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PL-14-1459Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL _ Phone: (305)795-2204 Fax: (305)756-89721 — Inspection Number: INSP-215478 Permit Number: PL -7-14-1459 Scheduled Inspection Date: August 26, 2014 Permit Type: Plumbing - Residd!ptial Inspector: Diaz, Osvaldo Inspection Type'pgssTed Owner: GOMEZ-BASSOLS, ISABEL Work Classification: Gas Job Address: 137 NE 92 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060133170 Project: <NONE> Contractor: ALLISON GAS PLUMBING CORP 15una comments 2 GAS TANK 100 GL FOR GAS LINE INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed 8 ' Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Phone: (305)303-9877 August 25, 2014 For Inspections please call: (305)762-4949 Page 9 of 39 AF BUILDING PERMIT APPLICATION 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 FBC 201® Master Permit No. RL S 13 - i 9.SS Sub Permit No. P / 1/1 BUILDING ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION RENEWAL PLUMBING MECHANICAL EjPUBLICWORKS [:]CHANGE CONTRACTOR CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: 13-4 0 e q 4 d City: Miami Shores County: Miami Dade Zip: I Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): —L—,SPhone#: Address: City: M Qui R l ra v' o Q State: Zip: 33 13 W Tenant/Lessee Name: Phone#: Email: 1 CONTRACTOR: Company Name: 9 S D aC_-� 9 Address: f., ( ( c) S C'D ') f w City: State: Zip: 3 3 1 �� Qualifier Name: _�M A &_ Phone#: a o.s' 3 ?3,? 9 g State Certification or Registration #: R.S ;! �� Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Wbrk for this Permit: so C) Square/Linear Footage of Work: Type of Work: Addition ❑ Alteration ❑ Ne��wy ❑ Repair/Replace ❑ Demolition Description of Work: —� �+S l� 1 ®o 1,,� 1- Fn' 2 � Q / iQ 2 D6 Po �a P0 D J4W 4k U S eci color of color thru the: s `x Submittal Fee $ Permit Fee $115-0, _;4y CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ U 9. 0 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 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. 4", Signature Signature Owner or nt Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20� , by�� s��s �` 1 SD�� .�?�' of 20 by D` � who is person Ily known to me or who has produce who is personally known to me or who has produce As identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: nt: P MyCommi on fres In= blicStateofFlorida NotaryPublicState of Florida MM Feliciano Joanna M Feliciano My Commission FF 082753My Commission FF 082753 Expires 0111212018 12018 Expjres0111212018 exp****** APPROVED BY Plans Examiner Structural Review (Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) Zoning Clerk Miami shores Y 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 part-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. 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. Owner ontractor w Print Name. Print Name: p C ® S Signature' 7 e CJ Signature: 1) State of Florida ) County of Miami -Dade ) Sworn to d bscribed day of Pubf�State of Florida ,Joan mPA Fel- 2753 wnQoB State of Flori County orf Sworn to �d� � day of Notary public State of Florida Joanna M Feliciano My Commissten FF nanv.. ,20 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 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: i Sri BUSINESS ADDRESS: �® ems± CITY a/® STATE r�-- ZIP CODE BUSINESS PHONE: Gkj�)'3,03 9 FAX NUMBER LW -C D CELL PHONE (3. (�,S ) 3013 9 QUALIFIER'S NAME: A aA w4,c, QUALIFIER'S LIC NUMBER: a S 916 AcaRff CERTIFICATE OF LIABILITY INSURANCE �...-�" /8/2'D°"""'I' 7leI2o14 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. ff the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. 0 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 fire certifidatts holder In lieu of such endorseme PRODUCER Torres Insurance Agency Inc. 6135 NK 167 STREET #11;25 Miami Lakes FL 33015 CONTACT Josset Jordan PHONE (305) 512-5880 FAX(30S)512-5881 E -1a j jordan@toreesiasuraneeageuey.com 8FFOR0I00 COVERAGE NAIC # tN8URERA b9UWRE INSURANCE COMPANY INSURED Allison Gas Plumbing Corp 6180 SW 20th Street Miami FL 33155 INsu e: INSURERC: wsURERD: RER E: RER : COVERAGES CERTIFICATE NUMHER-CL147320162 ITIMASION NHPARM- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTdNTHSTANDING 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. LIP TYPE OF INSURANCE D 5UBR POLICYNUMBERLIR4IS POLICY EFF GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 canumm$ 100,000 MEDEXP ere $ 5,000 A X COMMERCIAL GENERAL LIA9anY CLANSMOE ®OCCUR W0323949 /9/2019 /9/2015 PERMNAL & ADV INJURY $ 1,000,000 X $500 PD DED/N GENERAL AGGREGATE $ 2,000,00 GEMLAGGREGATE LMMAPPLIES PER: PRODUCTS -COMPIOPAGO $ a 000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY C RED SINGLE Ir ANYAUTO BODI_YMARY (Per persof $ ALL OWNED AUTPULED BODILY INJURY (Per ecldeM $ HIREDAUTOS AWNED PROPERTY DAMAGEMor azidem$ $ UMBRELLA A UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAO CLARAS-MOUE DED I I RETENTIONS $ NtORO RS COMPENSATION 1JItC ATU-Oi N- AND EMPLOYERS* LIABILITY YINRY ANY PROPRIETORIPARTtd OFFICeMEN SER E XCLUD NIA EL. EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ (klandeLory In NH} 0yes� d .1b.oundar pESCR�TIOOF OPERATIONS bebw EL DISEASE -POLICY LIMIT $ MAXLWTPERMOLS85W THEFT A MaLLL TOOLS—nNecHEDULmD I CP0323949 7/09/2019 /09/2015 =Dip $10,00 DESCRI T N OF OPERATIONS I LOCATIONS I VEHICLES (AUnk ACORD 101. A44111001 Remarks Schedule. U mare spree is requlrv} Gas S Plumbing Contractor. Installation and repair of gas lines for gas fixtures 6 gas appliances. Residential and Commercial. bUJ MI -SHORES VILLAGE BLDG DEPT 10050 NS 2ND AVE MIAMI SHORE, FL 33138 t UMM"Til 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 RRRRESYTATWE Nj E 1NS025 (2mmf-m The ACORD name and logo are registered marks of ACORD All rights Deserved. 08-30-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 10/05/2012 PERSON: ACOSTA FEIN: 010907945 BUSINESS NAME AND ADDRESS: ALLISON GAS PLUMBING CORP 6180 SW 20 ST MIAMI FL 33155 SCOPES OF BUSINESS OR TRADE: 1- PLUMBING NOC AND DRIVERS EXPIRATION DATE: 10/05/2014 ALEIDO A IMPUBTANT: Pursuant to Chapter 440 . 05114), 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 440.06112), 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 440.05113►, 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. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW 0 EFFECTIVE: 10/05/2012 EXPIRATION DATE: 10/05/2014 PERSON: ALEIDO A ACOSTA FEIN: 010907945 BUSINESS NAME AND ADDRESS: ALLISON GAS PLUMBING CORP 6180 SW 20 ST MIAMI, FL 33155 SCOPE OF BUSINESS OR TRADE: 1- PLUMBING NOC AND DRIVERS IMPORTANT FO 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 L under this section may not recover benefits or compensation under this D chapter. H Pursuant to Chapter 440.0502), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E 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. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 1002915 L®cal Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6306849 BUSINESS NAM&LOCATION ALLISON GAS PLUMBING CORP 6180 SW 20 ST MIAMI EL 33155 LBT RECEIPT No. EXPIRES RENEWAL 8673050 SEPTEMBER 30, 2014 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS ALLISON GAS PLUMBING CORP 205 DEALER/DISTR/INSTALLATION PAYMENT RECEIVED LPG25916 By TAX COLLECTOR $450.00 07/12/2013 CREDITCARD-13-002625 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, Permit or a certification of the holder's qualifications, to do business. Holder meet comply with any govemmemal or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles — Miami—Dade Code Soc So -276, For more information, visit vww.miamidAdeupyA ..__l,__t_r Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number: 25916 Business Mailing Address ALLISON GAS PLUMBING CORP 6180 SW 20TH ST MIAMI, FL 33155-2035 Licensed Location Address ALLISON GAS PLUMBING CORP 6180 SW 20TH ST MIAMI, FL 33155-2035 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LP Gas licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person, firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the department. All licensing requirements must be met by the transferee and a transfer fee of $50 will apply. To apply for a transfer, contact the Bureau of LP Gas Inspections at (850) 921-1600. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner, or end user upon request when engaged in the business of servicing, testing, repairing, maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: POST LICENSE CONSPICUOUSLY Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number: 25916 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31, 2014 850 921-1600 Date of Issue: September 1, 2013 License Fee: $200.00 Tallahassee, Florida Type and Class: 0803 Liquefied Petroleum Gas License LP GAS INSTALLER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is Issued under authority of Section 527.02, Florida Statutes, to: ALLISON GAS PLUMBING CORP 6180 SW 20TH ST ADAM H. PUTNAM MIAMI, FL 33155- 2035 COMMISSIONER OF AGRICULTURE ALEIDO ACOSTA ALLISON OAS PLUMBING CORP 6180 SUV 20TH ST MIAMI, FL 33155-2035 ALLISON GAS PLU, MING CORP 6180 SW 26TH ST MIAMI; FL -33155-2035 Certificate Numberlicense Number ` 24720 25916 This Master Qual'�rer Certificate is issued. pursuant to Chapter 627,1=1onda Statutes. This. certificate.- is valid only for the person and -licensed holder listed. Any changes fo the lUlaster` Qualifier status (iuSranerch ata#or#ermina#ion flf employment) must be cetaorted to;the Bureau of Lt=' Cas #nseobon C850)'921-1.600 immedia€e#y. The Master Qualifier Certificate is valid only through the, date noted on .the Certificate A notice of renewal will 6e sent to you in advance of your expiratiori date A Mester Qualifier'Cerlficate nay be renewed if certification of a minimum of 16 (sixteen) hours continuing: education is provided along with the renewal form. If training cannot be documented, an examination must tie taken: if there are any errors on the certificate, please submit all changes in writing to: Florida'Department of Agriculture and Consumer Services 'Bureau of Liquefied Petroleum Gas Inspection .2005 Apalachee Parkway Tallahassee, Florida 32399=6500