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PL-14-1755i Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-224043 Permit Number: PL -8-14-1755 Scheduled Inspection Date: December 02, 2014 Permit Type•. Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address: 190 NW 103 Street Miami Shores, FL 33150- Phone Number Parcel Number 1131010230010 Project: <NONE> Contractor: PC PLUMBING GROUP INC Phone: (305)640-5690 Isuuamg uepartment comments REINSTALL SINK. INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-223390. CREATED AS I " I REINSPECTION FOR INSP-217722. fix drain and provide escutcheons SAME AS ABOVE 11/25/14 Failed Correction Needed ❑ l Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. December 01, 2014 For Inspections please call: (305)762-4949 Page 24 of 36 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION F—IBUILDING ❑ ELECTRIC ❑ ROOFING AUG 1 FBC 2(fi 0 r' Master Permit No.` 114- C— 1 - °G9 Sub Permit NoIA-:- 14` F� 55 ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑■ PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP }' CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO. Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): er �( e Cl? �9 4 14 Phone#: 27t4— 3y�� " =:!!r 2 Address:, %Z /l` % j e1 City: State: /i'( Zip: Tenant/Lessee Name: Email: //- �s W CONTRACTOR: Company Name: PC Plumbing Group Phone#: 305-6405690 Address: 9520 sw 40 st #201 city. miami state: Fl Z;p: 33165 Qualifier Name: Jose F Palacios Phone#: 305-2196500 State Certification or Registration #: CFC057684 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $_A ®- Od Square/Linear Footage of Work: ° Type of Work: ❑ Addition 10Alteration � 1:1 New ❑ Repair/Replace ❑ Demolition Description of Work: 0-"- le I <V S /f���/(/S ! aJ Specify color of color thru tile: Submittal Fee $ Permit Fee $ f Scanning Fee $ Technology Fee $ Structural Reviews $ (Rev1sed02/24/2014) Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary Double Fee $ Bond $ TOTAL FEE NOW DUE $ , &® It 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 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 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. r A � Signature Signature OW N ER or AGENT CONTRACTOR The foregoing instrumentwa7.6, cknowledged before me this day of Y GL 20 / by /1, , e T,4 f// t who is personally known to me or who has produced- as identification and who 'd take an NOTARY PUBLIC: 1� Sign. ?o r Print: Seal: APPROVED BY e (Revised02/24/2014) The foregoing instrument was acknowledged before me this 26 day of JULY Jose F Palacios me or who has produced PKTM 20 14 by who is personally known to identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal: � MYCpq�yl� ��j "'•%lP;,�i�� IXPfRES: MeY 1, 201@ � ! rs Plans Examiner Structural Review Zoning Clerk C% .61944 rs� STATE OF FLORIDA 071:1.0/20-112le: 012314 • CF,C05168�4 The PLDNBNONTiCTOR' ; Named ]aelowCRRTIFILD Under the pinions o Chapter •89.,�LPS. Expiration AVG 31, 2014 ACLOSI ` I JOSH F PL G GROW INC XS. 40 ST #201 = FL -33165 RICK OTT DISPLAYi.,NS REQUIRED BY LAW a [416624 ocal Business TaX.Recei.pt Miami—Dade County, State of Florida -7HIS IS NOTA BILL -AO NOT'PAY 99GNAME/LQCAMON REOE�T NO. WASING GROUP WC RENEWAL SW 40 ST201 6683792 r, FL 33185 ' ovr�v SEQ#Lix07100099: KEN LAWSON SECRETARY LBT.:f s' EXPIRES SEPTEMBER 30, 2014 Must be displayed at place of 9uaiaeaa Porsuopt to Couety Code CdapteT GA- Art. 9 & 10 WMR SEC. TYPE OF HUSWESS PAYMENT fi iyiD = C PLUMBING GROUP INC 196 PLUMBING CONTRACM BY TAX C01 19FOR t7riler(5) 3 CFCD57684 0222 10%l/7013 0222-14-000024 r This Leval BWN&4$$T*x Reee111t only 1*400 payaoat of do Local Boehm Tax. Tie Receipt is net a Gcease, petail, or a eomeafiae ofth holders quardieetlesa to do bodhom Helder east coaMy wit• say liotnlnueshl Orneyaveraaoatal mlalataylaws ead royshetseaawlilcb Epplyto the issues. The RECINT A0. above 190t be dlaplayed on all coaaEkal vobicks,Ifiaai4kdo Cede See Ba -a18. Poraen irforaatloi,visitmwwaisaids�_yaanl�es0eetor JEFI= ATWATER CHIEF FINANCIAL *A CERTIF CONSTRUCTION IN This Certirles that the i EFFECTIVE DATE: PERSON: PALACI FEIN: 2639175 BUSINESS NAME AP 0 PC PLUMBING GRO 9520 SW 40 ST #201 MIAMI SCOPES OF BUSIN PLUMBING NOC AN DRIVERS Pursuantto Chapter 440.05(~4) net recover bsnants orcompen of the business or trade Rated e election to be exempt shall be certificate no longer mom the f person named on tha ceertifeate DFS-F2-DWC.262 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES 171VISION OF WORKERS' COMPENSATION TE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERV COMPENSATION LAW TRY EXEMPTION - jval listed below has elected to be exempt from Florida Workers' Compensation law, 111/2013 EXPIRATION DATE: 3/11/2015 JOSE F FL 33165 OR TRADE: tip officer of a corporation who etocts exemption from this chapter by filing 8 0e1ti6c9119 of ekctlon ander this section may mdet this ebaptof. Pursuant to Chapter 440.09(12), P.5„ Certificates of election to OR exempt.. apply on)y within the scope adca of elaclkM to be exempt, Pursuant to Chapter 446.60(131, F.S., Naitees of e)ec0011 to be exempt anti certificates or to merits o©hi ethal lactbn for lasuanoe o a serttn®te. Thef the epa tor meni shalilercvok as eordliicate st anyrliftlate. the o*rm named ilure of thean the or at the reaulrements of this sl c5on. OF ELECTION TO BE EXEMPT REVISED 07-12 WESTIONS7 (MAI -3-1609 =j- Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner —Workers' Compensation Insurance Exemption 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 post -time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if - 1 . f: 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 may be personally liable for the worker compensation injuries of any person 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 SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Print Signa State County of Miami -Dade ) Sworn tod s Ascribed before me this day of Y4t, 20/ By Owner (SEAL) wrr�nrti51t3N# FF01g59 EY,P113ES: ApY0 28, 2017 4-B Type of I ltl a produrer9 w cuum rimyswf= 'WT Print Nam Signature: State of Florida) County of Miami -Dade) �/ Sworn to an 'sub bed before me s 7d day of -From:Jimenez Ins. 305 264 5382 07/28/2014 15:37 #716 P.001/001 ._ GtKTIFIGATE OF LIABILITY INSURANCE DATE(NIMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIG07/28/14 HTS 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 polIcAles) 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 CO ACT JULIO JIMENEZ E: Jimenez & Co., Inc. PHONE (305) 2649900 FAx Nei, (305) 2645382 8000 Coral Way �M}�3Agl1Egjudo srQj€menezarxkbmpany com — Miami, FL 33155 ; Phone 305 2649900 Fax (305) 2645382 INSURER(9 AFFORDING COVERAGE MAIC g INSURER A: GRANADA INSURANCE COMPANY INSURED 0186FL00030890 PC PLUMBING GROUP INC SUR INSURER C, DAMAGE 70 RENTED P� 1 n S 100,000.00 9520 SW 40 ST #201 INSURER D Miami, FL 33165 1 INSURER E; INSURER F: COVERAGES cr=RTIFIt%ATF rurrseecn. THIS IS TO CERTIFY THAT THE POLICIES rccvlalVW NUMt3ER: INDICATED. CERTIFICATE EXCLUSIONS tSR L NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN. AND CONDITIONS OF SUCH TYPE OF INSURANCE GENERAL LIABILITY OF INSURANCE POLICIES. ADDt)gUSA THE LISTED BELOW HAVE BEEN ISSUED TERM OR CONDITION OF ANY CONTRACT INSURANCE AFFORDED BY THE LIMITS SHOWN MAY HAVE BEEN REDUCED POLICY NUMBER TO THE OR POLICIES DESCRIBED BY PAID PO DY EFF INSURED NAMED OTHER DOCUMENT HEREIN CLAIMS. MPOUCDY EXP ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS. LIMITS A ® COMMERCIAL GENERAL LIABILITY I❑ ❑ CLAIMS -MADE ® OCCUR ❑ 0186FL00030890 10/31/2013 10!31/2014 EACHOCCURRENCE 1,000,000.00 DAMAGE 70 RENTED P� 1 n S 100,000.00 MED EXP (qny one MMon S 5,000.00 j ❑ PERSONAL &ADV INJURY $ 1,000,000.00 1 GEA"L AGGREGATE LIMIT APPLIES PER ❑POLICY ❑ PR0. ❑ GENERAL AGGREGATE $ 1.0 0,000.00 I PRODUCTS - COMP/OP AGG $ 1,000,000.00 Y -- $ LOC I AUTOMOBILE LIABILITY ❑ ANYAUTO ❑ALL OWNED SCHEDULED AUTOS ❑ AUTOS 3�NEb I ❑ HIRED AUTOS ❑ NON ❑ ❑ ❑ UMBRELLA 1" ❑ OCCUR IA ❑ EXCESS LR ❑ CLAIMS4A DE OMBINED SINGLE LIMIT $ BODILY INJURY (Per parson) $ — BODILY INJURY (Per moldeni $ PROPERdTYDAMAGE r $ P� I Imo$ EACH OCCURRENCE $ 11 1 D ❑ RETENTION AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) I= describe under DESCRIPTION OF OPERATIONS below N / A $ ❑ W �TL1M ❑ OTH- --. E.L. EACH ACCIDENT $ E.L DISEASE - EA EMPLO $ _ E.E. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N more apace is rpquimd) �' PLUMBING RESIDENTAL AND COMMERCIAL CFC# 067684 CERTIFICATE HOLDER VILLAGE OF MIAMI SHORES 10050 NE 2 AVE MIAMI SHORES FL 33138 ACORD 25 (2010/06) QF CANCELLATION SHOUL.q 4w4PAATHEREOF. THE #BOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7HE E�gNOTICE WILL BE DELIVERED IN ACCO THE POLICY PROVISIONS. ©1988-2010 ACORD CORPORATION. All rights reserved. is ACORD name and logo are registered marks of ACORD