVERAGES CERTIFICATE NUMRFR- RPVIQrnM wI IRMco• 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 CONDITI NS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE INSR WVD POLICY NIMER III/p LIMITS GENERALLIASILI Y EACH OCCURRENCE $ 1,000,000. COMMERCIAL GENERAL LIABILITY CIAIMS MADE OCCUR P E8 0 $ 100,000. MED EXP (Any are person) $ 10,000. BADVINJURY $ 1,000,000. A AGL003117 -00 08/05/2013 08/05/2014 -PERSONAL GENERAL AGGREGATE $ 2,000,000. GEMLAGGREGATELIWAPPLIESPER: POLICY ECT LOC PRODUCTS - COMPIOPAGG $ 1,000,000. $ AU7090MLE LIABn,EY ANY AUTO CO NEE0rd) SINGLE IT $ ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON-OWNED AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per wcidw* $ PRO =DAMAGE P $ $ UMBRELLALUUS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ FA COIIUABILI Y� AND YIN S� RY LIAM 3 ER ANY PROPRIErORMARTNERIEXECUTIVE OFFICERIMEMSER EXCLUDED? NIA E L EACHACCO)ENT $ (Manddory In NH) Ii es, describe under DESCRIPTION OF OPERATIONS below ELDISEAa- EAFJdP10YEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERAWNB I ¢OOMONS I VEHICLES (Mach ACORD 101, AddlOonal Rernarke ScheduU, N more apace Is required) GENERAL CONTRACTOR LICENSE NUMBER: CGC1511172. PLUMBING CONTRACTOR LICENCE NUMBE R: CFC1427635, ROOFING CONTRACTOR LICENSE NUMBER: CCC1328217. CERTIFICATE unt non - ---_ -- - _ —_ -- VILLAGE MIAMI SHORES I BUILDING DEPT. 10050 NE 2nd AVENUE MIAMI SHORES, FL 33136 PH 305 795 2204 FAX 305 7568972 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 LUIS DE LA LLERA ACORD 26 (2010105) The ACORD name and logo are registered marls of ACORD 010 ACORD CORPORATION. Ali rights reserved. 01/23/2014 17:33 FAX 3052681108 DELTA INSURANCE UND. TRANSMISSION OH TX /RX NO RECIPIENT ADDRESS DESTINATION ID ST. TIME TIME USE PAGES SENT RESULT sss TX REPORT sss ss:s>SSSZgsa:sssss:s *t:essss 3439 3057568972 01/23 17:32 01,12 1 OK l�lnnl . , �� ► CERTIFICATE OF LIABILITY INSURANCE oATE l4 Y) � O, (tart �0w14 " �z 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 CONS71TVM A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHORMW REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the. certtfcate holder In an ADDITIONAL. INSURED, the pollcyr(in) must be endorses. if SUBROGATION IS WAIVED, subject to the tertian and condition of the polkyy certain policies nmy require an endorsement. A statement on this cerWkete does not confer rights to the certificate holder In lien of such endorse PRODUCER GT LUIS DE LA LLERA DELTA INSURANCE UNDERWRITERS, INC. 777 N.W. 72nd AVENUE, SUITE 3133 AfC No 305 - 2651107 No 305- 289 -1108 DELTAINSUND@AOL. COM MIAMI, FLORIDA 33120 INSURER(S)AFFORDING COVERAGE NAIC # INSURERA: ARCH SPECIALTY INSURANCE COMPANY 21159 IfR4U�D ACA CONSTRUCTION, INC. dba ACA PLUMBING INSURER 0, INSURER 6: PRMSEAS E $ 100,000. MED EXP (Any one 10725 SW 55 TERRACE INSURER D: PERe0NAL&ADVlNJURY MIAMI, FLORIDA 33185 91SUM INSURER F: ] :�:] AGL003117 -00 THIS TSTO 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 SF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAYPERTAIN, THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TI EOFINSUiANCE POiJCYNUwm LUUM GENEIMLIABMW J COWAMCIAL GENERAL LIABILITY CLAW -MADE V OCCUR EACH OCCURRENCE a 1,000,000, PRMSEAS E $ 100,000. MED EXP (Any one $ 10,000. PERe0NAL&ADVlNJURY S 1.004.000. A AGL003117 -00 00/00/2013 08=12014 GENERALAGOREOATE $ 2,000,000. LAGGMGATELWTAPPlJESPER' POLICY OI LOC PRODUCTS - COMPIOPAGG $ 11000,000. a AU7=0011 E LIASILrY COMINED SINGLE LImFT $ ANYAUTO AUTO$ AU LE0 8001Y INJURY (Per p0�t) S BODILYiNJURY } $ HIREDAUTOS ANUS E0 PROPE ORMA E a $ IIRIBRfiLLAUAB OCCUR EACH OCCURRENCE $ EXCEMI LIAB CLANS-MME AGGREGATE $ TEN OED RETION 8 $ coum !18NON AM YIN ANY PROPRIE7ORIPARTNERIEXECUTIYE a OFFICERAMENBER EXCLUDE07 iMlylamsdd.&: tq nCMJR�P7IAN NIA E.L. EACH ACCIDENT 8 ELDWME- EA�rtaYEE a AF r1PCR0TIl1NR bdav EL. DISPASE- POLICYLMT - $ ♦S��R�s �IOR� Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR I ARCHITECT Permit N. )2.1 ` CNW760S (Fee Simple Title Holder): J r owners Address: 'R d TI'i_tpc� .Phone—#.--- /.. - /k 5 -J Z; State: 0,8 %� °� Job Address (Of where work is being done): / > / City: Miami Shores State: Florida Zip Code: I --T/I "tea o Contractor's Com pany l\Iaft: /� �C!? ��I � c �� _ Phone #:— elf Address: �� 7 City: State: V' /" Zip Code: Qualifier's Name: _ c-��-:'C Lic. Number:.�.�y Architect/ Engineer of Record Name: Address: City: Phone #: State: Zip Code: Describe Work: 1163'a'9LE) I hereby certify that the work has been abandoned and/or the contractor/ itect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless for all legal involv nt. Signature Signature owner or Agent �enttwasa ctororA hitect The foregoing instrument was aknowledged before me The foregoing ins nowledged before me thisc�± day of � • ,201�jby this .� day of 2(V, Oy Who is personally known to me or who has produced wflp,ie rson own to me or who has produced �►'�� t'i G�J as indentification. indentification. AM Notary Publi otary c ' Pu'''g ALEJANORA BRITO Notary Public - State of Florida Sign: Slg ;�A a'c MY UU1111H. LXPITes Jun 10, 2014 '9�, OF i�OP�� Commission # 00 1000541 Seal: J. PHILLIPS "fill i' Commission # 1919343 ,..d; Notary Public - Caldwffia San Mateo Countq my comm. Wires Jan2540"- - _ Certified Building Contractors CBC 1257929 13876 SW Stith St. Suite N =136 Miami, FI 33175 Tei.305 380 -6656 Fax.305 380 -7082 December 14, 2013 Tim Brown Plumbing Company 11201 S.W. 551' Street Suite #271 Miramar, Fl 33025 Attn: Paul Timothy Brown CFC056933 Reference: Miami Shores House Folio 11- 3206 -013 -2330 Address: 165 N.E. 98tb Street, Mia Shores, Fl 33138 Renovation & Construction Group, Inc. will clear this permit violation within 10 days of this writing unless we receive formal objections to do SO. Permit # PL11 -584 In order to update this property old permit violations must be renewed and then All inspections cleared. We will take care of this process if after 10 days we do not receive official word from your company. Sincerely, Tammy Olen Fajardo CBC 1257929 New Construction Remodeling Projects Commercial Building Specialists 40 FLORIDA SHORT-FORM INDIVIDUAL ACKNOWLEDGMENT F.S. 695.26 State of Florida County of — Nd6-ft A A . 'I'40nol, Ag- e4w, I LESLIE $USIA Notary PuExpires State of Sep I -f LESLIE $USIA air Notary Publk - State of Rodda WMY carom. Com lesion EL MY Sep 19, 2015 Commission # EE 131836 Place Notary Seal Stamp Above The foregoing instrument was acknowledged or who has produced -41- ,--M-Fao- Type of Identification as identification. A - - Signature of Notary Public Name of Notary Typed, Printed or Stamped Notary Public — State of Florida Thqv,gh this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document I Title or Type of Document: Document Date: A 1-11 Number of Pages: Signer(s) Other Than Named Above: I I =$I - I i, t 5 1 ME E o a: 14 2 1 A L1 L01 V.1 E r;'{ I USPS.comt = USPS TrackingTM English Customer Service USPS MopRe y S . Page 1 of 1 Register t Sign In Search USPS.com or Track Packages Quick Toms Track Enter up to 10 Tracking *Find rind USPS Locations Buy Stamps ..._...� _.._...... ,.,..,..� Schedule a Piokup °a' cdTracking'�n Customer Service Have questions? We're here to help. Had anon Change of Address s..__:..__.... .............y ::::::...:::::. -_ - _._.......,,...�.. Tracking Number: 70132250000189041399 Expected Delivery Day: Wednesday, December 18, 2013 Requested label Is archived. Restore Archived Details) Track Another Package What's your tracking (or receipt) number? Track it LEGAL ON USPS.COM Privacy Poky) Government Services ; Terms of Use % Buy Stamps & Shop, FOIA , Print a Label with Postage) No FEAR Art EEO Data, Customer Service , Delivering Solutions to the Last Mile > She Index > Copyright@ 2014 USPS. All Rights Resemad ON ABOUT.USPS.COM About USPS Home, Newsroom , USPS Service Alerts) Fors & Publications > Careers, OTHER USPS SITES Business Customer Gateway > Postal Inspectors , Inspector General > Postal Explorer, https: // tools .usps.comlgolTrackConfinnAction .action ?tRe�fuRpage &tLc =1 &text28777 = &t... 3/5/2014 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: 3/12/2014 EXPIRATION DATE: 3/11/2016 PERSON: FAJARDO TAMMY 0 FEIN: 271079913 BUSINESS NAME AND ADDRESS: RENOVATION & CONSTRUCT[ 13876 SW 56TH STREET, MIAMI FL 33175 SCOPES OF BUSINESS OR TRADE: LICENSED BUILDING CARPENTRY FLOOR COVERING CONTRACTOR INSTALLATION OF CA INSTALLATION- R Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed 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 be subject to revocation If, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the 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 Miami Shores Village APR o X011 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 iNu. PA _a PERMIT APPLICA :_ D. Master Permit No. FBC 20 Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): ] a �' f r Phone#: Address: & F &I � 1 T City: � 2 -S State: T Tenant/Lessee Name: Phone#: Email: JOB ADDRESS• _ 165— sr City: Miami Shores q County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated.: Yes CONTRACTOR: Company Name: 1117- Address: //2,, .'1 . -SC - ,'� NO Flood Zone: city: State:' /7 Zip: •�� o 'f-- Qualifier Name: Phone#: State Certification or Registration #: Certificate of Competency #: (2 1✓ -'03-6 U3 Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ !V, L160.0 00 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ew ❑Repair/Replace ✓. SF s Description of Work: • -77 o ! ► n 7 p z „ ❑Demolition a Submittal Fee Permit )fee $ �� r�'�' e a Q Scanning Fee $ `s Rad6uVee $ 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`lstalionssndicate2l I certify that no work or installation has commenced prior to the issuance of a permit and that all wori "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 apprped and a reinspection fee will be charged. 0. Own Agent The foregoing ]nstrument acknowledged before me this day of IrtG 1Ct , 20 t , by Cjlkef -14 Alf- I i01- , who is personally known to me or who has produced D m L As identification and who did take an oath. Signature Contractor n The foregoing i strument was acknowled ed before me this day of , 20 C , by L , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Y�Q. �� c c Sign Sign: Print: Print: r` My Commission Exp' . My Commission Ex ires: 0„ `A" , ., • ' SIANE DA SILVA Notary Public - State of Florida J`l�' n �o ;a - ASILVA ry fate o Flpri a �k sksk�kakakdasIa�ks�esk'k�k ik slscdo •9, k!1€ 6Ql ex �a�el� ds�Ia�Ia =kikdask�k�kskKaBaaksk�ssk xe e�x s�IS g ec 9 A14 �,e o�•' ''��°� �Y` "� Commisslon # EE 49027 '9fF •e mm °, EE 49027 APPROVED BY aminer Structural Review Clerk (Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) ' 08/29/2011 08:53 9544305131 BUSINESS CENTER 1 PAGE 01 • r . 09 -20 -2010 ALEX SINK • STATIE OF FLORIDA - CHMIS F MCKL OFFICIM DEPARTMENT OF FINANCIAL SERVICES N DIVISION OF WORKERS' COMPENSATION CIffrIFICA'1'E OF ELECTION TO SE EAMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies thpt the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVir DATE: 09/09/2010 PERSON: BROWN FEIN: 850718177 BUSINESS NAME AND ADDRESS: TIM BRAN PLLMBING INC: 11201 S W HM ST #271 MIRAMAR FL SCOPES OF BUSINESS OR TRADE" 11- PLUMBIMO EXPIRATION DATE: 0910512012 TIM IMPORTANT,. Porenant to Chapter 441 . OSHA F.C. an Miner of a oarpmauae who elect$ esmmprtaa from this oknpter by filing a aertlticm at elactlaa cedar r ®in senian may not recover bonaflto or cnmpensarien under this cbapter. anraoant to Ckaptne 440.151TY1, P.B., Certtiteotas of election to bn exempt... 4PTJY only within 1169 scope of the Imalness or rrada itatad an the notice of aleetien to be exempt, Pastoral to Chapter 440,05{131, F.S., Notices of 91MCI n to be exempt and eertAfoates at election to fur oxoMpt akell be Object to revecatlon if, at any time a11er tha filing of Ike Noce or the iimllanae of the cortllicate, the permit named on the notice of carillicma no longer meets Ike requirements of this motion for [mate of a certificate. The drpaflmeat stroll revoke a certificate at any time for follere of the paraoo named an the aenifleatti to moet the regdifemacts of this o®cllee. QUESTIONS? i86O) 413`1609 VC -262 CERTIFICATE OF ELECTION TO BE EXEMFT REVISEb •09 -06 _• _laifal 7Y�'M�t16if trr>'WW'11111' II— 1;;WVMU —ZWFjh311T&-f0Q 1 115 S. Andrews Aver RIn. A -100, 'Ft. Lauderdale, FL 33301 -1895 — 954 -831 -4000 VALID OCTOBER 1, 20 .0 THROUGH SEPTEMBER 30, 2011 bk1A:'" ReCelpt 1E:182 -3-318 BusIneft Name• • TIM BROWN PLIMING INC Business Type: SPF YPe (FL MBINf3 COMM) Owner Dame: PAUL TIMOTHY• BROWN BusIness Opened:il /18(1996 Business Location: 11201 SW 55 ST 271 Stalte /CoUnty/CertlReg:12FC056983 MIRAMAR Exemption Code :NQNBXEMPT Business Phone: 628 -9003 _ Rooms sem Employees Nlachinss Prolessionatt 1 For Ye ag 9esfirtess only Numfoer of IRroehlnr�t Vsr..ienn Tuna• Tex Amount Trarabr Fee NSF Fee Penalty Prior Years C011t Sarum CAM TAI Patti 87. -00 0.00 Q -00 2.70 0,00 0.00 29.70 t 08/29 }2011 08:47 9544305131 BUSINESS CENTER A bP CERTIFICATE OF LIABILITY INSURANCE 0/13/2011 THIS CERTIFICATE 19 MSUED AS A MATTER OF INFORMATION ONLY AND COMFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAM%tY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OR INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURM(S), AUTHORED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: H the certltlaate holder 191 an ADDITIONAL INSURED, the poliay(les) must be endorsed. U ROGATION 19 WANED, subject to the terms and conditions of the policy, Certain policies may require an endorsement. A Staloment on this Certffleate does not confer rights to the rerMale holder In lieu of such endorses S PRODUCER ZOt Insurance Agency 5360 S University Drive Suite #+4 Davie FL 33328 NAT jUjie WO7.£ t3ir�) 6RIO -8080 (M)611-7625 a j+Ili ezotinsnraaae.Dom INSUIM AMORO1 GCOVERAGE WOUIMRA- Vestern Haerita 113 Insuranrm Cc 37150 INSURIM TIM BROyP1FT PLDABIbIG INC 11201 SK 55 Street #271 Miramar FL, 33025 JJ= a jfL MUFAR D a ea Fa %0%fw G,1w -%wW %& .M a,r1Yli 1" MUMLMF.Mw. —A rww6 i1wM 1 1qV1w§wVff%w THIS 18 TO CRdR17FY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THIN POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TR RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WNICN THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THIE INSURANCE APPORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OP SUCH POLICIES. LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. TVPB OF IN9URAMOE p01.10Y CEP Wr6nS a.,ENSMIAIAMUT1 H 4 'U NI',E $ 1, 000,000 X COW&MCAL GENERAL LVG[LITY $ 100 000 A GIAN8 -MADE ©O00UR 8-1611 /7.6/8015 /16/8018 MR0 EV tae $ 5,000 4 OATE UM APPL= P$R$ X I PO .PRO- m AUTOMMU L)AMU Y ANY AM 0W $CWEDULCO AAULL HIRED AUTOS AUT�WNED UNIZIR ei a e UAR OCCUR mum= L� r., Amacna8nc PH i 'for , a, WSORIFnON OF OPHRATIONEI! LCCA7[CNS VE;p6tM H3 (Aimee ACE>itC 799, AalB6aaaaat Ragaasla� 5dbedue, E mma► N Ica mipdmzI) BLIMT= CXWWAM CITY OF NXMI SHORES 10050 NE 2ND AVE NMMU SHORES, FL 33138 (20x10105) IMMONAL & AMl INJURY $ 1,000,000 AEOPALAGGREGATE $ 21000,000 PRODUCTS.CMWJOPAM I R 11000.000 IIOD9.Y INJURY (Pelt BwLY INJURY (Pelf now" q $ $ S+ 4OUW ANY OF THE ABOVE DESCRIBED POLICIES BE CANC&LEb BEFORE THE EXPIRATION DATE THERROP, NOTICE WILL BE DELIVIUM IN AGORDANCE9 WITH THE POLICY PROVIS109L Locnam%MUI31'1A 0 1888,2010 ACORD MDU W (201=nOl The ACORV name and logo are registered marls of ACORD