PL-15-379Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-228683 Permit Number: PL -2-15-379
Scheduled Inspection Date: March 19, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo Inspection Type: Final
Owner: , Work Classification: Addition/Alteration
Job Address: 126 NW 101 Street
Miami Shores, FL
Phone Number (305)219-8267
Parcel Number 1131010220190
Project: <NONE>
Contractor: EF DESIGN & CONSTRUCTION Phone: (305)409-4581
Building Department Comments
REMOVE AND REPLACE ALL PLUMBING SYSTEMS AS
PER PLAN.
INSPECTOR COMMENTS False
Inspector Comments
Passed El/
Failed
Correction
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
March 18, 2015 For Inspections please call: (305)762-4949 Page 13 of 38
a
BUILDING
PERMIT APPLICATION
VBLUILDING
MBING
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
❑ ELECTRIC ❑ ROOFING
FEB 1 P 2015
FBC 20 la
Master Permit No.
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /"� & /'V •tv - /0
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): 2)InZ) ;F- A,1yeS Ti4 e n 7-A1Zc P P hone#: 305--2/9-P2!67
Address: -R/S0 GJ ` ( ®411 15;WC-
City: /%t 0 bec %1 State: rl�t- Zip: -?-?Of U
Tenant/Lessee Name: Phone#:
Email: d4wyd q'pe-
CONTRACTOR: Company Name: DP�/_�j �1- 0 "d -1V �gPj �►e'-Phone#: �Of �' l
Address: c ) I A) 1-J 15-2 ^v -e
City: �' 10s t7 �� State: lCiL Zip
Qualifier Name: E0114'- 4=� ®� �� Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer:
hone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Q 00 4) - enc Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: Ret'nov-e- 6t Re I tq L�e- q C l I°l V W1 by t', q I -em J
4'5 pee- pine
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ �2� • "� CCF $ CO/CC $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 23� •cilo
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. 1 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 charge
Signature
OW4R or AGENT
The foregoing instrument was acknowledged before me this
day of / . 20 by
17) ILJ4Y who i rsonally know o
me or who has produced as
identification and who did take an oath.
d.
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
ate- day of %® , 20 /5 , by
'i-E—WR °i�R who iersonally know o
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
Seal:
SANDY ROMERO
Z: := Commission # EE 1 16040
MY Commission Expires
,°,",`, July 26, 2075
APPROVED BY°S Plans Examiner
Structural Review
(Revised02/24/2014)
as
Zoning
Clerk
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 Exem tion
,
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..
Therefore, You may be personally liable for the worker compensation iniuries of any person allowed to work under this
ep rmit• 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 OTICE AND UNDERSTAND ITS
CONTENTS.
Owner
Signae:
State of F ori
County of Miami -Dade
The foregoing was acknowledge before me this
day R , 20_/ -5 -
By Va
who is ersonallknown me or has produced
as
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 12.
day of J1' ,20/8'
By r 06
who i ersonally known to a or has produced
as
Notary: z"� „k�''' �" N
SEAL: ° s °f SANDY ROM�it�p Sl
:- ommis
pn . Sion # EE 1160
fission if EE 1
V co M,4 k4; 44;.;2016
EF Design & Construction, Inc.
297 NW 152nd Avenue
Pembroke Pines, FL 33028
AFFIDAVIT
I, Edgar M. Fajardo, will be the only person working on the project at 126 NW 101 St
Miami Shores, FL 33150-1214.
Edgar M. Fajardo
(305) 219-8267
daviddapc@gmail.com
Signate-
The foregoi g instrument was acknowledged before me this day of /t ,
20
By r T r� , who isqgs to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
GSignatu e:
Print:
Seal:
SANDYROMERO
y*
c Notary Public . State of Florida
. JP; My Comm. Expires Jul
26, Commission # EE 1160400
1 04015
APC Engineering Enterprises, Inc.
2150 West 10th Avenue Hialeah, FL 33010 Phone: (305) 885-5371 FAX: (305) 885-5073 apcengineedng@gmaii.com
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