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PLC-15-1440 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-241662 Permit Number: PLC-6-15-1440 Scheduled Inspection Date: August 20,2015 Permit Type: Plumbing - Commercial Inspector: Diaz, Osvaldo Inspection Type: Final Owner: CONDOMINIUM, MIAMI SHORES Work Classification: Sprinkler System Job Address:9022 NE 8 Avenue Miami Shores, FL Phone Number Parcel Number 1132060420110 Project: <NONE> Contractor: ROBAINA WELL DRILLING INC Phone: (786)683-7437 Building Department Comments ADD 1 ZONE AND 20 SPRAY HEADS TO COVER Infractio Passed Comments WESTERN PROPERTY LINE INSPECTOR COMMENTS False Inspector Comments Passed QUALIFIER WILL BE AT THE PARKING LOT OF THE CONDOMINIUM. PLEASE CALL JIMMY AT305-297-8050 Failedt - S Correction , 2 Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. August 19,2015 For Inspections please call: (305)762-4949 Page 31 of 41 it 'oLC-64 -1440 ♦5N� s L�� Miami Shores VillageIn F�Gi1 Imbin�,-Ci1r#rr>tarcial 10050 N.E.2nd Avenue NE ` r ` r11 2 Wr c 1a " Spilinklair SyatOM Miami Shores,FL 33138-0000 P'd Phone: (305)795-2204ROVED •• • ,.. ± .. FCORtDA i . issuetIte:6LEll1 Expiration: 1211312015 LU Project Address Parcel Number Applicant r...,,...._-.._... ,_._. .. ...�..,.�_._ .�.... 9022 NE 8 Avenue 1132060420110 MIAMI SHORES CONDOMINIUM Miami Shores, FL Block: Lot: Owner Information Address Phone Cell MIAMI SHORES CONDOMINIUM 9022 NE 8 TH AVE MIAMI SHORES FL 33138 Contractor(s) Phone Cell Phone Valuation: $ 5,500.00 ROBAINA WELL DRILLING INC (786)683-7437 (786)683-7437 Total Scl Feet: 00 Type of Work:ADD 1 ZONE AND 20 SPRAY HEADS TO CO Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Classification:Residential Underground Sprinkler Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.60 Invoice# PLC-6-15-55945 DBPR Fee $2.48 06/11/2015 Cash $ 50.00 $ 138.56 DCA Fee $2.48 Education Surcharge $1.20 06/16/2015 Cash $ 138.56 $0.00 Permit Fee $165.00 Scanning Fee $9.00 Technology Fee $4.80 Total: $188.56 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 zoning. Futhermore, I authorize the above-named contractor to do the work stated. June 16, 2015 Author' ed Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy June 16, 2015 1 Miami Shores Villages JUN, Y 1. 2015 Building Department (� 10050 N.E.2nd Avenue, Miami Shores, Florida 3313E BY: lVTel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 /L) BUILDING Master Permit PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION 0 RENEWAL �LUMBING ❑ MECHANICAL F-]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 4 � CONTRACTOR DRAWINGS JOB ADDRESS: �U l� C� A V: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: /Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): t,=A,J Phone#: -7--6(15, 5—��6�0 Address: MIAMI `c�t'1��=S L!A A'D A--,5, 3(f- 5 SSS a( C City: �G��L-C, J t�CIS State: r (_ Zip: 3 Tenant/Lessee Name: n Phone#: Email: yl,\ z- in, r®2 *O %"C.5 , La✓- CONTRACTOR:Company Name:ICt7�a/l1� 0/00r/ I yJ34 Phone#:? Address: a-I� 5 f � 0`�Yl ?I-� City: State: Zip: Qualifier Name: Phone#: State Certification or Registration#: < ejc e 0 Certificate of Competency#: ooOr6 DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ S '- Square/Linear Footage of Work: Type of Work: ;+ Addition /❑, Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: ��� A � a0 Specify color of color thru tile: Submittal Fee$ Permit Fee$ t��--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 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 x Signature ER or AGENT CONTRACTOR The foregoing in ru was acknowledged before me this The f egoing instrument was acknowledged before me this day of / !',�i° 20 ! S by i` day of 1w 20 /.5 by /h c` who i ersonally known to be-nowho' •personallyknown.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. NOTARY PUBLIC: NOTARY PUBLIC: Sign: /� Sign: l- Print-.; Print: JASON SCHOENHOLTZ JASON SCHOENHOLTZ Pn Pie' n Seal: ;? —�„` Notary Public-State of Florida Se 2 Notary Public-State of Florida My Comm.Expires Dec 14,2015 R . -_ My Comm. Expires Dec 14,2015 e: `I`� Commission # EE 153231 ' 'Wo Commission # EE 153231 ° °; ° Bonded Through National Notary Assn. i •�� 4p= to ******** Bonded T 8 y M W ******* APPROVED BY o ls�/ �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) �. STATE 00 hORIDA WATER WELL,CONTRACTOR LICENSE Issued to JOSE ROB. License Noy ' 7/31/2015 DISTRICT CEFRK , IOM OFFICER QUALIFYING TRADE(S) 0003 LAWN SPRINKLER Charles Danoer P E f Secretary of the Board WWW Local Business Tax Fbcei pt M lam I Dade County, State of Florida THIS IS NOTA BILL DO NOT PAY 5881496 BUSINESS NAId E/LOCATION RECEIPT N ROBAINA WELL DRILLING INC RENEW 24425 SW 214 PL 6134 MIAMI,FL 33031 O':'CER ROBAINA WELL DRILLING INC C/O ROBAINA,JOSE Worker(s) 1 MvsLocal Busineft permt,or a card• or MIAMF� The EXPIRES SEPTEMBER 30, 2015 Must be displayed at place of business Pursuant to County Code Chapter 8A-Art.9&10 PE OF BUSINESS PAYMENT RECEIVED SPECIALTY PLUMBING BY TAX COLLECTOR CONTRACTOR 82,50 10101/2014 09P000660 0226-15-000005 ipt only confirms payment of the Local Business Tax.The Receipt is nota license, e holder's qualifications,to do business.Holder must comply with any govefnmental latory laws and requirements which apply to the business. above must be displayed on all commercial vehicles-Miami-Bade Code Sec ftp-276. For more information,visit www.miamidadeowftx oIIgctor ' ® DATE(MM/DD/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 6/5/2015 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(ies)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 CON NAME: Iiasso AX Blackadar Insurance Agency, Inc. PHONENo.E :407- 1- vc No: 1436 N Ronald Reagan Blvd E-MAIL Longwood FL 32750 ADDRESs:Pattl blackadar.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Aut Owners Insurance 1 INSURED ROBAWEL-01 INSURER B: Robaina Well Drilling, Inc. INSURERC: 24425 SW 214 Place INSURER D: Homestead FL 33031 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:265364480 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY 72030277 /27/2014 /27/2015 EACH OCCURRENCE $500,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $300,000 CLAIMS-MADE JA I OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $500,000 GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU-LIMITS OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE FN/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Well drilling&lawn sprinklers 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 ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave NE Miami Shores FL 33138-0000 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD x JEFFATWIATER. CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL-SERVICES { OMSION'OF WORKERS'COMPENSATION. CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORg'COMPENSATION LAW•* �� CONSTRUCTION INDUSTRY EXEMPTION V This certifies that the individual listed below has elected to be exempt from Fio,'da Workers Cora EFFECTIVEDATE: 613/2014 [aeltsation law. EXPIRATION DATE: ti12/2016 PERSON: ROBAINA JOSE FEIN: 061790496 BUSINESS NAME AND ADDRESS: "R v ROBAINA WELL DRILLING INC 111 SW 53 CT MIAMI FL 33134 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRILLING NOC AND DRIVERS IRRIGATION OR DRIVERS DRAINAGE SYSTEM Pursuant to Chapter 440.05(14)•F.S.•an officer of a corporation who elects exemption from this chapter by tiling a certificate of election under this section not recover benefits w comPensalfon under this er pursuant to Chapter 440.05(12),f.S:,Certificates of, ... ctlort•lobeexempt . apply only ,wlUan i' perms' - ,� r^ a aertlllgte at_, � �, 77F1,LN47fi •.;�E C 0}TO BE MC � � � z Std 0712 Robaina Well Drilling Inc 24425 SW 214th PI Miami, FL 33031 (786)683-7437 Date State of County of !"V/- AM Before me this day personally appeared SUS 4N ,e( ,41r-)/4 who, being duly sworn, deposes and says that he or she will be the onl person working on this project located at 9022 NE 8th ave Miami Shores, FL 33138 Sworn to (or affirmed) and subscribed before me this day of e- 2015 By Personally know Or produced ID Type of ID produced 4 Notary Name/Stamp d ,.•. " �.,: REGINA QUART Notary Public-State of Florida My Commission Expires Sep 14,2017 4' ,�;�•,.��. Commission#F FF 023143' S�ORe2 D4 Miami shores Village loss ..... Building Department y� OR c 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 has acknowledge 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. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade +1, The foregoing was acknowledge before me this day of 204�. Bye N PIT C U,�. '\T who is personally known to me or has produced rL �� � ( as identification. Notary. SEAL: ,.•`i��`"��''., REGINA DUART Notary Public-State of Ffotida s". �=My Commission Expires Sep 14,2011 xrz'O'FI :�`'� Commission N FF 023145"