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PL-15-949Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-233074 Permit Number: PL -4-15-949 Scheduled Inspection Date: April 27, 2015 Inspector: Diaz, Osvaldo Owner: PENSON, JOHN & STACY Job Address: 270 NE 92 Street Miami Shores, FL 33138 - Project: <NONE> Contractor: A YOUNG PLUMBING CORP tsunatng uepartment comments REMOVE AND RESET DISHWASHER KITCHEN SINK AND GARBAGE DISPOSAL. TO REPLACE PERMIT PL13-187 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number ()_- Parcel Number 1132060133380 INSPECTOR COMMENTS False Phone: (305)924-2243 April 24, 2015 For Inspections please call: (305)762-4949 Page 27 of 36 Inspector Comments Passed E2 Failed/-� Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 24, 2015 For Inspections please call: (305)762-4949 Page 27 of 36 Owner Information Address Phone Cell JOHN & STACY PENSON 270 NE 92 Street (305)333-8798 MIAMI SHORES FL 33138-3132 Contractor(s) Phone Cell Phone A YOUNG PLUMBING CORP (305)924-2243 Type of Work: REMOVE AND RESET DISHWASHER KITCHEN Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $100.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $108.60 Valuation: $ 450.00 Total Sq Feet: 0 Pav Date Pav Tvoe Amt Paid Amt Due I Invoice # PL -4-16-55284 04/22/2015 Cash 04/24/2015 Cash $ 50.00 $ 58.60 $ 58.60 $ 0.00 AvallaDIe Top Out Final In consideration bf the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto 4nd in strict confo ig with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting t peniiit I assume res on ibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required fort"ECTFICAL, PLUMBIN ECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNE�FFIDAVIT: I certify that a the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constru , iM on a'hdZ, ing' F�ulhe ore, rize the above-named contractor to do the work stated. ':�`'m--C April 24, 2015 / Applicant / Contractor / Agent Building DepartMent Copy April 24, 2015 1 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: (30S) 762-4949 ❑BUILDING ❑ ELECTRIC ❑ ROOFING Master Permit No APR 2015 FBC 20 L� PU IS --CH9 Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ RENEWAL PLUMBING ❑ MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Address: % City. State: Zip: Tenant/Lessee Name: Phone#:_ Email CONTRACTOR: Company Name: Address: �✓ City: Qualifier Name: ✓► mD State Certificatio or Registration M DESIGNER: Architect/Engineer: A Address: 447-1 Value of Work for this Permit: $ Type of Work: ❑ Addition Description of Work: —C,:) ❑ Alteration n of Competency #: v Square/Unear Footage of Work: ❑ New ❑ Repair/Replace �-- f:Z�cVA Specify color of color thru tile: Submittal Fee $ �" 0� Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ _ (Revised02/24/2014) X151 ❑ Demolition T—T 4, �-� CCF $ CO/CC $ _ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ O Bonding Company's Name (if applicable) Bonding Company's Address city' LIM State Mortgage Lender's Name (if applicable) _ Mortgage Lender's Address City A State `rW Zip Zi 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, certified copy of the recorded notice of commencement must be posted at the job site for the first inspection rc occurs leve 7) days after the building permit is issued. in the absence of such posted notice, the inspection will not be Prov an a r ' spection fee will be charged. Signatu OWNER or AGENT The forgoingpffis�fiu �t was cknowledged before me this 6/daf 20 by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Print: 0 LOUGE00 Seal: w .: Notary Public - State of Florida My Comm. Expires Jun 14, 2018 Commission # FF 119080 Wed Through Nation0l N{WyAW APPROVED BY I d s (Revised02/24/2014) 4e Signature \J V 60NKtiCTOR The foregoing Instrurngnt waslacknowledged before me this day of20 by GJ who is personally known to as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print• Seal: Plans Examiner Structural Review My Comm. EapBeS Jun 14. 21 COMMIS" 0 FF 119080 as Zoning Clerk �k (Revised02/24/2014) 4e Signature \J V 60NKtiCTOR The foregoing Instrurngnt waslacknowledged before me this day of20 by GJ who is personally known to as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print• Seal: Plans Examiner Structural Review My Comm. EapBeS Jun 14. 21 COMMIS" 0 FF 119080 as Zoning Clerk 51UL egl!qxj sTv vi AG-"N"F 164 -CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 04/13/13/15 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 WANED, 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 Global Insurance 6175 NW 153st street Suite 100 CONTACT NAME: JESSICA MENENDEZ PHHONN 94;(305) 512-9721 FAX No ; (305) 512-9889 -MAILADDRESSw jessica@globalinsurancefla.com INSURER(S) AFFORDING COVERAGE NAIC d Miami Lakes, FL 33014 INSURERA: ASCENDANT COMMERCIAL INSURANCE Phone (305) 512-9721 Fax (305) 512-9889 INSURED INSURER B INSURERC: AYOUNG PLUMBING CORP INSURER 0: 740 NW 91 AVE INSURER E: PEMBROKE PINES, FL 33024 (305) 924-2242 AUTOMOBILE LIABILITYCOMBINED ❑ ANY AUTO ❑ ALL AUTOS OWNED ❑ SCHEDULED AUTOS NON -OWNED F1 HIRED AUTOS ❑ AUTOS ❑ ❑ INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILS TYPE OF INSURANCE ADD INSR UBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MNMO LIMITS A GENERAL LIABILITY 0 COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAMS -MADE Q OCCUR F]04/06/2015 GL 0000016219 04/06/2016 EACH OCCURRENCE $ 1,000,000.00 DAMAGEESS (RENTED PEa occurrence $ 100 000.00 REM IS MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'LAGGREGATE LIMIT APPLIES PER:PRODUCTS- E] POLICY El JET ❑ LOC COMP/OP AGG $ 1,000,000.00 $ AUTOMOBILE LIABILITYCOMBINED ❑ ANY AUTO ❑ ALL AUTOS OWNED ❑ SCHEDULED AUTOS NON -OWNED F1 HIRED AUTOS ❑ AUTOS ❑ ❑ SINGLE LMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ ❑ UMBRELLA UAB ❑ OCCUR ❑ EXCESS LIAR ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION❑ AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) ❑ desce under If yes, rib DESCRIPTION OF OPERATIONS below N / A TWORY L RS 1:1ETM E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Reniarks Schedule, K more space is required) PLUMBING RESIDENTIAL AND COMMERCIAL CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 NO AVE 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 PROMISIONS. AUTHORIZED REPRESENTATIVE ©1988-2910 ACORD CORPORATION. All rlahts reserved. ACORD 25 (2010/05) QF The ACORD name and logo are registered marks of ACORD A Young Plumbing 740 NW 91 Ave Pembroke Pines, FL 33024 Licensed & Insured April 13, 2015 State of Florida County of Dade Before me this day appeared 71, who, being duly sworn deposes and says: That he or she will be the only person working on the project located at1.12 6?a'&-r 4 A74133159- Worn to a affir ed) and subscribed before me this aday ofaJ- 20/ , by Ci Personally know f/ OR Produced Identification Type of Identification Produced l Print, Type or Stamp Name of Notary ALIM LOUGE00 qty P'1 - State of Florida • Aly Conuo. E�1ras Jun 14, 2018ss� Comndi FF 118080 dttndltl Ntlieslllalsyllesn. fly Pf$i4�1know 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• 4ompensavon 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 and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELO�Y NO Cf GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. / ' Signature: Owner State County of Miami -Dade The foregoing was acknowledge before me this day oAA11 , 20 By_ A AAcm who is p Zonally known to me or has produced as identifi n go,3 11%A�6t�;1c LOU GE00 Notary Public - State o1 Florida Notary: (J : • My Comm. Expires Jun 14, 2018 Ad, Commission N FF 119080 SEAL: �laBonded Pffougt National Notary Asan i .i Y