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PL-14-1453 r Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-215448 Permit Number: PL-7-14-1453 Scheduled Inspection Date: July 14, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: WILLIAM J.JURBERG, R.ANDREW DE Work Classification: Gas DACQ Job Address:9350 NE 12 Avenue Miami Shores, FL 33138- Phone Number (305)609-3851 Parcel Number 1132050070150 Project: <NONE> Contractor: JZ PLUMBING CORPORATION Phone: (305)218-8078 Building Department Comments GAS CONNECTION TO GAS POOL HEATER (NATURAL) Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed 'I Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. July 13, 2015 For Inspections please call: (305)762-4949 Page 2 of 41 Policy Number: GL-0504009534-1 Date Entered: 07/09/2014 '4�" CERTIFICATE OF LIABILITY INSURANCE DATEI M/DD/YYYY) 2014 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 WAIVED, 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 CONTA T FLORIDA BANKERS INSURANCE NAME' PHONE . (305)643-2445 F'� 1631 W FLAGLER ST Ne: (305)643-6413 E-MAIL MAIKEL@floridabankersinsurance.com MIAMI FL 33135 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: FEDERATED NATIONAL INSURED JZ PLUMBING CORPORATION INSURER B: INSURER C: 17921 NW 82 CT INSURER D: HIALEAH, FL 33015 INSURER E: 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. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $300,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED GL-0504009534-1 8/21/2013 8/21/2014 PREMISES Eaoccurrence $100,000 CLAIMS-MADE X OCCUR MED EXP(Anyone person) $5 000 A BI/PD $250 DED PERSONAL&ADV INJURY $300,000 GENERAL AGGREGATE $600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $300 000 POLICY PROT- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N T RY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) PLUMBING CERTIFICATE HOLDER CANCELLATION MIAMI SHORES BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Producedusing Forms Boss Plus software.www.FormsBoss.comlmpressivePublishing 800-208-1977 Miami Shores Village Building Department JUL 0 8 2014 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 LBY:_ _ Tel: (305)795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 20/O BUILDING Permit No. P/ /1-- PERMIT APPLICATION Master Permit Noa /L/-- os- Permit Type: PLUMBING JOB ADDRESS: O o� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder):_ Avze&+,j _/ rphone S 1Z , �28 Address: �J /VC City:�/1�1� �S State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name. GG(/vfW/V Com' W Phone#: 3,9,4-, 6► ��D�U Address: /Z ZI F-4 jvCf City: State: Zip: Qualifier Name: Phone#: State Certification or Registration#:_ IFC 1k2 fa j0 Certificate of Competency#: Contact Phone#:— -30 el` DSe ' 90 9 Email Address: "i OW 10 f Z U n"1.D I f rlci - L t5v-y-% DESIGNER:Architect/Engineer: Phone#: 1 S q u a r mear"I"ao N r+AA' Typo of Wark ddar�ss r" ONew .:, Q +� u teraUon epar�Iteplac+ C1Demolition 13es y, 00, Submittal Fee$ Permit Fee$_X CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$A` Bonding Company's Name(if applicable) Bonding Company's Address 10 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 ELECTRICAL WORK,PLUMBING, SIGNS, WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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, Signature Owner or 4ent C tractor x The am as acknowledged before thio The for oing instrument wap acknow d e me this day obyA day of ,2��, ywhome or who has produced who 1 ono y o to me or who has produce As identification and who did take an oath. aside ' cation ho did take an oath. NOTARY PUB I NOTARY P IC: Sign: ArnSign: °� Notary Public-State of Florida ,�` >7: Notary PubNc-State of Florida Print: Print: My Commission ° F �A�', Commission#E EE 173842 My Commissio pP;; Commission N EE 173842 Bonded Through National Notary Assn. ''•��9;;,:�•`' Bonded Through National Notary Assn. APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)