PLC-11-2065Miami 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
Permit No.
Master Permit No. CC) k – o C)
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): be v i h e I la. , LLB.
Addresss: (9 L N L kel S D f
City: IAA %..& � J G I State: F t-
Tenant/Lessee Name:
ITECEIVE;D
NOV 0 7 2011
BY: 12-7---1_
Phone #: 36 5"' a / ?c5 - 297-6
Email: V 14 a.1 4. iQ D tt6 b U < I sv k Yip T
JOB ADDRESS: Cl to 5 P0.. c k D r t y—
City: Miami Shores
Folio/Parcel #:
County:
zip: 3 31 y1
Phone #:
Miami Dade
Is the Building Historically Designated: Yes NO
zip: 33 /3 F
Flood Zone:
• - , LL
CONTRACTOR: Company Name: a r 11 Q.4k WI et- Sie./a 1 P) I+G4 1 µPhone #: it 07 +%%07- g ?.D
Address: •J 10 !�/ SItc -k k d Li 31/ l S l t.l "f( ills-
/
City: A I.1 & W. O 1PCk S Z. c � qS State: 1 F j•- zip: 3 o� 7 1 7
Qualifier Name: A 1` 1 Q. i. K 1 e, r S ! e a �/ Phone #: 41 07 - q Dg a.3 13
State Certification or Registration #: [.'. V (.. I Li 9., 954/Certificate of Competency #:
Contact Phone #: t•J, 197 -- q OR- t=1.3 (3 Email Address: (It) K 51 "7 ® u3 wk Cowl\ c° C"r Gb r�
�
DESIGNER: Architect/Engineer: M OA k A 0,0_14.11..c.1 1 1 A CL L (t c I }— Phone #: 3 4 ?sq. a 3 is.
Value of Work for this Permit: $ caC4 Od 6
011-
Square/Linear Footage of Work: g I 1) IVO S. f,
Type of Work: OAddress DAlteration UNew
Description of Work: ¶ S "V" S 1 131'l(.' + 4,40 () tiA'f iTi -
/�� (1) C•cf>r I,rL.
•
epair/Replace ODemolition
* * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * ** *** Fees************* * * * * * * ** * * * * * * * * * ** * * * * * * * * * ***
0----
Submittal Fee $ Permit Fee $ 9 CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 1
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
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 approved and a reinspection fee will be charged.
Signature
The fore
day of
h. •
Owner or Agent Contractor
trumen edged befo - me this The foregoing instrument was acknowledged before me this S
201, by i ' . _ /A,.. day of O bcx , 20 11 , by Brian �-1 us t�C.�GI ,
own to a .r who has produced / o is personally known to me or who has producedfo
TrIY44,S L►1uDA as ide
NOTARY PUBLI
:4*. $I._Y,.,
NOTARY
Sign:
Print:
My Commission Expires:
APPROVED BY
Si
Print: /4iK,L iee
My Commission Expires: 01/0 i / a o, 2
***** ************* ********* * ****** * * ** ** use ******** ******** *** *ar*. * **
2 •Plans Examiner Zoning
Structural Review
(Revised 07 /10 /07XRevised 06 /10/2009)(Revised 3/15/09)
Clerk
-f■ ;74,7"
4•, . ,
Altamoife: S.pringi
vislitist TAX ItEttilit.
12-00001947
12-00001946
540 N STATE ROAD 434 145
ALTAMONTESPAINGS FL 32714
CLASOESORtP1ON
SEMINOLE COUNTY REGULATED
CONTRACTORS-PLUMBING
4'. A
•
BRIAN27 OP ID: TO
AC CPRCE
CERTIFICATE OF LIABILITY INSURANCE
I DATE (MarDOPANY)
0710212
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 poilcy(Ies) 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 407. 869-0982
SIHLE INSURANCE GROUP, INC.
P. O. BOX 160398 407 - 774-0936
ALTAMONTE SPRINGS, FL 32716
Torn Knt en
Cathy Queen
s,. y:407- 389 4599 I atc. Not 407 -389 -3580
ADDR6 Certlflcates@sihle.com
INSURERS) AFFORDING COVERAGE
NAIC 0
INSURER A : RetailFirst Insurance Co
GENERAL
INSURED Brian Kierstead Plumbing, LLC
540 N S.R. 434, Suite 145
Altamonte Springs, FL 32714
_
INSURER B:Old Dominion Insurance Company
40231
INSURER c :
INSURER D :
04/14/12
INSURER E :
EACH OCCURRENCE
INSURER F :
1,000,000
CO
•
THIS IS TO CERTIFY
INDICATED. NOTWITHSTANDING
CERTIFICATE MAY BE
EXCLUSIONS AND CONDITIONS
THAT THE POLICIES
ANY REQUIREMENT,
ISSUED OR MAY
OF SUCH
U�
OF
PERTAIN,
POLICIES.
omit
INSURANCE
SUER'
m
LISTED BELOW HAVE BEEN
TERM OR CONDITION OF ANY
THE INSURANCE AFFORDED BY
LIMITS SHOWN MAY HAVE BEEN
POLICY NUMBER
ISSUED TO
CONTRACT
THE POLICIES
REDUCED BY
Y�vyff
THE INSURED
OR OTHER
DESCRIBED
PAID CLAIMS.
taxDNr a
NAMED ABOVE FOR THE POLICY PERIOD
DOCUMENT WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS.
WITS
WM
TYPE OF INSURANCE
B
GENERAL
LIABILITY
COMMERCIAL GENERAL
lCLAIMS-MADE
LIABILITY
OCCUR
MPG96971
04/14/12
04/14/13
EACH OCCURRENCE
$
1,000,000
X
DAMAGE TO RENTED
RREMISES tEa oc�xgram�e)
$
800,000
X
MED EXP (Any one person)
$
10,000
PERSONAL & ADV INJURY
$
1,000,000
GENERAL AGGREGATE
$
2,000,000
GEN'L AGGREGATE LIMIT
APPLIES PER
nLOC
PRODUCTS - COMPIOP AGO
$
2,000,000
7PJCYI IJ!lRC.
$
AUTOMOBILE
—
LIABILITY
ANY AUTO
ALL OWNED
HIRED AUTOS
AUTOS
SOS
COMBINED SINGLE LIMB
Ms accident)
$
_
BODILY INJURY (Per person)
$
_
BODILY INJURY (Par accident)
$
_
_
IPPRCeOPIDIAMAGE
$
B
X
! LA LIAR
Ix
OCCUR
GLAIeMS MaDE
CUG95871
04/14/12
04/14/13
EACH OCCURRENCE
$
1,000,000
AGGREGATE
$
1,000,000
MD I X I RETENTION $ 10000
$
A
WORKERS COMPENSATION
AND OYYERS' LABILITY
ANY PFEOPRIETORfPARiNEFUEXECUTIVE
OFFICERIMEMBER EXCLUDED?
L�,
DEldfiIPTIONOF OPERATIONS
YIN
N I A
520 -38110
07/01/12
07/01/13
g�
X I TORY LIIMITS I I ER
E.L. EACH ACCIDENT
$
600,000
E.L. DISEASE - EA EMPLOYEE
$
600,000
below
E.L. DISEASE • POLICY LIMIT
$
600,000
B
Inland Marine
Contractors Equip.
MPG95971
04/14/12
04/14/13
Unsched.
Ded,
26,000
250
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Addltona) Remark Schedule, If more space Is required)
Miami Shores Village is included as additional insured for General Liability
where required by written contract.
I
MIAMSHO
Miami Shores Village
Building Deparbinent
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.
AUTHORIZED REPRESENTATIVE
--ekraiuLx0-,445e4U-L(124-1A
ACORD 26 (2010105)
01988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
r
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 166393 Permit Number: PLC -11 -11 -2065
Scheduled Inspection Date: December 17, 2012
Inspector: Hernandez, Rafael
Owner: LLC, DEVINELLA
Job Address: 9165 PARK Drive
Miami Shores, FL
Project <NONE>
Contractor: BRIAN KIERSTEAD PLUMBING LLC
Permit Type: Plumbing - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)785 -8990
Parcel Number 1132060141350
Building Department Comments
9 SINK 4 BATHROOM AND 2 WATER HEATER AND 1
WASHER
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
December 14, 2012
For Inspections please call: (305)762 -4949
Page 4 of 41
J-4 1•.-INTI vtn,i,AHu titk- it “t,,,VR,WL ■ArWrI
EiSOCiX3 01 TO EXPOt3E. ADHESIVE, REMOVE LINER -8aNi :31\(04ai .:TAS:4141:-Af :::4E0dX3 01 TO EXPOSE:. ADHESIVE, flEMOvE UNER iNri 3,Knii3U
1.=:F; - FM01/1a8 assOca 01 To EXPOSE ADHEEiVE, REMOVE LAMER ti 31 OKBH '3AIS3Hatf :,:K;Oz-SX3 oi o 41EVL, REMOVE LINER Ul
MIAM
1
MIAMI-DADE WATER & SEWER DEPARTMENT
METER OPERATIONS & MAINTENANCE
CROSS-CONNECTION CONTROL UNIT
1 N.W. 11Th STREET', MIAMI, FL 33136-
Phone (305) 547- Fax (7: ) 268-
1
PREVENTION ASSEMBLY TEST REPORT FORM
NAME OF TESTER:
1
BUSINESS NAME
s t.,4)
TEST KIT MAKE
4
icSkv..5
MODEL It
CERTIFICATION ft:
-b9S9
BUSINESS ADDRESS:
PLEA Ail
EXPIRATION DATE PHONE:
/1 ” 30- /3 3o5"-- 237-I6P
0 3 Ock
0--4A-1■;t $41r -FL
DATE LAST CAL 1
q-11-12.
ZIP CODE:
33 (c.
SITE TUBE
YES / NO
MAKE OF ASSEMBLY: MODEL NO.:
1IJAftS 00
LOCATION OF ASSEMBLY:
INITIAL TEST:
Alb() s-i-dp_ to,C
fiNgliffiana,
CLOSED TIGHT:
LEAKED:
Closed Tight
Leaked:
CI< VALVE
f
ANNUAL TEST:
SignEEYNAR
CLOSED TIGHT:
LEAKED-
RP.
SERIAL #:
2-77 o23
HAZARD/SERVICE:
ATE OF TEST:
I
c_bp-etko_;E`c.
SIZE
METER NO.:
qb• OE 104
METER READING:
o 5 0
LINE PRESSURE: 65 P.5-1
OIFVRENTIALREUEP%ALVE
PRESSURE STABLE:
NO
RV.
AIR INLET CHECK VALVE
LEAKED:
OPENED AT: HELD AT:
PSI
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI
IF - E EMBLY EARS ECK- -S :N;c9NIKETE THIS SECT
REMAFMS/ REASON FOR FAILURE (IF APPAREN1):
Closed Tight:
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
FAILED TO OPEN
2.0 PSI. OPENED AT: 3 4, (t2 PSI.
FAILED
TO OPEN
PSI,
AND NOTE RE,PAIR
2
0,.
LU
CC
CLEANED:
VE NO.2 VAL
CLEANED: CLEANED:
CLEANED:
REPLACED:
REPLACED: REPLACED:
REPLACED:
C.V
RRLA
CHECK VALVE NO. 1
CHECK VALVE NO. 2
DIFFERENTIAL RELIEF VALVE
P. .
R INLET CHECK VALVE
LEAKED:
Closed Tight
Leaked:
PRESSURE DIFFEREN11AL ACROSS CHECK
PSI.
CE
Closed light
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
FAILED
TO OPEN
FAILED TO OPEN
PSI. OPENED AT: PSI.
ECTION CONTROL MANUAL AND THAT NITRE
TWYT I HAVETESTED litEARNEASSEROYIN ACCORDANCE WITH THEANWA CROSS
OPENED AT: HELD AT:
PSI
PSI
N iS ACCURATE T
SIGNATURE OF CrIFIED TESTER:
NOTE: TEST FORM MUST BE COMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL BE RETURNED.
110_01-158 8/09 www.miamidade.goviwasdicross-connection.asp
Permit Number: PLC -11 -11 -2065 J
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
((-0‘..‹)
Inspection Number: INSP - 183163
Inspection Date: December 21, 2012
Inspector: Hernandez, Rafael
Owner: LLC, DEVINELLA
Job Address: 9165 PARK Drive
Miami Shores, FL
Project: <NONE>
Contractor: BRIAN KIERSTEAD PLUMBING LLC
Permit Type: Plumbing - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)785 -8990
Parcel Number 1132060141350
Building Department Comments
9 SINK 4 BATHROOM AND 2 WATER
WASHER
HEATER AND 1
Infractio Passed Comments
INSPECTOR COMMENTS False
Passed
■
Inspector Comments
CREATED AS REINSPECTION
FOR INSP - 166393. pending hrs
0)
�
B,
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled
re- inspection fee is paid.
until
December 20, 2012
For Inspections please call: (305)762 -4949
Page 1 of 1