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PL-13-1014Miami 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 FBC 20 BUILDING Permit No. PERMIT APPLICATION Permit Type: PLUMBING JOB ADDRESS: / o / o Master Permit No. IO City: Miami Shores County: Miami Dade Zip: 3 3 , 3 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder):ZbzzGzAr so R -✓EP Phone#: 50S. Address: ZO / 0 F AIC /.r 71 A/E City:. ate,. XXaY'es State:L zip: �3d3� Tenant/Lessee Name: Phone#: Email: CONTRArTOO_R: Company Name: 4AJ J <C� ,�7�!/!u� ! Q Phone#: 30o-"— 893' -21 Address: &,5' /V 45 / 30 `*- City: W.;*A44` State: Zip: -53 Ko Qualifier Name: Z7o-A e% M G,4-1'.S'_Y�� Phone#: State Certification or Registration #: Certificate of Competency #: t Contact Phone#: 9—q 3 7/Email Address:.sl� C 6g 417r oXAE�%— DESIGNER: Architect/Engmeer: Phone#: Value of Work for this Permit: $ ct�_ ©, Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: Submittal Fee $ Permit Fee $.' CCF $ CO/CC $ Scanning 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 1 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: 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 Owner or Agent The foregoing instrument was acknowledged before me this day o U�� , 20 by /715 v9/c� S G �'''-ems'• w s personally known to me or who has produced/3 6.5-2- /7 3.3 y236 As identification and who did take an oath. NOTARY PUBLIC: Sign: My Commission Expires.",% �- .I�jenn �public g� i. ta,• r a s91pO@IlOf Floricle *a •Qry+H1i AO Signature ,-JZ — Contractor The fore ing instrument was acknowledged before me this day of , 20/y, by n L�Ss�ea' w o ' personally known to me dlho has produced4•c;2 36 73 zh ,?rZ°5hs identification and who did take an oath. APPROVED BY ��W77/ Plans Examiner Structural Review (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) NOTARY PUBLIC: My Commission N Jpspublic g� 4�.._ $ M ae Of Clerk BUILDING Miami 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 APPLICATION Permit Type: PLUMBING 7. � CFI E 5 MAY 0 9 2013 BY: FBC 20 Permit No. F1 ,�)— io Master Permit No. JOB ADDRESS: 149109 Me- i Y A y6 City: Miami Shores County: Miami Dade Zip: 3 3 ► <S 6 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): e07 1',_4W ' AW1eA1,<r Phone#: ?O -r '573y 7s -al Address: /0/D P A16 A !x%1/6 City: x1ld e cr State: rL Zip; �313� Tenant/Lessee Name: Email: 1061 &P RJl�rl�f�'leopra-1 Cel9) CONTRACTOR: Company Name: �l S �%� /� /v / y N 9 Phone#: R ©m� Address: o4C6 , A) 5 k �® �T City: 06 RT to W \ /� M State: zip: 9 S C� Qualifier Name: _ Phone#: 30 r-152* _'.097-75 %5 State Cerlification or Registration #: e XG. �� g6, Certificate of Competency #: Contact Phone#:' �'�Z' �'v�D�� Email.Address: -�'� � ���✓h� DESIGNER: Architect/Engineer: Phone#: _ Value of Work1or this Permit: Square/Linear Fo7epair/Replace a of Work: 1 Type of Work: ❑Address ❑Alteration ❑New ❑Demolition '40 AX -r Submittal Fee Scanning Fee $ Notary $ Permit Fee $ 106 CCF $ CO/CC $ Radon Fee $ DBPR $ Bond $_ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ e Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 6 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. 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 Owner or Agent The forego g instrument was day o , 20113, by NOTAR Sign: Print: this -1 o to me or who his produced identification and who did take My Commission Expires: APPROVED BY Signature�__ A e7�� Contractor The foreg g instrument was ackn 1 dged be ore m day okM —,2013, b Plans Examiner Structural Review (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Sign: Print: My known to me or who has produced identification and who .: Zoning Clerk Af �O® CERTIFICATE OF LIABILITY INSURANCE 8/201 01122 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 policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 Mack, Mack Sr Waltz Insurance Group, Inc. 1211 S Military Trail suite 100 Deerfield Beach FL 33442 Melissa Ribm PN NE F( ) (954)640-6226 .mribm@mackinsurance. cx�m INSUMSJ AFFORDING COVERAGE NAIL 0 IISURERAMid-Continent Casualty Company 23418 INSURED Lasseter Plumbing Company, Inc 865 N.E. 130 Street North Miami FL 33161 INSURERB-Mrbdgefteld Employers Ins. Co. 10701 INsuRER c Assurance Co. of America 19305 IN RERD: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER:CL1282026607 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. Im TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WWLL BE DELIVERED IN City of Miami Shores Village POLICY NUM13OR POLICY CY ENS UNITS ACWMS-MADE GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY OCCUR Greg Waltz/14ELISS 4CLL000830044 /1/2012 /1/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea ocmu nr $ 100,000 M� �P $Lj�� PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 MMG M AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ X AUTOMOBILE LIABILITY X ANY AUTO ALL OWNEDSCHEDULED AUTOS OS HIRED AUTOS NON -OWNED AUTOS(Parecaderm 9/1/2012 9 1/2013 COMBINED SINGLE MIT 1,000,000 BODILY INJURY (Per persun) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORIKANCOMPENSATIONOTH- AND ENPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIDMCCUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yre8 describe under DESCRIPTION OF OPERATIONS belay NIA I 3021471 /25/2012 /25/2013 ER EL EACH ACCIDENT $ $00,000 E.L DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS l VEMCLES (Attach ACORD 101, AddlBwW Rarttarks SethMule, B more space Is requbsd) Plumbing contractor work CERTIFICATE HOLDER CANCELLATION (305) 756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WWLL BE DELIVERED IN City of Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Eiviva AUTHORIZED REPRESENTATIVE 10050 NE 2 Ave Miami., FL 33138 Greg Waltz/14ELISS ACORD 25 (2010105) ®1988-2010 ACORD CORPORATION. All rights reserved. INS025l2num n1 The Af _tWM vmnaa snrl Innn aro mnlatamd manna of AMRn pu -- 1014 (305)893-7180 Fax(305)893-7852 Lasseter Plumbing Co. Inc. 865 NE 130 Street North Miami, FL 33161 CFC041696 MANOMETER TEST Ion_ Minutes W.C. Test /o (0S 4)� / S ! f4 ve: Job Address Installed and tested in accordance with Florida Statutes, Section 527.01 through 527.18 and rules and regulations of the State Fire Marshall and N.F.P.A. Pamphlets 54 and 58. Date: /V1 R 13 2,0 t Installedby: (Print Name) Installed by: ignature) WHM Change Out El Change Out OMeter Set s Piping ORange Change Out FIRST-CLASS U.S. POSTAGE i PAID WAK FL PERMT NO. 291 ��qq������qq THIS IS NOTA BU1—DO NOT PAY BUSS NAIiflE / LOCATION jj�I EWAL LASSETER PLUMBING CO INC STATE#, CFC041696 092209-7 865 HE 130 ST 33161 NORTH MIAMI OWNER SmLPSS5iER PLUMBING CO INC ushmils WORKER/S CONTRACTOR PA jjnl;ffi TAX 07/13/2012 600 0000111 000045.00 SEE OTHER SIDE DO NOT FORWARD LASSETER PLUMBING CO INC 865 NE 130 ST N MIAMI FL 33161 rv+ ;Ijw 11 Y yy 2 0 4'Jz"s f f'qj}$a"'''r - H31 G _- 1 FL y3WEYQ o'K` c' c y' R 41 ,i -; �. o} _e�� I' ✓ L Y ° +: i"+y f 1. L :>� � F ,.,F� t. �j �{�� r ;r CC Di-sptAY AS' RLCUIREQ B =LAW , ADDENDUM TO BUILDING PERMIT APPLICATIO14 (All APPLICATION FOR BUILDIPG PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS BEr OBTAINED, THE OWNERS NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS!) PLUMBING ELECTRICAL MECHANICAL ITEM UNIT BATH TUB FEE ITEM SWITCH OUTLETS UNIT FEE ITEM SPACE BEATERS UNIT FEE BIDET LIIITT OUTLETS CENTRAL HEATING DISFIWASHER DISPOSAL DRINKING FOUNTAIN RECEPTACLES SERVICE TEhi'ORMYI SERVICE SIZE IN ALPS A/C (WIND) A/C (CENTRAL) DUCT WORK l FLOOR CIUIIN GREASE 1f AP INTERCEPTOR ___._ SERVICE REPAIM-TER CIINNGE APPLIANCE OUTLETS RANGE TOP REFRIGERATION PROCESS NU PRESS PIPING._j UICERGROUNO TANKS 1 LAVATORY LAUtrURY TRAY OVEN ABOVE ABOVE GROUtID TNIKS WATER HEATER PRESSURE VESSELS CLOTHES WASHER MOTORS 0- 1 Ii' STEAM BOILERS %K)WER SINK, POT/3 Op. SINK, RESIDENCE SINK, SLOP MOTORS OVER 1— 3 FP MOTORS OVER $— 5 H' 610TORS. OVER 5— 8 IP WTORS OVER 8— 10 IP IIOT WATER BOILERS NIECHAN I CAL VENT I LAT I ON TRNISPORT RIG ASSEWL IES ELEVATORS/ESCALATORS I T _ TEM?ORARY WATER CLOSET URIKAL MOTORS OVER 10— 25 II' MOTORS OVER 25-100 HP FIRE SPRINKLER SYSTEMS COOLING TOWERS WATER CLOSET MOTORS OVER 100 IP VIOLATION s INDIRECT WASTES WATER SUf PLY TO: A/C WIHDOW AIR CONDITIONERS REINSPECTION j A1C UNIT STRIP HEATER FIRE SPRINKLER HEATER—NEW INST. HEATER—REPLACE LAWN SPRINKLER—WELL GENERATORS TRANSFORMERS GENERATORS TRANSFORMERS GENERATORS TRANSFORMERS SPECIAL PURPOSE i l SW16TAING POOL OUTLETS C06AIFRCIAL WATER SERVICE SIGN TIRES SEWER CONNECTIONS SIGN TRANSFORMERS UTILITY—SEWER SIGN TIME CLOCK UTILITY—WATER FIXTL>RES SEPTIC TANK ANTE NNARELAY TELEVISION OUTLETS ; DRAINFIELD, 4" TILE/RES. VIOLATION Fu,P & ABANDON SEPTIC TANK REINSPECTION SOAKAGE PIT W. FT. CATCH BASIN DISOIARGE WELL DOMESTIC WELL NIEA. WIN l(YOF INLET )OLAR WATER HEATER 'IRE STANDPIPE WL PIPING ,AWN SPRINKLER SYSTEM AS RANGE ETER SET (GAS) AS PIPIIG EHEE Lv:q�_ I I A AJ /✓r'' S �y