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PL-14-1294Miami Shores Tillage r�-FC'FTVF Building Department � JUN 18 2014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �Y Tela (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (300) 762-4949 FBC 24 tO BUILDING Master Permit nto. Nl--\ — 12Cl I PERMIT APPLICATION Sub Permit No._2 1 IL4 --1 zq � ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑REN'EWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP i �� CONTRACTOR DRAWINGS !OB ADDRESS: 1 �� N t 0S f l V I T M1 m! Shores County Miami Dade Zip 1 Fof o/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type Load Construction Type: Flood Zone: BFE: FFE: - OWNER: Name (Fee Simple Titleholder): O�Z I A, SI i f HPhorse#: —7o � � 2,80 Address: 1-700 N r 106.s; 'r . City: NS7 State: FL zip:3� 13 Tenant/Lessee Name: Phone#: Email: H L) NJ ( J C SH l r-14 (2.. ,A T T , Al E_ CONTRACTOR: Company Name:' j (� it ; i Phone#: Address: City ' state: X3123 �..__ dip; p� J. , Qualifier Name: _—"Tr jL Phone#: 7Z- — , 5 a,'7 - /v i r State Certification or Registration #; _ t' o3 i 3.3 Certificate of Competency #: O o o ®1_/3 3I LI DESIGNER; Architect/Engineer: _ � I S� LL-0L� Phone#: 7Ao- 23 i�- 6 Address: City:kl Aki S %Mate• Zi Value of Work for this Permit. $ 0 ®. Square/Linear Footage of Work: 35 SQ1 Fi' Type of Work. ❑ Addition Description of Work: M Alteration ❑ New ❑ Repair///Replace El Demolition ie U_.C-1.�l� 'k -- Specify color of color thru tile: Submittal Fee $ Permit Fee $ _ C� �o� CCF $ C0/CC $ Scanning Fee $ Radon Fee '$ Technology Fee $ Training/Education Fee $ Structural Reviews (Revised02/24/2014) DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name(ifapplicable) Mortgage Lender's Address City Zip 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 ELECTRIC, PLUMBING, SIGNS; POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 EI;EFORE 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 falth that a copy of the notice of commencement and construction lien low brochure will be delivered to the person whose prop is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the Job site for the first"(Inot�,e ion which occurs sevg (7) days er t building permit is issued. In the absence of such posted notice, the inspection approved and a r�efisdectio ee will b choraed. Signature ER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this JY- day of _ _ .20 by `0� , who is personally known to me or who has produced aE; �IF�K identification and who. did take an oath. NOTARY PUBLIC: The foreng instrument was acknowledged before me this day of 20 by e L who is personally known to me or who has produced _V identification -and who did take an oath. 1 . - - - T Print: rY c tate of Flaida Seal: • �: Joanna M FeliCiBnp Seat: MY Commission FF 082783 otn ExPkes01N2/2018 APPROVED BY 6 Pians Examiner Structural Review (t evisedO2/24/2014) SOMA DUMTE W CONUSSIOM i FF 128139 EXPIRES: Jima 9, 2DIS ft" ThioNftyPueNe1 A 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 18 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 STATE REGISTERED CONTRACTOR LICENSE OR 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 AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: JIAI,_() t V1 CITY J CU t, STATE T_ L_ ZIP CODE '3 13 3 BUSINESS PHONE: I- FAX NUMBER (321 &' -'- 2� 41S V, CELL PHONEQUALIFIER'S NAME:' QUALIFIER'S LIC NUMBER' C) G (_G 6 t 33 0- 14Rr' CERTIFICATE OF LIABILITY INSURANCE DATE MIAMI SHORES VILLAGE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 6/18/14 PRODUCER Bentley Insurance & Associates 10050 NE 2ND AVENUE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 11402 N.W. 41st Street, Ste #208 Miami, FL 33178 Phone (305)463-7775 Fax (305)463-7772 MIAMI SHORES, FL. 33138 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED H & F Plumbing Corp. INSURERA: ATLANTIC CASUALTY INS CO. INSURER B: 2340 SW 28 St INSURER C: Miami, FL 33133 INSURER D: Fax #305-805-4247 INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 OF MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L ILTR NSRD SRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMtDD POLICY EXPIRATION DATE (MMIDDIM LIMITS A GENERAL LIABILITY 0 COMMERCIAL GENERAL LIABILITY ❑❑ CLAIMS MADE ©OCCUR ❑ L144000278-5 08/15/13 08/15/14 EACH OCCURRENCE $1,000,000 PREMISES EaENrence $100,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 ❑ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PROJECT ❑ LOC PRODUCTS - COMP/OP AGG $1,000,000 Deductible $500 AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) ❑ ❑ SCHEDULED AUTOS ❑ HIRED AUTOS BODILY INJURY (Per person) INJURY (Per accident) E] NON NON OWNED AUTOS 1-1 PROPERTY DAMAGE (Per accident) ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG ❑ EXCESSIUMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE EACH OCCURRENCE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? ❑ WC STATU- ❑ OTH- TORY LI ZITS E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS PLUMBING CONTRACTOR v—unarwcrt rAUPet I ATnnu © ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE MIAMI SHORES VILLAGE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO BUILDING DEPT THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY 10050 NE 2ND AVENUE OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE y - MIAMI SHORES, FL. 33138 ACnl*n or MMA ln01 Av © ACORD CORPORATION 1988 unntrvc COWrnrt, i�t�l, �[� 3313 ~;• _ . IN Jm. 03 ul 1(Z ceJ i p, C aC9 a ,Z C 215 V� mo U. O� Wp a W D p� ,oma 03 �< zo w Y� .p',r !'' r C3 C3 rn aco g UJ LLI zU l z; a w J (j cell! Q Of N co A'i s Jg p tI% Ul W Qr Y J� x �v LL J W W QP DF - (D Z ui �'.0 K, OC 0 20 ma EA gc 2.6D o CP 5 CL P w Miami S hores V ills e 9 Building men 10050 N.E:nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Alotice to Owner — Workers' Compensation Insurance Exemptior Florida Law requires Workers' .Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officersor members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1.. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you play be Rersonally liable for the worker compensation injuries of any Rerson allowed to work under this permit, Please check with your insurance carrier. since most property insurance policies DO NOT cover this type of liability. BY, SRnG :BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS *iG� Oner �, j) Contractor Print�C {"� _ c+�?. / Cl Print Name:Sign Signature: State o`1 Florida) State of Florida ) County of Miami -Dade) County of Miami -Dade) Sworn to and subscribed before me this Sworn. to and subscribed before me this day of _Jun e —,20JLI. day of , 20 t By e By SMADU� ' •rlEXPIR 9, (SEAL) �— .� (SEAL) „g;i • : Bo edTlgati�f�Pmblal! R Notary Public State of Florida Joanna M FelicianoMy Commission FF 082753 Expires 01/12!2018 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMP NSATION * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA W RKERS' COMPENSATION LAW " CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida' Workers' Compensation law. EFFECTIVE DATE: - 10/25/2013 PERSON: PEREZ FEIN: 592036072 BUSINESS NAME AND ADDRESS: H & F PLUMBING CORPORATI 48 SUFFOLK AVE HIALEAH EXPIRATION DATE: 10!25(2015 JOSE F FL 33010 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS exemption I on within the scope Pursuant to Chapter compensation n underr this chapter. pursuant to Ction who hapter 440.05(120 FS!SCert ficetes of eter by lection on to be exto be xem ta certificate of election er N s section may not exempt, pursuant to of the business be or em" shad beosn the notice of ubjeG to revocation if, ation to a Y time after the Sing of Chapter or5the issuanceoof heocertifica�e. the person namedononand �lhetnotice or election to p tate certificate. The department shall revoke a certificate at any time for failure o the no longer meets the requirements of this section for issuance of a CeftHi person named n the certificate to meet the requirements of this lectin. QUESTIONS? (850)413-1609 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 Me 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: 9/25/2013 EXPIRATION DATE: 9/25/2015 PERSON: PEREZ GIANCARLO D FEIN: 592036072 BUSINESS NAME AND ADDRESS: H & F PLUMBING CORPORATI 8228 SW 5TH ST MIAMI FL 33144 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS 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 fine 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 F I Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number INSP-214430 Permit Number: PL -6-14-1294 Scheduled Inspection Date: July 22, 2014 Inspector. Diaz, Osvaldo Owner: SMITH, ORFA Job Address: 1700 NE 105 Street 404 Miami Shores, FL Project <NONE> Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number (786)253-2869 Parcel Number 1122300500610 Contractor. H&F PLUMBING CORP Phone: (786)367-1895 eumung Department comments CONVERT TUB TO SHOWER INSTALL NEW FIXTURES Infractio Passed Comments IN SAME PLACE I INSPECTOR COMMENTS False Inspector Comments Passed E�r_ Failed Z2" Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. July 21, 2014 For Inspections please call: (305)762-4949 Page 11 of 33