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PL-15-398 (4) • Miami Shores Village Building Department P 24 tell 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 10 BUILDING Master Permit No.V—\5 PERMIT APPLICATION Sub Permit No7?L— iS - 318 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 10I ,off CONTRACTOR DRAWINGS JOB ADDRESS: (p(/1 IBJ U 1 ` D e l� City: Miami Shores County: Miami Dade Zip: S3 1 3 rj Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: 'Construction Type: 7 /� Flood Zone: BFE: FFFE: Qrn OWNER: Name(Fee Simple Titleholder):_ I `t Q n"� `—�C 1�C Phone#:-1�L -� 1� /J"3 Address: l V0( ti Uj 100-f'P_ Cr City: m )aXn� 5 10rf 5 Stater Zip: 3 I Tenant/Lessee Name: Phone#: Email: �>> 9 7 CONTRACTOR: Company Name: � S' �n C. Phone#: �4 Address: City: 2 State: 144. Zip: Qualifier Name: O -14 SPhone3�� C'/7 G 7d State Certification or Registration#: if Cm lv 3 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$I It;o Q �-� Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New [Repair/Replace/ ❑ Demolition Description of Work: j20- 0 11} Ce- ��F G S' e7 n i6 Specify color of color thru tile: Submittal Fee$ 60 '00 Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TT�OTAL FEE NOW DUE$ (Revised02/24/2014) n �r�[ i r ' 0 , 1 Bonding Company's Name(if applicable) Bonding Company's Address City State Zip 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 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 reinspectio a will be arged. Lam.. AONTRAC'o Signature Signature OWNER or AGENT R The foregoing instrument was acknowledged before ?is The foregoing instrument was acknowledged before me this C � � b day of +✓� 20-15 by / day of !n 20J y 2AIQ bo s personally known to uNcUGt.^� 0 ja S ,who vo is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOT UBLIC: NOTARY PUBLIC: D' Sig ��. Sign: Print: L ��� � /` Print: Seal: '""�G'••,, NAPMLCAREAGA Seal: ELIODORO VALLEJO MY COMMISSION M EE 095077 "Y OSP Bl', 0 r EXPIRES:July 4,2015 :a• Notary Public-Stale of Florida BondedThNNoteryPublicUndemldters v My Comm. Expires Jul 9,2017 Commission # FF 004890 PlUlttl'I tlI ')I�s'♦I. ************** APPROVED BY �5 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC049431 The PLUMBING CONTRACTOR IGO Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 ." ,�. 906 1 Q■ �❑� ROJAS, EDWARDO ' EDWARD ROJAS PLU P _ . 880 NE.111 TWST' . -BISCAYNE PAR 3161 ' . .. � A , k , ISSUED: 08/05/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408050001639 y Local Business Tax Receipt Miami—pude Coranty, $ ate of fiorida' -TWS is NOT R BILL-DQ NOT PAY 5175658 •B+�$INq,B$ LB -*/LOCATION; RECEIPT NO. EXPIRES SriNAiD'ROJAS PLUMBING RENEWAL' G �l CORP SEPTEMBER 30, 2015; v r * 2371350 Must be displayed at plate of buSuSess g CA NE PARK,'F� 33161 PursuanttoCountV'Cude Chapter 8A,-Art. &10 QWt11E .SEG.TYRH OF BUSINESS R0,140LUMBING CORP , ,qgg P�1INIBING PAYMENT RECEIVED BY TAX COLLECTOR CONTRACTOR 45.00 07/18/2014 Worker(s) 1 CFC049431 0224-14-006140 This local Business tax Receipt only confirms 11110900f the Local Business Tax.The Receipt Is not a license, permit or a certiRetit on of the holder qualificad"0,to do business.Holder must comply with any governmental or nongovernmentdl regulatory laws and requirements'which apply to the business. The RECEIPT NQq above must,be{Iisplayed 4, 11 commercial vehicles-tMlaml-Dada Code Sec 08-276. M For more Information,vises i y i 02/18/2015 15:22 TAX) P.0011001 rHls cERnFlcarE Is ISSUED A8+A 1 gTTt IFICATE OF LIABILITY IN CERTIFICATE DOES NOT AFFIR ER OF IN1=0)tMA UE�I'1NCE DATE(MWpp�yyyy) MATIVEr_Y OR NEGATIVELY EXTEND OR ALTER THE COVE BELOW. THIS CERTIFICATE OF INSU AND CONFSRg NO RIII UPON THE CE 02/18/15 REPRESENTATIVE OR PRODUCE RANCE DOES NOT CONSTITUTE RTIFICATE HOLoER.THIS IMPORTANT: II the cortlRcete holder la sn ADp1T 0 gND THE CEN8URE0Atho ;1:1114:111 LDER. A CONTRACT'BETWEEN THE ISSUING AFFORDED BY THE POLICIES filo forme end condglons of ISSUING IN DED AUTHORIZED certHlcats hpldsr In Ilou olsueh Policy,osltaln pollgeS may oa)must bo entloraed. If gUBROG ondorsomtoon p, y ro0ulre on ondonament A e ATdoe Is yycc, sub s PRODUCER tetBmont on this eerfiflcate dose n 1 cf to Accurate of cc, rights to file 8300 Weet Flapler Suite 114 PH NEN Lucia E@trese Miami,FL 33144 305)226-8727 Phone (305 228.8727 IuG 1011*180*111 not (305)226•@787 INSURED FaX 305)228-8787 INBugeR sAFF Edward Rous Plumbing Corp INSURER A: Grenada Insurance Co.pING COVERADE MAIC M 880 NE 111 St NS R R a. 19 R C: Biscayne Park.FL 33161. INSURER; COVERAGES IIIBURE E: 1191 I'IFIC TE N THIS IS TO CERTIFY THAT THE PpL�IEs OF INSURANCE LISB Eb BEL IN URER F: INDICATED. N6TWIT ISSUE DING qNY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACT CERTIFICATE MAY BE ISSUED OR AY PERTAIN,THE INSURANCE AFF OEO 8Y THEIPOLI SO THE INSURED NAM EVISION NUMBER; ---- EXCLUSIONBAND CONDITIONS OF SUCH POLICIES.LIMITS SHpyvfy OR OTHER DOCUMENT WITH RESPECT TOLWHICH THIS ryPE OF INSURANCE ADD UaR MAY Hq DESCR18ED HEREIN IS SUBJECT TO ALL T VE BEEN REDUCED BY PAID CLAIMS. GENERAL LIABILITY NE TERMS, ryry P IICY NUMBER P IC F P UCy xp t>rJ COMMERCIAL GENERAL LIABILITY ❑ ❑ 11"5-MADE LIMITS A L Jn © OCCUR A H CCURRENCE I 1 OOO,OOp,00 y 0185FL00051045 E R N ED ❑ r B 100,000.00 08/06/2014 08/08/2015 MED Exp( ens 4r@on G�EjN AOGRECATE LIMITAPPLIE9 PER PERE B 5.000.00 POLICY ❑ P @NALAADVINJURY s 1.000,000.00 AUTOMOaILE UI U LOC GENERAL AGOAEGATE PRO .000.00 ❑ ANY AUTO DUCTS-COMP/OPAOG $ 1,000000.00 ( pp AUT NED ❑ AUTOS ULED 4 IN@ IN L IT s LJ HIRED AUTOS r--I MON•OWNEp BODILY INJURY(Par L_I AUT08 ) s ❑ 9001 INJURY(P0r @0d00o1 s UMBRELLA uAe ❑OCCUR P OPER A OE ❑ EXCESS CLAS s CLAIMB•MApE s IAr01I COMPENBATIGN EACH OCCURRENCE AND EMPLOYERS'LIAaq TTY AGOAEGATE S ANYPRDpRIETOR/PARTNER/EXECUTIVE VIN s OFFICERIMEMSER EkCLUDED9 (Mandslory In NN) Ir- N/A WC TATO. S Ns 00401 a under U 0T}1 0 BCRIPTION OF OPERATIONS Dypy E.L.EACH ACCIDENT EI.OIBEASE. 3 - - EA EMPLOYE S^ ` E.L.olf EASE•POLICY LIMIT i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AlteeM AC ORD ORD+ot,AddIIII Ra wrks Sch@dwo,it more @19400 Is required) ERTIFICATE HOLDER CANCELLATION City Of M(anti Shores Building Department SHOULD ANY OF THE gepVg DE9CRIeEd POLICIE red Ave THE EXPIRATION DATE THEREOF S eE CANCELLIED Mlamf Shores,FL 33188 ACCORDANCE WITH THE ppLf TICE WILL BE DELIVERED IN BEFDRe VISIONS. 954.456•9812 AUTHoRIZEp REPREBENTA DRD 26(2010/05)OF Lucia Estrella ®19@8. CORPORATION. Ali ACO Dnamed logo are gte;ema kof ACORD Report Viewer • Page 1 of 1 Y T m 100".6 JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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: 7/12/2013 EXPIRATION DATE: 7/12/2015 PERSON: ROJAS EDWARDO I 3 FEIN: 453073611 BUSINESS NAME AND ADDRESS: EDWARD ROJAS PLUMBING CORP BOO NE 111 STREET BISCAYNE PARK FL 33161 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS { Purs-1 to Chaptaf 44005(14).F S.a oKxer of a corporation who elects exempn n from this chapter by hbng a cenMcete of election under this section may I notrec—benefitsorccmpensetwn under this chapter Purwanttd Chaphrg4005(12),FS Cemhcates o}"lection to be eeemot eppiyonlywnhinthe Ecooe Of the busmese or trade Osted on the notice of efecoon to be exempt pi,muanito Chapter 44405(131 F S Notices of election to be exempt and cerbfcates of elect,on to be exempt shall be subject to r—Coboh if at any time alter the Mrig of the notice or the issuance of the cerbliKate,the person named on the notice or cenificate no .ng the the requnemants of thre aecbon for issuance of a 0110 cate.The department Ehall revoke a temfitete Many time for ftnWre of the pens-named On the testi ate to meet the'equ,rements of tME section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413.1809 #3 t I Report Viewer Page 1 of 1 a. JEFF ATWATER •ham"�fi CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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: 4f7/2014 EXPIRATION DATE: 4/6/2016 PERSON: ACUNA LEONARDO A FEIN: 453073611 BUSINESS NAME AND ADDRESS: EDWARD ROJAS PLUMBING CORP 800 NE 111TH ST BISCAYNE PARK FL 33161 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pursuant to Chapter 440.05(14),F.S.,an offcer of a corporation who elects exemption from this chapter by fling a certificate of election under this section may not recover benefas dr wmpancatbn under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt..apply only within the scope of the business of trade Wod on the MOM of election to be exempL Pursuant to Chapter 440.05(13).F.S.,Notices of election to be exempt and cedir"tes of election to be exempt shelf be subject to—cation if,at any time after the filing of the notice or the issuance of the certificate.the person named on the notice or certificate rlo longer meets Oso requaemenis 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 ceNfxate b meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)4131609 file:///C:/Users/RUTHL/AppData/Local/Temp/Low/4MFJ4QW5.htm 4/7/2014 5HORFs ... „,..M Miami Shores Village Noted Building Department ��ORiDp' 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 and acknowledges 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 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 r C ntractor Print Name: a n�� ` ll Print Name: S' Signat e: Signature: (,ut State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to�_§nd subscribed before me this 2 Swornto nd subscribed before me is day of vQe- 2 day of 20 S0 / -7— . By By (SEAL) (SEAL) P i P •,, E Type of I a�prodbiq�jlFub i - _ Type of Identi h uEe e o it My Comm. Expires J 9,2017 • ' , f Commissi #FF 004890 Commission #F 004890 i, UFc ,. Bonded Through National Notary Assn. Bonded Through National Notary Assn. EDWARD ROJAS PLUMBING SERVICE January 29, 2015 State of Florida County of Miami Dade Before me this 29 Day of January, 2015, deposes and says: I Leonardo Acuna owner/Partner of Edward Rojas Plumbing will be the only persons working at the job located 166 NW 100 Teff. Miami Shores Village, FL 33150. Swo to (or lrm d) and subscribed before me this 29 Day of January, 2015,by nardo Acuna Personally known ✓ Produced identification � Type of Identification E,1 ANA PARRILLA tary Public-State of Florida Comm.Expiresommission# Apr 21,2011 EE 867787 dna VCA f f iG Print Type or Stamp Name of Notary o�► Y P�'�. Jacobo Kli8man cDma' 'F nrwon#FF061271 E p Oct 09, �F�„�ctrclL JaS /✓o �r �= ✓ 880 NE 111 ST BISCAYNE PARK,FL 33161