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PL-14-2471syr 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-233579 Permit Number: PL -11-14-2471 Scheduled Inspection Date: April 30, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Owner: PETERSEN, CARSTEN Job Address: 1209 NE 98 Street Miami Shores, FL Project: <NONE> inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)807-2221 Parcel Number 1132050090230 Contractor: BROWN PLUMBING LLC Phone: (305)764-1731 comments ADD NEW BATHROOM, RENOVATION OF 2 EXISTING ---- ------ BATHS _____BATHS INSTALLATION KITCHEN APPLIANCES AS INSPECTOR COMMENTS False PLANS. Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-233484. CORRECT SINK WASTE CONNECTION Failed Correction ❑ � ����.� Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 29, 2016 For Inspections please call: (305)762-4949 Page 21 of 29 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 20 BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No:_)_-�) 1-4 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION r-1 RENEWAL PLUMBING ❑ MECHANICAL [_]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I/I q6 S� City: Miami Shores County: Miami Dade Zip: 3313 0 Folio/Parcel#: //- 3_:)®J`'- 00-27-0930 Is the Building Historically Designated: Yes NO Occupancy Type: � Load: Construction Type: V4 Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): �lJ�'L�Tc�r� ��6 rew-5 Phone#: Address: City: Tenant/Lessee Name: Email: State: hone#: CONTRACTOR: Company Name: x9a)60/y P/C44,1/;"0q Phone#: Address: _O -7 dA,ag GHQ • `47 City: 0,0'a Q6 r StateZip: 054 Qualifier Name: Phone#: 305- '76 State Certification or Registration #: CAZ� / �Jfi'!?: 7_4�: 9Z Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: ZipQ Value of Work for this Permit: $ �� 71- Square/Linear Footage of Work: 0 Type of Work: ❑ Addition Alterationl ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: q ��/� /> Q14 J2 2 S. e11,'ean a.o.�/, U,65_f 1A' b1,.vs Specify color of color thru tile: q Submittal Fee $ " dJ Permit Fee $ ��s" CCF $ 1 CO/CC $ Scanning Fee $ (JO Radon Fee $ DBPR $ 3 ° S Notary $ Technology Fee $ c� ' �� Training/Education Fee $ (7) r GDouble Fee $ Structural Reviews $ ® Bond $ 0 TOTAL FEE NOW DUE $ 1 �)9 • 11�_fo (Revised02/24/2014) 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. /n the absence of such posted notice, the inspection will not be appro reinspection fee will be charged. Signature Signature dv OWNER or AGENT The foregoing instrument was acknowledged before me this day of 20 ® , by who i ersonally know�to me r who has produced �r identification and who did take an oath. CONTRACTOR The foregoing instrument was acknowledged before me this day of J 20 % , by who ' personally known t me or who has produced as identification and wh NOTARY PUBLIC:,«" w REY44REYES NOTARY PUBLIC: MY COMMISSION #EE2060?2 EXPIRES: JUN 07, 2016 Bend through tet Stets Imurma ri ; Print: Seal: Seal: APPROVED BY el-�®'Od -0''7' Plans Examiner Structural Review (Revised02/24/2014) REYNA REYES IS MY COMMISSION #EE 606 EXPIRES: JUN 07, 2016 Bonded through 19t State Insumme Qr,'& WA /, Ai Zoning Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROF CONSTRUCTION INDUSTRY LICENSING 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 BROWN, ROBERT A BROWN PLUMBING LLC 13172 SW 45 DR MIAMI GARDENS FL 33027 Congratulations! With this license you become one of the nearly one mi9ion Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architectsto yacitlt brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For Information about our services, please log onto www.nryflaridaitconse.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida. and congratulations on your new Gcensel DETACH HERE RICK SCOTT, GOVERNOR REGULATION (850) 487-1395 �1 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND y PROFESSIONAL REGULATION CFC1427691 ">. ISS1jED1- 08/31/2014 CERTIFIED PLUMBING CDA�&ACTO_ R BROWN, ROBERT -A _ - BROWN PLUMBING LLC IS CERTIFIED under the provisions or Ch.488 FS. ftkdm date :. AUG 31, 2D16 L140M KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1427691 Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 BROWN, ROBERTA BROWN PLUMBING LLC 13172 SW 45 DR MIAMI GARDENS 'FL 33027 ISSUED: 08/312014 DISPLAY AS REQUIRED BY, LAW 0p SEQ m9 1.140&310003883 Local Business Tax Receipt Miami—Dade County, State of FloridaLBT -THIS IS NOT A BILL =00 NOT PAY 6399877 13USINESS NAMEILOCATION RECEIPT NO. EXPIRES BROV6W PLUMBING LLC RENMAL SEPTEMBER 30, 2015 2007 OPA LOCKA BLVD OPA LOCKA„FL 33054 8662944 Must be displayed at piece of business Pursuant to county Code Chapter BA -Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS'; PAYMENT RECEIVED _ BROWN PLUMBING LLC 196 PLUMBING BY rax COLLECTOR CONTRACTOR 49.50 10/02/2014 Worker(S) 1 CFC1427691 0225-15-000001 This local Bminess Tex Reasipt only confirms payment of the local BasinasTax. TheABcceipt is -a ficeme. penin,ora certification ofdwhoWersgnalNCations,todobusiness lWWaremstcomplyWftany gavommealel or mmgova nneftl regalatmy laws ead regairemealswitch apply to dm busies The RECEIPT N0. above ram be dispMW on all comammial veftlaN Miami-06de Cade Sw 69-DIL M For more irdornmtion, visit wwwmiarrill I i• NPPP I -- CERTIFICATE OF LIABILIT INSURANCE11 D)Y 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRAC REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS TER THE COVERAGE AFFORDED BY THE POLICIES BETWEEN THE ISSUING INSURER(S), AUTHORIZED IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pol"Iss) must be endo". the terms and condifiolts of the policy, certain policies may require an endorsement. A statement certificate Folder in Ileu of such endorsement(a). If SUBROGATION IS WAIVED, subJect to on this certificate dams not confer rights to the PRODUCER Preferred Insurance Advisors, Inc. 8000 Governor Square Blvd Ste 106 Miami Lakes, FL 33018 Phone (305) 698-9880 Fax (305) 698-57$ Ga CONTAC E• Madlin Ruiz PHONE 305) 698-9880 F N,). (305) 698-5756 L iz®prererredinsuranceadv.com 11/07/2 14 INSURERS) AFFORDING COVERAGE NAICs INSURER A : ranada Insuram a Company INSURED Brown Plumbing LLC 19101 NW 37 CT Opa Locks, FL 33055 INSURER B ❑ INSURER C: GEN'L AGGREGATE LIMIT APPLIES PER 11POLICY 1:1 PRO- ❑ LOC INSURERD, $ INSURER E AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED❑ SCHEDULED AUTOS ❑ AUTOS NED ❑ AUTOS RNUTOBw ❑ INSURER F : GOVERAGES CERTIFICATE NUMBER: I 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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES )ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR TYPE OF INSURANCE ADD SR POLICY NUMBER POLICY F ML' POLICY EXP MM/DD LIMI78 A ' GENERAL LIAIBLITY 0 COMMERCIAL GENERAL LIABILITY ❑❑ ❑ CLAIMS -MADE ❑ OCCUR Miami Shores, FL33138 0261148815 11/07/2 14 11/07/2015 EACH OCC RRENCE $ 1 M0,P00•00 DAMAGE TO RENTED PRE IBES Ea n� $ � one `5011 $ 5,000.00 MED EXP (Anyone PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER 11POLICY 1:1 PRO- ❑ LOC PRODUCTS - COMP/OP AGG $ 0.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED❑ SCHEDULED AUTOS ❑ AUTOS NED ❑ AUTOS RNUTOBw ❑ OMBIN tSINGLE LIMIT BODILY INJURY (Per person) $ BODILY INJURY (Per acddent $ Pei e$EntHIRED $ ❑ UMBRELLALUU3 ❑ OCCUR ❑ EXCESS UAB ❑ CLAIMS -MADE N / A EACH OCCURRENCE $ AGGREGATE $ ❑ DED 0 RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) It yyeess describe wider DESCRIPTION OF OPERATIONS below $ C STATU- ❑ OTH- ❑ Two E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMB $ DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES(Attach ACORD 101, Additional Remarks Schedule, H mo Plumbing Work. space le required) I�L��TICIf�ATL-YAI M= i=8N1_FI ldll(Un _ ©ISBB-ZULUAWKtJWrRPUf%M1Run- /YII1V-.vim'--' ACORD 25 (2010106) OF ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Deparment THE EXPIRA ACCORDANC ON DATE THEREOF, NOTICE WILL BE DELIVERED IN WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave AUTHOR ED ESENiAT)VE Miami Shores, FL33138 ©ISBB-ZULUAWKtJWrRPUf%M1Run- /YII1V-.vim'--' ACORD 25 (2010106) OF ACORD name and logo are registered marks of ACORD r 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 EFFECTIVE 06/01/2014 EXPIRATION DATE: 05/31/2016 PERSON: ROBERT BROWN FEIN: 261148815 BUSINESS NAME AND ADDRESS: BROWN PLUMBING LLC 13172 SW 45 DR MIRAMAR, FL 33027 SCOPE OF BUSINESS OR TRADE 1- LICENSED PLUMBING CONTRACTOR IMPORTANT Pursuant W 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. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on Rthe notice' of election to be exempt 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. CUT HERE QUESTIONS? (850) 413-1609 +s Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 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 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 Contractor Print Name: Print Name: /U MISSION #EE20M Signature: EXPIRES. JUN 07, 2016 Signature: _T6_ Owed through 1st State Insumn State of Florida ) State of Florida) County of Miami -Dade) County of Miami -Dade) Sworn to and subscribed before me this 7 Sworn to and(subscribed before me this 7 day of A101), , 20day of �1/ , RE By EYNA REYES By ISSION # EXPIRES. JUN 07, 2016 6oRded through 1st'Swaim (SEAL) (SEAL) Type of Identifi _ Type of Identification produced