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PL-14-413 f t 12- 151 /6 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-222341 Permit Number: PL-3-14-413 Scheduled Inspection Date: October 28, 2014 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: POLLEY, RUTH Work Classification: Gas Job Address: 935 NE 95 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060143110 Project: <NONE> Contractor: D& D PLUMBING CORP Phone: 305-379-0516 Building Department Comments GAS Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. October 27,2014 For Inspections please call: (305)762-4949 Page 29 of 35 D & D PLUMBING CORP. 3145 SW 19 Street Miami, FL. 33145 PH: 305-979-0516 FAX: 305-643-9755 CFC- 1426173 DROP TEST CERTIFICATION Florida Building Code, Fuel Gas Section 406 (IFGS) Inspection, Testing and Purging 406.1 General. Prior to acceptance and initial operation, all piping installations shall be inspected and pressure tested to determine that the materials, design, fabrication , and installation practices comply with the requirements of this code. Owners Information: Permit: PL-3-14-413 Ruth Polley 5935 NE 95 Street Miami Shores, FL. Installed gas stove in new location and tied in to existing gas meter. Then proceeded to test system. System pressure from meter 6psi. Water column: 4.7 Duration of test: 24 hours Date of test: 10/21/14 David Diaz State of Florida County Miami-Dade Sworn to and subscribed before me this may of Q 201,Yby who i ally known to me. Notry Signature ��oM�tss�ctdoetw��, `b p Miami Shores Village7BY: 2014 4�� ..� Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 20 BUILDING Permit No.}� PERMIT APPLICATION Master Permit No.20, 19 Permit Type: PLUMBING JOB ADDRESS: 935 NE 95 Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder):Ruth Kettane Polly Phone#: Address:935 NE 95 Street City: Miami Shores State: FL Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: D&D Plumbing Corp Phone#: 305-979-0516 Address: 3145 SW 19 Street City: Miami State: FI Zip: 33145 Qualifier Name: David Diaz Phone#: 305-979-0516 State Certification or Registration#: CFC 1426173 Certificate of Competency#: Contact Phone#: Email Address: dndcorp@aol.com DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$500 Sauare/Linear Footage of Work: Type of Work: ❑Address OAlteration ❑New ❑Repair/Replace ❑Demolition Description of Work: Install gas for new stove ***************************************Fees******************************************** Submittal Fee$ '09 Permit Fee$ ��' CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 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 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 w' be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of corttmencem must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued,. Int � e_nce of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature ��A.� 1 i�)ni C)��LW+Ngnature. Owner or Agent Contractor /'L The foreomg instrument was ac owled ed before a this The foregoing instrument was acknowledged before me this(G ri7 day of e Vt1k ,20� y aN. �K11111aN kega►��n , ' day of.�-►�'S __ O..ly,by Q 1!�l„/ 'b who is personal nown to a or who has produced 'who is personally known to me or ho has produced FO. As i ication and who did ake an oath. as identification and who did take an oath. NOTARY C: `� NOTARY PUBLIC: /;: AUCIA L VANDAMA g =' = MY COMMISSION#FF 023557 Sign: -.: Print Print "F `r Bonded Th°'Nor/Public Undenydten My Commission ” Notery PU0110,fttO of Florida My Commission Expires: Commibtiloho Et 101d�6 M+I Cafflttl:eRirNe 9NMtlq,1p1b ************* ************** ******************************************************************************* APPROVED BY c% ��' `f Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06110/2009)(Revised 3/15/09) /:ILY/UIN\IUd7Pe�:/eR`t•�tNNI(la0/1:1d1N:(lrael)J�IHOPd IN:UJ9:11/a�1/lEtt7 AICIa14L•\9:(�JL\eq/ea7/1JS\9.1: %C# 62 6.2 8 0 7. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#L1208110063! LICENSE BR 108/11/20121128037011 JCFC1426173, The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chaptet',v :80, FS. Expiration date: AUG 31, 2014 z DIAZ, DAVID D & D PLUMBING CORP 3145 SW 19TH STREET MIAMI FL 33145-1927 ' RICK SCOTT KEN LAWSON GOVERNOR - SECRETARY DISPLAY ASREQUIRED:BY LAW Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL'-DO NOT PAY LBT 5268586 BUSINESS NAME&OCATION RECEIPT NO. EXPIRES D&D PLUMBING CORP RENEWAL SEPTEMBER 30, 2014 3145 SW 19 ST 5505483 Must be displayed at place of business MIAMI FL 33145 Pursuant to County Code Chapter 8A-Art.9&10 SEC.TYPE OF BUSINESS PAYMENT RECEIVED OWNER 188 PLUMBING CONTRACTOR BY TAX COLLECTOR D&D PLUMBING CORP CFC1426173 $45.00 07/24/2013 Worker(s) 1 TXHS1--13-035406 This Local Business Tex Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit or a certification of the holders qualifications.to do business. Holder must comply with any governmental or nongovernmental regulatory laws and trequirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 80-276. For more information,visit ww miamidade 9yAg1collector Local Business Tax Receipt Miami—Dade County, State of Florida A-1 -THIS IS NOTA BILL - DONOT PAY BT ) 5268586 v BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES D&D PLUMBING CORP RENEWAL SEPTEMBER 30, 2015 3145 SW 19 ST 5505483 Must be displayed at place of business MIAMI FL 33145 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED D&D PLUMBING CORP 196 PLUMBING CONTRACTOR BY TAX COLLECTOR Worker(s) 1 CFC1426173 $45.00 08/03/2014 CREDITCARD-14-031179 This Local Business Tex Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holder,"s qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 6a-276. For more information,visit www.mismidadgggv_h„#g9 lector ....... - ... .. . ....... ._ . . ...-_....__. _.___ .._.................... ...._.. .. .-... ........ ._....._.. .._ RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION cf , CONSTRUCTION INDUSTRY LICENSING BOARD .; CFC1426173 The PLUMBING CONTRACTOR �?�3 Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 .0 DIAZ, DAVID D& D PLUMBING CORP 3145 SW 19TH STREET MIAMI FL 33145-1927 Rti ISSUED: 08/11/2014 DISPLAYAS REQUIRED BY LAW SEQ# L1408110001168 Vyf U141cV l4 13:ao TAX) P.0011001 A4L', ' CERTIFICATEF 09/04/14 O LIABILITY INSURANCE DAT Y1� 09/04/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATS 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 la an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and condltlons 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 andomement(s). PRODUCER NAMNTACT E. Lucia Eetrella Accurate pH E (305)226-6727 FAx (905)228-8767 8300 West Flagler Suite 114 luclaestrella®bmasouth net — Miami,FL 33144 INSURER 3 AFFORDINGCOVERAG! NAICI! Phone (305)226-8727 Fax (305)226-8767 INBURERA.- AvWdent Insurance Comp INSURED • ....... INSURERD: 0&D Plumbing Corp INSURER c: 3271 NW 6 Street INSURER D• Miami,FL 33125- (305)979-0516 I ITER 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 ECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESP CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE ADDL SUOR POLICY EFF POLICY EXP MR NND POLICY NUMBERMN o VIAL _ LIMITS oeNlRAL LIABILITY ® COMMERCIAL GENERAL LIABILITY EACH OCC RREN 5 1,000,000,00 ❑ ❑ CLAIMS-MADE DAMAGE TO RENTED PREMISES IEa occu = 5,000.00 A © OCCURMGLO13L54W3 , 0.00 ❑ Y Y MED EXP one s 100 00 11!26/2013 11/26/2014 PERSONAL t,ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: _ ❑ POLICY ❑ m LOC PRODUCTS-COW1OPAGO $ 1,000,000.00 AUTOMOBILE LIABILITY S OMBW D IPl((tLE LIMIT ❑ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per peraon) 8 ❑ AUTOS ❑ AUTOS BODILY INJURY(Per eooldent 9 ❑ HIRED AUTOS ❑ AUTOS MON-O�ED PRPEERi AMAGE S n- or ❑ UMBRELLA LIAR ❑OCCUR ❑ EXCESS LIMB ❑CLAI18 MADE EACH OCCURRENCE S AGGREGATE 6 ❑ DED [3 RETENTIONS .. • WORKERS COMPENSATION -• _ ; AND EMPLOYER$'LULINUTY ❑ STATU- OTH- ANYPROPRIETOwPARTNERIEXECUTIVE/N OMEMBEXCLUDED? ❑ NIA A E.L EACH ACCIDENT a D(NanrLtbmdmtc orY In NH)H) E.L.DISEASE-EA EMPLOY S ESCRprelp u OPERATIONS below E.1.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attaeh ACORD 101,AddManal Remsrke aoMduN,it more !Pea Is requrred) Ucenae#CFC1426173 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 NS, Miami Shores,FI 33138 AUTHORIZED REPRESENTATIVE faX 305-756-6972 Lucie Estrella ACORD 25(2010105)QF 01888-2010 CORD C ORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD w JEFF ATWA,TER CHIEF FIWANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION •*CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW :ONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 3/22/2014 EXPIRATION DATE: 3/21/2016 PERSON: DIAZ DAVID FEIN: 200604412 BUSINESS NAME AND ADDRESS: D&D PLUMBING CORP 3145 SW 19 STREET MIAMI FL 33145 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation 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 or trade listed on the notice of election to be exempt.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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 • ,5t/ORFS Miami shores Village Building Department OR 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 yvs H 0 ra,A; Contractor Print Name: R1 xffi .� Print Name: �. Z m��Z ' Signature: � N Signature: 'osa State of Florida State of Florida) m�v County of Miami-Dade) I/ o 0 o County of Miami-Dade) Sworn and jubscribed before meds / Sworn to and subscribed before m \tA's� �//1�i, day of 120,1 day of S '7 20� By By _ 3 ?016 IF (SEAL) (SEAL) r�''°COIZrgissr r Type of Identification produced 9 Type of Identification produced';,S'� ' .. 79 .. ' F L O ��0