RC-13-569 (3) Miami Shores Village c—
Building Department EIVED
` ;aN 3 2014
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax: (305)756.8972 �BY:
INSPECTION'S PHONE NUMBER: (305)762.4949
FBC 20
BUILDING Permit No.P ( I ?) — 6 12—
PERMIT APPLICATION Master Permit No.-)c - 5
Permit Type: PLUMBING
JOB ADDRESS: k2e All- 99,17;lz
City: Miami Shores County: Miami Dade Zip: 3313c12
Folio/Parcel#:
Is the Building Historically Designated: Yes NO i,� Flood Zone:
OWNER:Name(Fee Simple Titleholder): 40s� Phone#:
Address: /,P� illi 9 9 77V S7��'7L-
City: IV)� r� S s'e---s State: Zip: (3313d'
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Com an Name: "Nr?�Li vet/� m � ��Phone#:
P Y
Address: 3-.6c) cj
City: State: ��-' Zip: `7Z
Qualifier Name: Iva Phone#:
LESIGNER:
S;ate Certification or Registratio i.' 02 �` Certificate of Competency#:
hone#: �o $% 02 mail Address: ` :
Architect/Engineer: ` Phone#:
,
Value of Work for this Permit: $ i did• Sggare/Linear,I ootag of Work:
Type of W ess ❑Alteration ONew OReir/Replace ❑Demolition
D
i
Submittal Fee$ 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$ 267�'2
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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subjL' h
hment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspe ionurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will no e ad a reinspection fee will be charged.
r-
SignatureSi
—Oi9�0411er or Agent Contractor
The foregoing instrument was acknowledged b fore me this ZL The foregoing instrument was acknowledged before me this �/fl
day of t�,tJp�t 20 ,by %U lA X7"4 da 0 r by �e Y
who is ersonall known t e or who has produced SAN ' ' o ally own t V who has pro ucec*� ,
As identification and who did to as ide a, n tid 'Ab did take,dWPo9%4filtorida
cx ires Mar 31.2016
NOTARY PUBLIC. o�acY tc�Q 9� N ARY PUBL m sion#EE 184297
'toppuu�Q .�y GO��'gs\On �\O�a� _
+,,,ec,�.., ` N � National Notary Assn.
Sign: Z' •• � Sign: .
Print: 1-- Print: 1-2�Vleer
VOW
My Commission Expires: My Commission Expires: ���//A6
APPROVED BY �_L �5O Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
01/21/2014 09:51 9544223991 JEFF SIVALLS PAGE 02/03
STATE OF FLOE HDA
°.w DEPARTMENT OF BUSINESS AND FROpESSIONAL REGULATION
CONSTRUCTION I INDUSTRY LICSN3ING BOARD
1940 NORTHOT STREET FL 32399-0' 83 (850) 487-1395
T�ASBE$
aEFFRRY
MXEiSIVALLWt7M PLUS L
LLG LLC
1231 SB 1 Avg
POMPANO BEACH FL 33060
Congratulations? With this liaenSe you bec meOne the y one million
nearlst•AM of F'LoRVA ACS'P, 2 3 r, 7
Floridians
licensed by the Department of 'tress and Professional Regulation. DRPARTM$N'T OF EWZ=S'3 ANI
Our prOessionais and businesses range architects to yacht brokers,Ttom PROFESSIONAL, RgaurATIOX
boxers to barbeque restaurants,and they I eep Florida's economy strong.
Every day we work to improve the wary webusiness in order to serve you Ostler, CFC1427397 07/31/1 120046E
For information about our senric�es,please o9 ont0 www.myfloridaliconse.com.you can find more' ons yfioridaliconse.com. CERTIFIED FL RACTOR
ourimpact you.subscribe to deeppaa tten news D t m and dam mare bthe ut te regulations that gNALLS. JEFFREY L
Department's initiatives, M1LLFblQNI17L� pLM4131M LLC
Our mission at the Department is_license ific+'entty,Regulate Fairly.We
constantly strive to serve you better so thal you can serve your customers.
Thank you for doing business in Florida,ar d congratulations onour new license! is �n under arae
Y p=wisioao 02 ch-48
-ssr=tlen dace= AUG 31, 2024 zxa07310202
DETACH HERE
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6236753 STATE OF FLORIDA
DEPARTMENT RBIII � �IISTOF84SIG RQULATIONDIIRy CMW9ONBDI
I $ NB 8EQ#I,1207310;26
707/3!12(012112004663.3. CFC 427397
The PLVMBnW CONTRACTOR
Named below IS CERTIFIED
Under the provisions of C aRpter 489 FS.
Expiration date; AUG 31, 2014
NZ EIM UM PL�I TG LL
231 SR I AVE
PONPANO BEACH
Fr, 33060 ,
1�Tnrr• anh.t+R,
• r►t+7.r T a rgOn�r
01/21/2014 09:51 9544223991 JEFF SIVALLS PAGE 01103
CH CRAFT,ST. LUCIE COUNTY TPU(COLLECTOR
FACILITIES OR EXPIRES SEPTEMBER 30, 2014
MACHINES J ROOMS SEATS EMPLOYEES 2
TYPE OF -,, 1799
1799 MISC/SPECIALTY C CTOR
BUSINPSS�' (PLUMBING)
BUSINtSS/Millennium Plumbing �T
DBA NAME 'w' rD
elp
MAILING Millennium Plumbing �e(mmt.TM'P
ADDRESS 5609 Raintree Trl Tf RENEWAL
Ft Pierce, FL 34982 J ORIGINAL TAX $12.35
PENALTY
BUSINESS 5609 Raintree Tr) elF ti` COLLECTION COST
LOCATION Ft Pierce, IL 34982 l� �.�� TOTAL $12.35
St Lucie County ac*3268380
L06000090317
Paid 09/19/2013 12.35 0025-20130919-013638
Law requires this Local Business Tax Rece t
01 to be displayed conspicuously at the place of business in such a manner
that It can be open to the view of the publ and subject to inspection by all duly authorized officers of the county.
Upon failure to do so, the Loral Business xpayer shall be subject to the payment of another Local Business Tax for
the same business, profession, or ocp�pa n.
Pursuant to State Law,all Local Business T x Receipts shall be sold by the Tex Collector beginning July 7 st of each
year and shall expire on September 30th f the succeeding year.Those Loral Business Tax Receipts renewed
beginning October ist shall be delinquent nd subject to a delinquency penalty of 10%for the month of October, Pius
an additional 5%penalty for each month f delinquency thereafter until paid; provided thatthe Notal delinquency
penalty shall not exceed 25%of the Local usiness Tax for the delinquent establishment.
In addition to the penalty, the Tax Coll r shall be entitled to a collection host fee of from $1,00 to $5.00, based on
the amount of the Local Business Tax, wh shall be collected from delinquent taxpayers after September 30th, of the
business year.
This receipt is a Lozal Business Tax only.I does not permit the Local Business Taxpayer to violate any existing
regulatory or zoning laws of the state, cou Ay or cities. It also does not exempt the Local Business Taxpayer from any
other taxes, licenses or permits that may required by law.
Local Business Taxes are subject to chang t according to law.
P
Millennium Plumbing
5609 Raintree Tri
Ft Pierce, FL 34982
r
01/21/2014 09:51 9544223991 JEFF SIVALLS PAGE 03/03
JEFF ATWATER STATE OF FLORIDA
CI F FIRANCIAL OFRCER DEP . ENT OF FINANCIAL S1=RVICES..
DIVI ION OF WORKERS' COMPENSATION
*. CERTIFICATE OF•ELECTION In BE EXEMPT 'FROM FLORIDA WORiriERT COMPENSATION. LAW
CONSTRUCTION INDUSTRY EXEMPTi N
This certifies that the individual listed bels rij has elected to be exempt, from Florida Workers' Compensation law.
EFFECTIVE' DATE ' 02/0712 EXPIRATION DATE: 02/06/2014
PERSON: SIVALLS JEFFREY L
FEIN: 412221717
BUSINESS NAME AND ADDRESS:
MILL6111411LIM 'PLIAMBING LLC
1502 SE 10TH AVE
DC£RFIELD BEACH FL 34982
SCOPES .OF BUSINESS .OR TRADE:
1- PUMiBING
IMPORTANT. Pursnom to Chapter "it c554%.p- Nn•effide of a torporetles Who elects ekw,pptlaR from Ws chapter by fllllnt s certdleete of etaettoe raJtir this
'Ocmo msy " recover h moons air compensation ander ibis ch' pter_ Persnaat•to chaptsv 44e,OSfn2), F.S.; Certilrcgtea of election to be exec
scope of tlKi'business or trade Ilated on the netleo el elwctiaa to be ox**pt, Pam to Chapter 440,e4{13f, Natices of ale M"' opply only vilhlr the
:election to be OX0011pt shall be Ublect to revar-stioe if, atoil slew to be exempt Nod certilienes-of
taste chat the fill et the The
or the issllnwa of tae entlflcote, fhe Pereaa tterartJ an t),p• Nellie ar
innnede�te uo loa9m etewto the t [tie requirements
of thbs section lar issRante of • eattaiCNta. lire department shell revoke a ed"iflcate n any Ntoe for failure of the person
aarnd ee rho tertrffcno•to gloat the rogatrenterOa d lets setxi n.
)WC-252 CERTIFICATE Or ELECTiON TO BE EXEMPT REVI 01;11 QUESTIONS? (850)•413-1609
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA .
DEPARTMENT of FINANCIAL sERvla= IMPORTANT
DIVISION OF WORKERS'COMPENSATION .
CONSTRUCTION INDUSTRY 0 Pursuant to Chapter 440.051141, F.S., en officer of a corporation who
CERTRCATE..OF ELECTION TO BE EXEMPT FROM FLORIDA elects exatttption from this chapter by filing a certificbte of election
WORKERS'Co!uft'rSVS►►71oN LAW �- under this section may not recover benefits to compensation under this
EFFECTIVE 02/07/2012 ERPIRATION 'DATE 02/06/2014 Ctuter_
PERSON: .JEFFREY L SIVALLS i„I Pursuant to Chapter 440.05112), F.S., Certificates of election to be
FER1f 412221717exempt- apply only within the scope of the business or trade
E the notice Of election to be exempt listed an
BUSINESS-NAME AND ADDRESS: R.
MILI "Um PLUMBRIG LLC ETurswt to 'Chester 440.05(13); F.S., Notices of election W be exernpt
1502 SE IOTrr AVE and certificates of election to be Oxempt Shell be subject to revotaltdon
DEERFIELD aEACK.FL 34952 if, at any time after the filing of the notice or the issuance of the
C"fificate, the person named on the (notice or 'certificate' no longer meets
the requirements of this• section for'issuance of a certiflOMte. .The
SCOPE OP'BUSINESS OR TRADE; department shall revoke a certifies at any time for failure of the
I- PLtlbllNrn person named on the certificate tb meet the requirements of this .
section_
QUESTIONS? (850) 413-1609
!„ CUT MERE
Carry bottom Portion on the job, keep upper portion for
Your records.
uC-252 CERTIFICATE OF ELECTION.TO 8E EXEMPT REVISE 1 01-11
01/21/2014 14: 14 7724650840 PRESTIGE INSURANCE PAGE 01/01
i
DATE(NMM11MM
CERTIFICATE OF LIABILITY INSURANCE
101/2112014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE {IDES 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 TIME CERTIFICATE HOLDER.
IMPORTANTs It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. H 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 endorsements)
PRODUCER N FACT BRENDA L.LEA
PRESTIGE INSURANCE ENTERPRISES INC PHO'Q Evk(772)463_2886 �"91:772-455-0840
5001 S FEDERAL HIGHWAY % e*:
FORT PIERCE,FL 34982 INSUR AFPORDfNO COVERA43E NAIL s
_ 1NSURERA.GRANADA _
Ir13tfRED INSURER e I � ,
MILLENNIUM PLUMBING LLC INSURER C:
5609 RAINTREE TRAIL INSURER V!
FORT PIERCE, FL 34952 INSURER E-
i
fN R 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. NOTwiTH5TANDING 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.
1 P hF POLICY i7(P
L7R TYPE OF INgURANCE N RR POLICY NUMOER MMI MMIDO LIMITS
OeNCRAL LIABILITY gg OCCURRENCE S1 000 000
T COMMERCIAL GENERAL LIABILITYI OCCV,Ir I PREMISES IEe $100 000
CLAIMS-MADE ;X OCCUR I I I MED EXP Anyone person 125.0 O
A 0185FLOO17467 2/15/2013102/15/2014 PERSONAL 8 ADV INJURY $1.()00.000
GENERALAGGREOATE S2,OOO,000
GEN'L AGGREGATE LIMIT APPLIES PER j PRODUCTS•COMPIOP AGG 51,000,000
I
POLICY PRO I LOC I $
AUTONOB0.E LIABILITY COMBINED SINGLE LIMIT
gryyqUTp j BODILY INJURY(Per person) .$
ALL OWNED SCHEDULED
AUTOS AVrOS SODILY INJURY(Per eccident);s
( NON-OWNED FR07ERTv OAMAO
HIRED AUTOS AUTOS (Per.scPds^.�) S
g
UMattELLA LIAR OCCUR EACH OCCURRENCE $ _
~�r=953LIAB CLAIMS-MADE I f AGGREGATE S
DEC) RETENTION S
$
i WORXERS COMPENSATION VYC STATU-
AND EMPLOYERS'LIABLITYILIMITS Fig
VIN
ANY PROPRIETORIPARTNEWEXECUnVE F7 1 N f A j E.L.EACH ACr,IDENT' S
OFFICERIMEMBER EXCLUDED?
(MsrdM-y it.MH) I E.L,DISEASE-EA EMPLOYE S
If yes,'"CrIbe under I — --•
DESCRIPTION OF OPERATIONS below i EL,DISEASE-POLICY LIMIT S
I i
i
OESCRBMON OF OPEPATIONS f LOCATIONS f VEHICLES(Mach ACORD 104,Addleeeal Rarnarls Sciam rle,if I•.w*epme to mgW,ed)
CERYIFICATI_HOLDER CANCELLATION
MIAMI SHORES VILLAGE BUILDING DEPARTMENT SHOULD ANY OF THE ABOva DF90RIDED POLICIES BE CANCELLED BEFORE
THE UMRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS•
MIAMI SHORES,FL. 33138
AUTHORIZEDREP
FAX: 305-756-8972
BRENDA L GENT
®1988- 10 ACORD COIfPORATION. A!1 rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD