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PL-15-886nn R Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 rrojecc Aaaress Parcel Number Applicant 320 NE 100 Street 1132060135460 LEAH GROSSMAN Miami Shores, FL 33138-2421 Block: Lot: Owner information Address Phone Cell LEAH GROSSMAN 320 NE 100 Street (786)342-8921 MIAMI SHORES FL 33138- 320 N E 100 Street MIAMI SHORES FL 33138 - Contractors) Phone Cell Phone AA MASTERS MECHANICAL AIR MOV (305)559-7004 Type of Work: REPLACEMENT OF SINK, TOILET, TUB AN Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF $1.20 DBPR Fee $2.25 DCA Fee $2,25 Education Surcharge $0.40 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $160.70 Valuation: $ 1,400.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -4-15-55209 04/22/2015 Credit Card $ 110.70 $ 50.00 04/15/2015 Cash $ 50.00 $ 0.00 Avaua0le lope Final In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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 honing. Futhermore, I authorize the above-named contractor to do the work stated. April 22, 2015 Authorized Signature: Owner / Applicant / Contractor Building Department Copy April 22, 2015 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-232564 Permit Number: PL -4-15-886 Scheduled Inspection Date: May 26, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: GROSSMAN, LEAH Work Classification: Addition/Alteration Job Address: 320 NE 100 Street Miami Shores, FL 33138-2421 Phone Number (786)342-8921 Project: <NONE> Parcel Number 1132060135460 Contractor: AA MASTERS MECHANICAL AIR MOVING AND ENGINEERIN Phone: (305)559-7004 lsuuamg uepartment comments 'REPLACEMENT OF SINK, TOILET, TUB AND FIXTURES. IPassed Comments INNSPECSPEC TOR CQMMENTS False May 22, 2016 For Inspections please call: (305)762-4949 Page 10 of 42 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid May 22, 2016 For Inspections please call: (305)762-4949 Page 10 of 42 Miami Shores Village BuildingDepartment p APR 1 015 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 ��• INSPECTION LINE PHONE NUMBER: (30S) 762-4949 FBC 2011^^0 BUILDING Master Permit No. —" _ 9q PERMIT APPLICATION Sub Permit No.F_E`15-" Pi Piro ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: L3 20 dj loo d - City: Miami Shores County: Miami Dade Zip: 093/317 Folio/Parcel#:, 0/3 ^ 6-jq(oo Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Phone#: J 04- X0:93 Address: J AP NIE . 100 4 - City: 9ilim; SAoeeS State: FL_ zip: AS 13 9, Tenant/Lessee Name: Email: AL )A CONTRACTOR: Company Name:: / ��li��s/�,(JJ/CdlPhone#: Address: City: 1 A114A,11 4/L// State: �` Zip: Qualifier Name: one#: 5-070-/—az Gl/ State Certification or Registration #: CA"G Certificate of Competency #: DESIGNER: Architect/Engineer: ,LI& Phone#: At. A Address:_ N /* City: X 1A State: AgIAZip: Value of Work for this Permit: $ 0 h%PJD• o° Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New EN Repair/Replace ❑ Demolition Description of Work: er2,,Gl ' a� SM � ®i ee T . ,-rub . Fi X l tCS Specify color of collo�rrtthru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews (Revised02/24/2014) CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ lJ Bonding Company's Name (if applicable) Bonding Company's Address &f M ' City A l State At IJA Zip 111 f A Mortgage Lender's Name (if applicable) Mortgage Lender's Address 4 A AA City 111 State Ja log 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature V" � OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The f goinj instrument was acknowledged before me this ,, 02� day of �"Il f k , 20 by day of ®;✓ , 20 , by ef-- _LP_" 6toS$/ aei , who is personally known to `, �%a- —Iaw- , who is personally known to me or who has produced FL.M &&J6 63q J3 F&60 as me or who has produced 67 as identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY PUBLIC: Sign: Sign: ?� CJIB NUI ` o',.•r M O QFF188688 Print: Print: _ •til" :'''. CR9 sT116AN GRILL® 7) 3eao163 Ffori r 7, 2018 Seal: � :`_ MY COMMISSION # EE09M3 Seal: dallotaryseMce.cm EXPIRES May 31, 2015 (40� 398 0153 FlorideNowySmice.com APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) • AA Masters Mechanical 15591 SW 105 Ter. Miami, FL 33196 CFC#13003152 04-13-2015 State of Florida County of Miami Dade County Before me this day personally appeared ��Sv3 who, being duly sworn, depose and says: That he or she will be the only person(s) working on the Plumbing aspect of the project located at 320 NE 100 St. Miami Shores, FL. Sworn to (or affirmed) and subscribed before me this 13 day of 2015, by ob ,Terg-S Personally Known Produced Identification_ Type of Identification Produced Notary Seal MY COMMISSION # EE098903 Y %may EXPIRES May 31, 2015 (407�„+ A"' 153 ftdallotauySemlcexom - . % Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 r 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 themseles from this requirement for an construction project prior to obtaining a building permit. Pursuant to the Florida Division of 11 orkers' Compensation Employer Facts Brochure: An employer in the construction industn who employs one or more part-time or full-time emplo%ees. including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability compare (LLC) in the construction industry may elect to be exempt iE I . The officer owns at least 10 percent of the stock of the corporation. or in the cast of an LLC. a statement attesting to the minimum 10 percent ownership: _'. 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 \ears or until a voluntarc revocation is filed or the exemption is revoked b} the Di%ision. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use dad labor. part-time employees or subcontractors for \our proiect. The contractor has provided an affidavit stating that he or she \\ill be the only person allowed to work on your proiect. 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 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: d Owner State of Florida County of Miami -Dade The foregoing was aeknoaledge before me this /3 da\ of fi .20 0Y By g�rx& who is personall\ known to me or has produced �L as identification. Notarv: CRISTFIIAN GRILL® % SEAL: MY COMMISSION # EE098903 �`' EXPIRES May 31, 2015 /I