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PL-15-232 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-228169 Permit Number: PL-2-15-232 Scheduled Inspection Date: August 20,2015 Permit Type: Plumbing - Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner: CLARKE, LAUREEN Work Classification: Addition/Alteration Job Address:126 NW 109 Street Miami Shores, FL 33168- Phone Number Project: <NONE> Parcel Number 1121360100190 Contractor: CHARLIE SWAIN PLUMBING Phone: (954)961-5527 Building Department Comments REPLACE GAS WATER HEATER WITH THE ADDITION Infractio Passed Comments OF THERMAL EXPANSION TANK INSPECTOR COMMENTS False nspector Comments Passed lal/ CREATED AS REINSPECTION FOR INSP-227568. no one answered door Failed - - — Correction Needed Re-Inspection R �� Fee (� No Additional Inspections can be scheduled until / V� re-inspection fee is paid. August 19,2015 For Inspections please call: (305)762-4949 Page 3 of 41 Miami Shores Village FES o 2 2015 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 FBC 20 10 BUILDING Master Permit No, L 5 " 3a PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 126 NW 109TH STREET City: Miami Shores Countv: Miami Dade Zia: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: CB Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):LAUREEN A. CLARKE Phone#:305-525-3430 I Address: 126 NW 109TH STREET City: MAIMI SHORES state: FLORIDA Zip: 33168 Tenant/Lessee Name: Phone#: Email: ArtFerret@aol.com CONTRACTOR:Company Name: CHARLIE SWAIN PLUMBING Phone#: 954-961-5527 Address: 6299 JOHNSON STREET City: HOLLYWOODstate: FLORIDA Zip: 33024 Qualifier Name: ROaer+ cle1Qer Phone#: State Certification or Registration#: CFC 025560 Certificate of Competency#: DESIGNER:Architect/Engineer: N.A. Phone#: Address: City: State: Zip: Value of Work for this Permit:$1115.00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑■ Repair/Replace ❑ Demolition Description of work: Replace gas water heater with the addition of thermal expansion tank. Located in the garage. Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 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 co o the notice o commencement and construction lien law brochure will be delivered f rY f f e ed 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. SignSignature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 29 January 15 29 January 1 day of ry .20 by day of ry 20 5 by Laureen A. Clarke who is personally known to Robert Geiger who is personally knower to me or who has produced FL DLC462521627210 Vas me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Al;- Print: Print: SHELLIE LL Seal: •�� Notary Public-State ofDFlorida Seal: ='a° •�� Notary Public-State LL E Florida 5 My Comm.Expires Sep ' iE My Comm.Expires Se 28,2016Commission!EE 82 +, °; Commission EE 828757`?:e' 5k�Bonded TAroigh Natrona)Not �''��"� Bonded Through National Notar n *sssss**� APPROVED BY Z'Z�7✓ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) IES ` 5". CR 3 main 11111t" Miami shores Village Building Department OR 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. -/ COPY OF QUALIFIER'S STATE LICENCES B. _j/ _COPY OF LOCAL BUSINESS TAX RECEIPT C. �COPY OF LIABILITY INSURANCE* D. ✓ COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: ��tf' LI�� Il� bit1C1 BUSINESS ADDRESS: �� Ti�h�SQ�1 �� CITSTATE_ ZIP 3 BUSINESS PHONE: ( 51) qbl -55 I FAX NUMBER )�IVZ-6�1 CELL PHONE 6 )45—645� QUALIFIER'S NAME: ' QUALIFIER'S LIC NUMBER: O t-C.QZC�5- 10C% STATE OF FLORIDA - DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFCO25560 � 4 he PLUMBING CONTRACTORS famed below IS CERTIFIED 'w;x',r Jnder the provisions of Chapter 489 FS. °9p --xpiration date: AUG 31, 2016 GEIGER, ROBERT C CHARLIE SWAIN PLUMBING 6299 JOHNSON STREET ' HOLLYWOOD FL 33024 `= BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT" 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 r VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 C Si I DBA: Receipt#:182-232071 Business Name:CHARLIE SWAIN PLUMBING Business Type:PLUMBING/LWN SPRNKL/CONTRhC'TOR Owner Name:GEIGER ROBERT C/QUAL Business Opened:o3/25/201.0 Business Location:6299 JOHNSON ST State/County/Cert/Reg:CFCO25560 HOLLYWOOD Exemption Code: Business Phone: 954-961-5527 Rooms Seats Employees Machines Professionals 8 For Vending Business Only _Number of Machines: Vending Type: TaxAmounl Transfer Fee NSF Fee Penalty Prior Years Collect .ion Cost Total Paid _ _ 27.00 0 00 0.00 0.00 0.00 0.001 - 27 ' — 00 n: L THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business narne has changed or you have moved the F' business location. This receipt does not indicate that the business is legal or that it is in compliance with Stale or local laws and regulations. Mailing Address: �i CHARLIE SWAIN PLUMBING Receipt #05A-1.3-00011.123 2.1 SE 10 S'r Paid 09/1)/2019 2�.oo DEERFIELD BEACH, FL -33441 �i 2014 - 2015 ��;-,,_`_,�!:t�;:'a!a"+ b<.'aRi�.:-.'E �='c:,r.r!1L-',�3`w;"d'.y=;�?l?c•�'F:it.��Z.`�Fk'.:t"�",As=`">�,it?�'. .Y.';7trrX'�:i"n+:+as:?wb".$'FZ:-�Z.'rX Fa"4's°�,.i"a�i�GSi:] ii''fs'a�.` i r ,4coRU® CERTIFICATE OF LIABILITY INSURANCE M'°°"'" 1/229129/200 15 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 CONTACT NAME: _ Bateman Gordon and Sands P"c"0 954-941-0900 in/c,No):95441-240th 3050 North Federal Hwy E-MAIL Lighthouse Point FL 33064 ADDRESS: hnsonndbasagency.com INSURERS AFFORDING COVERAGE _ _NAIC M_ INSURER A Amerisure unance INSURED ADHPL INSURER 8 Arr efisu_re-MUlua- lnsumnce-C.2-. —. — —. - ___Z3396 ADH Plumbing,Inc. INSURER C AMeriSWEQ dba Charlie Swain Plumbing INSURER D: 21 SE 10th Street -- Deerfield Beach FL 33441 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1670930815 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 DOL I POLICY EFF POLICY EXP LIMITS LTR INR POLICY NUMBER MM/DDIYVYY MM/DD/YYYY A I GENERAL LIABILITY GL20657200601 /1/2014 /1/2015 EACH OCCURRENCE 81,000.000 'X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100,000 TI CLAIMS-MADE OCCUR - MED EXP(Anyone person) $5,000 ��-- PERSONAL 8 ADV INJURY $1,000.000 GENERAL AGGREGATE $2,000,000 _ [[GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000JEC - POLICY PRO- LOC �J E C AUTOMOBILE LIABILITY CA20658760601 /1/2014 /1/2015 Ea accident 51.000,?go X ANY AUTO BODILY INJURY(Per person) S Y—i ALL OWNED SCHEDULEDO — —— e - _ -- — — Illttt I AUTOS AUTOS BODILY INJURY(Per accident){$ X NON-OWNED PROPERTY DAMAGE $ t^ I HIRED AUTOS AUTOS Per awdent) S B X UMBRELLA LIAR X OCCUR ICU20658890602 /1/2014 /1/2015 EACH OCCURRENCE _ _ $5.000.000 — — — EXCESS LIAB LCLAIMS-MADE AGGREGATE $5,000,000 F" DED iX RETENTION$0 s A__T WORKERS COMPENSATION IVVC206572107 /1/2014 4/1/2015 FX W'CU- .OFR.TTH-i AND EMPLOYERS'LIABILITY 1,/N - TOgYSTAT11T�; _ ..—. —. ANv PROPRIETOR/PARTNER/EXECUTIVE O N/A E.L EACH ACCIDENT i$1.000.000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E .DISEASE-EA EMPLOYEE$1.000.000 If yes.descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 ` II DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Work performed at 126 NW 109 Street, Miami Shores (CFC 25560) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village-Bldg dept ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Ave 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 II