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PL-14-2427 r "P, �' � i+ ? Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-222842 Permit Number: PL-11-14-2427 Scheduled Inspection Date: August 27, 2015 Permit Type: Plumbing - Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner: BUCKLAND,CASSIDY Work Classification: Addition/Alteration Job Address:358 NE 94 Street Miami Shores, FL Phone Number (786)797-0522 Parcel Number 1132060136150 Project: <NONE> Contractor: 1A FLORIDA PLUMBING INC Phone: (305)967-5037 Building Department Comments INTERIOR REMODEL ADD NEW BATHROOM, KTICHEN Infractio Passed comments REMODEL AND RELOCATE LAUNDRY ROOM INSPECTOR COMMENTS False 03/17/2015 PERMIT IS ON HOLD AS PER QUALIFIER. MR. CUE IS NO LONGER WORKING ON THIS PROJECT. THE OWNER HAS TO PROVIDE A CHANGE OF CONTRACTOR WITH REVISION. nspector Comments Passed DI/ Failed Correction ❑ Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid August 26,2015 For Inspections please call: (305)762-4949 Page 2 of 44 art , r K7.f� 5Ea € l �lY Miami Shores Village 10050 N.E.2nd Avenue NECIA o Miami Shores,FL 33138-0000 Phone: (305)795-2204 Expiration: 07113/2015 i,�= . Project Address Parcel Number Applicant 358 NE 94 Street 1132060136150 CASSIDY BUCKLAND Miami Shores, FL Block: Lot: Owner Information Address Phone Cell CASSIDY BUCKLAND 358 NE 94 Street (786)797-0522 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,380.00 1A FLORIDA PLUMBING INC (305)967-5037 Total Sq Feet: 0 Type of Work:INTERIOR REMODEL ADD NEW BATHROOM, Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Return: Top Out Classification:Residential Scanning:3 Rough Rough Rough Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 Invoice# PL-11-14-53473 Change of Contractor Fee $75.00 11/18/2014 Credit Card $67.80 $50.00 Change of Contractor Fee $75.00 DBPR Fee $2.00 11/04/2014 Credit Card $50.00 $0.00 DCA Fee $2.00 Education Surcharge $0.60 Invoice# PL-12-14-53925 Permit Fee $100.00 12/16/2014 Credit Card $78.00 $0.00 Scanning Fee $9.00 Scanning Fee $3.00 Scanning Fee $3.00 Invoice# PL-3-15-54834 Technology Fee $2.40 03/18/2015 Credit Card $78.00 $0.00 Total: $273.80 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 a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning.,Fu ermore,I uthorize the above-named contractor to do the work stated. March 18,2015 Authorized SI r .O ner / Applicant / Contractor / Agent Date Building Depa ment Copy March 18,2015 1 �L.E�S% f-tOV/S Ir s Miami Shores Village 1 7 E Building Department A° 201 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 1(0 BUILDING Master Permit No. �"j qZD PERMIT APPLICATION Sub Permit No. -2-� ❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑MECHANICAL [:]PUBLICWORKS VICHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS:358 N.L 94'� EA. City: Miami Shores County: Miami Dade Zip: 3313 , Folio/Parcel#:I%�,Z6(po 13b 15 Q Is the Building Historically Designated:Yes NO Occupancy Type:S(oL"AL Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):- Phone# Address:358 N.E. q4 ti Sa, city:UIRU% :Sba= State:JL_ Tenant/Lessee Name: Phone#:---MQ— i`(-052 Z. Email: CONTRACTOR:Company Name:X A F\blkNa YhAn2 ems arc. Phone#: 30S %0_1 —50'6-1 Address:LAZ-:�p )...o,1 aye P-Lz 'Dc # iOUt city:LA�� state:'YL. zip:3332 Ca Qualifier Name:1l3� S . 1ycing jj ae— Phone#: State Certification or Registration Mcfl 14 an� Certificate of Competency#: DESIGNER:Architect/Engineer: FW" JDA 11M( -Nn®Q h1/ LNG i N tit P-ti K'G Phone#: bS Address: -1500 NV, 750 5VEer, 5UI'46 -24 � city: / �AIA( State: FL Zip: 31 ��- Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace F-1 Demolition Description of Work: I�Y6 pg `�Mo \— A-pq N-6 W 6 V-W� > kLIKM Specify color of colo hru 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$ ::�(PJ (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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. ZSignature /&wSignature OW E rAGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this n day of rr1 '::40—C-H ,20-IS ,by Lo day of Momb ,20 r3 .by �J Sl p l '"vVtio i[personally known to 3'=$:,3. ?Dyl- I,t� .who i ersona to me or who has produced t"� l as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: \\��allllli��i��i,� NOTARY PUBLIC: C31 4 go qp �lfAtlp�L•X711 V ILP s rM1&{dL UO s s I U1 W 0 �*= PdY COd1AISSIOAI EE 867545 Sign' _ Sign. EXPIRES• 60� dad14N Undviallem Print' - mt MONO Seal: ''�. say y�:a $'�5eal: APPROVED BY �� Plans Examiner Zoning Structural Review Clerk (Rev1sed02/24/2014) 4 4 Q Vp mail ® a111M Miami shores Village Building Department 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. 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 CERTIFICATE 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: l A F6� � h-h ntt r%c BUSINESS ADDRESS:' V%L A"'04 CITY ,- STATEf�ZIP�3' BUSINESS PHONE:OM-)qo-1 57Q371 FAX NUMBER( ) CELL PHONE QUALIFIER'S NAME:MWo LK: "Q TvL \ko. QUALIFIER'S LIC NUMBER: 4� 0310612015 13.40, To P.0011001 ACSIVCERTIFICATE OF LIABILITY INSURANCE DATE( YYYYI a3/W1/ofi/15 THIS CERTIFICATE IS ISSUED AS A MATTER ON 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 In an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WANED,subject to the terns end eondltlone of the policy,certain policies may require an andorsamenL A statement on this certificate does not confer rights to the cOMflcate holder In[IOU of such andolsem nVai. PRODUCER gmONg� T Luka Estrella Accurate 8300 West Flagler Suite 194 �! e.s:)_ (308)22!3-8727 cam.Nm: (30$)228-8787 tusie9streue,�bellsouth.net Miami,FL 33144 INSURER(Sl AFFORDING COVERAGE NAIL# Phone 305 226-8727 Fax (305)22"767 INSURERA: AaldentlnsmrmCo. INSURSO INSURER IN! PrOOM" A 1A Florida Plumbing Inc. INsumm o. Ascendent Insurance Cc 423 Lake View Dr. #104 SURER D: Weson,FL 33328- RER E: COVERAGES CERTIFICATE NUMBER: nus 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 CONTRACTOR 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. ILTR NR TYPE OF INSURANCE AD SU POLICY EFF _ Po cr NUMOIR LIMITSGENERAL LIABILITY ' EACH OCCURRENCE 1,000,000.00 ® COMMERC WL GENERAL LIABILITYY AMA-EUI E TO RENTED 1 00,000.00 A Q C) Ct A1Me MADE ® OCCUR COD00003786-01 MED :E:aern p,,n) S 5,000.00 ❑ -- ,_._. 04/22/2014 04/22/2015 PERSONAL&ADV INJURY S 1,000,000.00 GENERAL AGGREGATE ss 2,000,000.00 GEPPLAGGREGATELIMITAPPLIESPER PRODUCTS-COMPIOPAGG S 1,000,000.00 I POLICY ❑ PR ❑ LOG IS AUTOMOBILE IJAMUTY INEDtSWGLE IN 0 ANY AUTO B ❑ ❑ OEO ❑ ULED BODILY INJURY(Pepets-) 8 10,,000 AUTOS 033366-0 .00 HIRED AUTOS AO 10/21/2014 10/21/2015 BODILYINJURY(per uddrt E .00 AUTOS ,g,M rAMAGE $ ❑ UMBRELLALIAB ❑OCCUR $ •• ❑ EXCM LUT CI1►IMS.M OE EACH OCCURRENCE $ 6LOGREGATE i ❑ DEO RETE _ WORKERS CONPP.NSATION S AND EMPLWMW LIABILITY wC STA . 'El 91"' ANY PROPRIETORIPAR ERIEXEOUTWE N WC�660S6-0 C OFFIGEWMEMDER EXCLUDED? NIA E.L.EACH ACCIDENT 9 100,000.00 (Mnn Inn NH) 10/02/2014 10/02/2015 oyee �under E.L.DISEASE.EA EMPLOYE E 100,000.00 DEtr+�RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT IS 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICL!$(Aftwh ACORD 191,AdCitional Ram wUv Sd*dWe,it more space is roqulrcd) Contractor License#CFC1423753 I CERTIFICATE HOLDER CANCELLATION -� Miami Shores Village SHOULD ANY OF THE ABOVE DEScRi CANCELLED BEFORE 9 THE EXPIRATION DATE THEREOF,NO VEREp IN Building Department ACCORDANCE WITH THE POLICY PR N . 10050 NE 2nd Ave AUTHORIZED REPRE9MMIr VE Miami Shores,FI 33138 305-756-8972 Lucia Estrella ACORD 25(2010/03)RF ®1888-2010 ACO ION. All rights reserved. The ACORD name B d logo era registered marks of ACORD STATE E OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULA11ON CONSTRUCTION INDUSTRY LICENSING BOARD (850)487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 PANEQUE,JORGE J 1A FLORIDA PLUMBING INC 423 LAKEVIEW DR,#104 WESTON FL 33326 Corn�ionsf wdhthis licenio you ns ori of the ready one minim►Floridians licensed by the Deparknent of Bum and Professional Regulation Our proftslorift and bushmm r ow STATE OF FLORIDA from architects to yacht brokers,from boners to S. DEPARTMENT OF BUSINESS AND and they keep Florida's economystrong. PROFESSIONAL REGULATION Every day we wok to improve the vmy nue do business in order to CFC1428753 ISSUED: 08/09/2014 serve you better. For Information about our services.please log onto wwwAyflorklailcense,cwn. Thene you can find rnore mon CERTIFIED PLUMBING CONTRACTOR about our d uWans and the regulallons that Impact you,subscribe PANEQUE,JORGE J to depadrnent newslellers and leam more about the Department's 1A FLORIDA PLUMBING INC initiatives. Our mission at the DeParlrnent ls:License Eftlently,Regtlafe Fairly. We constantly wive to serve better that you can serve your custor ners. Think you for doZg in Rlarida, IS CERTIFIED under the provisions of Ch.488 FS. and congratulatlors on your now iicensel :AuGM.are na DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTPAEfff OF BUSINESS AND PROFESSIONAL REGULATION! CONSTRUCTION INDUSTRY LICENSING BOARD CM1428763 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provmns of Chapter 489 FS. Expirafion date: AUG 31,2016 • PANEQUE,JORGE J 1A FLORIDA PLUMBING INC a • 423 LAKEVIEW DR,#104 s �, WESTON FL 33326 r1#_CPr AV A-q RF01HRF®BY LAW SEQ# L1 .P20-4'' -! 5-0 JORGE JUAN i PANEQUE 423 LAKEVIEW DR API 104 rr�r t.FL 333N-WW Y966 5E�" At W2010 NtV 12. 3.2019 SAFE DRNER s.�zatwn d 0 mots wi-jo COMM#-caMarr t f�•ady utxte;y •HNxfefi hS 41w L BROWARD COUNTY LOCAL BUSINESS TAX_RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 DBA:1A FLORIDA PLUMBING INC Receipt#:PLYING/LWN SPRNKL/CONTR�,CTO} Business Name: Business Type: (PLUMBING Owner Name: ToRGE J PANEQUE Business Opened:ol/11/2013 Business Location:423 LAKEVIEW DR #104 State/County/Cert/Reg:CFC1428753 WESTON Exemption Code: Business Phone:954-336-3365 Rooms seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.001 0.00 0.00 0.00 1 0.00 27.00 i I 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 said, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: 1A FLORIDA PLUMBING INC Receipt #OIA-13-00005470 423 LAKEVIEW DR #104 Paid 07/18/2014 27.00 WESTON, FL 33326 2014 - 2015 1 DANG, P.A. Attorne.ys at Law March 4,2015 VIA CERTIFIED MAIL Hector Cue Supreme Plumbing Corp. 840 E. 50' Street Hialeah, Florida 33010 RE: Job Address: 358 N.E. 94th Street Miami Shores,Florida 33138 Owner: Jonathan C. Buckland Master Permit No.: RC-9-14-2031 Sub Permit No.: PL-14-2427 Dear Mr. Cue: ' Please allow this correspondence to serve as formal notice that the above-referenced Owner hereby terminates his owner-contractor relationship with your company due to your company's abandonment of the work. Please be advised that the Owner will be submitting a Change of Contractor Form to the Village of Miami Shores' Building Department within 10 business days from March 4, 2015. V ery Truly Yo s, on an C. Buc land,Esquire Cc: Florida International Engineering,Inc. 7500 N.W. 25th Street Suite 241 Miami, Florida 33122 12700 Biscayne Boulevard • Suite 305 • North Miami, Florida 33181 • Phone(305)400-8082 • Fax(305)400.8083 www.bdpalaw.com COMP 27LIVERY SENDER: COMPLETE THIS SECTION LETE THIS Sl�:C-,ION('N.f� ■ Complete Items 1,2,and 3.Also complete A.Signature Item 4 if Restricted Delivery Is desired. ❑Agent ■ Print your name and address on the revers1=i AddressQe e, so that we can return the card to you. B. Rem tinted } C.Date of Delivery m Attach-this card to the back of the mailplece, or on the front If space permits. D. dellvetYadtlress diller iro h qm 1? CI Yes 1. Article Addressed to: t�YE$`enter delivery add rs bR' ❑'No 1 No ad Miff d ExpresC ` ❑ gistgr�ed" •d J9ett" Recelpt for Merohandlse mare Collect on Delivery W1Y X 4. Restricted Delivery?(Extra Fee) ❑Yea 2` eNumber, 7014 0150 0002 010'4 5585 -1 afar frbm service fabs/) -- _ Ps'Form 3811,July 2013 Domestic Retum Recbipt . r a r Miami Shores Village Building Department artment 11 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 BUILDING Master Permit No. RC— I-1 q — 2o3I PERMIT APPLICATION Sub Permit No. PL --14— 24 2,3- ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [ LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP �('�.� CONTRACTOR DRAWINGS JOB ADDRESS: 3['JDQQ 1V pr•E • qq "1 STOEjEr City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11c3 20 60 1161 go Is the Building Historically Designated:Yes NO Occupancy Type: J r*L "Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): :t0W"EI'N C - 6VCy_Ut' j> Phone#: 2 Address: 5Y NK. qI{114 � City: MIW� S"of-es State: F� Zi 3313 Tenant/Lessee Name: Phone#: 6 Email: CONTRACTOR:Company Name: 'q °0' fi+ Phone#: Address:i i ` � City: f/-l�A4► State: �� Zip: 333010 Qualifier Name: 4 EC4706, Phone#: 505 316-105e State Certification or Registration#: CFt— iq Oa'7 - Certificate of Competency#: DESIGNER:Architect/Engineer: F-Lg)gIVA- INTe-jAlI aWAj_ ;Ejj6r,N&-)LiKfG Phone#: '305 3--8`— Address: 7'500 N.W. ZS +i I Su 1'M 240 City: MI wj State: Zip: 33 122 Value of Work for this Permit:$ 2�?j$ Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: I BIZ 0I, R1e M,ODt L, ., ATV N rG W 6 fi KOO M VG1tCMg'�4 {1,SM ODE C ASC MOK (Li✓MObk L 112 LGCA1* LA-UNP(Z)f Ro M Specify color of color thru We.- Submittal ile:Submittal Fee$ Permit Fee$'' CCF$ CO/CC$ r Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ l 6 (Revised02/24/2014) p r 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 abs ce f such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OW1 JER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of pu"80ff 20 �� ,by day of 20 by ,who isersonally know to I" ho is personally known to me or who has produced as me or who has produce L �3(0 3aS73 as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTAJPBSign: Sig Print: Print: �as'Sc� Seal- NOTARY PUBW Seal: dh STATE OF FLORIDA \\a„y p•a Cmnl#IFFOO 87 ?o� �e%- MELISSA TARAZONA • Notary Public-State of Florida Expires 2/12/2018 *xl**x/�1* �1*Ixl��llx�l*�Il�xllx�l*xllxxl*Ixxl***�Ilx*+xIx�xlx�l�llx**�x�l/xl�lx�l�l�l�l**�I�I�I�I�IIx* lig1>iY�l�k4 �lt�&If �tlt� °FocF\o\° Commission#EE 872382 APPROVED BY —];�?�ts� �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATIONe s CONSTRUCTION INDUSTRY LICENSING BOARD CFC1428027 The PLUMBING CONTRACTOR Named below lS CERTIFIED " ,M1�` Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 0 RED 0 CUE, HECTOR EDUARDO i SUPREME PLUMBIING,CORP _ ! 840 EAST 5 STREET HIALEAH FL 33010 ISSUED: 08/21/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408210001429 Miami—DadeGountyr $t Ft ridgy TmisisNOTAMLL-DO NOT PAI' s T;, 68 7628 "auSlntEss hlaanE -QCF�t7oAI RECEIPT Igo.srP :�Ms�n�G GciR�, = R�, wAk EPT SMBER; �," � H IALF�F `3W X0 Muse Lie dismal i pii c o busina -: P4raudRt tQ tsurlty CQ[i9 - ' . 0ap#8r 8A Arta&10 OWNER SEC.TYPE OP13USINF-S3 PAYMENT RECEIVED SUPREME PLUMBING CORP 196 PLUMBING BY TAX COLL-0MR CONTRACTOR 45ti(10 0911$12014 wodcer(S) 1 CFC1428027 ,. .CReDITCAR4)-14-038344 This Local,Rosiness Tax Mmwp ply coub=payment Gift Local Bwkt"sTm-7 HeCeipt is ff"icroste. pera t,arazortificafto otbe hbidoes qualifications,to do blatiioe m Holder must complYtiirltb anv 9ev0iumulal er noagovmm mel mgalat qtm aad m4okenemm width appli m'ffie ba bom The BCCEIPT NO.a"na18t be displayed an a11 commcW radicles-AAiesni-Dada Coda Sac 1N-2T6 y . F'ilimoreiaion�attiam.risitwiaw.miam�dadoaovhalmoil .i_r EDF LIABILITY 12112114 THIS CERTIFICATE IR ISSUED AS A MATTER OF INFORMA6T ON ONLY ANO CONFEiIr$NU IAP""UF?ON.T i CERT1I ATATE ffOLDEFi.TIIIS__ CERTIFICATEDOES NOT lKFFIRMATIVELY OR i EGAII I_ Ly(1AMEND,EXFENO OR ALTEf3 THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DQES NOT.CONSTITUTE A CONTRACT BETWEEN THE ISSUING NOUREK(S),AUTHORIZED 7 REPFiERF.N ATIVI~QIT PRODUCER,AIVD THE '"ACATE."OLQEIi. 'IiR 1AN1:If fh�cardtkat ttiiTdar is en ADDIimAL IEISEfRED;ftie ppttcy{iea)rn k be sFiclQrsasf,tf$UBI{ICiAA170N I5 WAtV ,eubjgct to ---- the tWMS artd mWifians'of the ollcY.COMM pdkles may regtaalre an.ellderaement A statement Cn#d8 corfiflcate dose np t Comer rights fo the oertiftate tw1dor In lieu of such endowment(s). k PRODUCER A MARC4StIARE2 � Suarez&Associates ,.��••-• � ...�!t►('uN+?t.:e; M15977 7400 N.W.South River Drive,#$1A hamar��fieti�Ultlret_ _ Medley,FL.3313 1N , irnRizlinta coVE► caE _roc C_— Phone (306)88"4-SMW Fax {313& 4 6977 v w — INWREAS'fARR it UFMNiFY W8,00. INSURED WSURER S: SUPREME PLUMBING CORP 8 ERC 640 E'8TH ST INSURER tti __ HIALEAH FLM,10 iNSIIRER E i _ W F, COVERAGES T CER I17CATEIVUISBEI REVISION NUMBER. THfS ISIS TO CERTIFY THAT THE 1 3UCIE5 OF INSURAPIGE LIS f>nD WOW HAVE BEEN ISSUED Tp THE IN UIiEq tdRMEO IIBgVE FOR THE POLICY PERIOD { tNDtCATED. NQTW1TtISTANDpVl3 ANY REQUIREtdlENT,TEDD OR:CONDiTit)N OF APfY oomTRACTm Owes powwNT WITH RESPECTTO WHICH THIS I CERTIFICAT9MAYBE ISSUED CYdt'MAY PERFAIK TAS I.NSfj- 0E:AFF0RAE0BY tHI=POLIOIES:f)FEWOW HENEIN IS SU6JECT TO ALL THE TERMS, EXCLUSIONS AND CWMMONf OF SUCH POUCtES:LIMiT$4HQ*taMp,Y HAVE BEEN REDUCED b1*PAIi?;CiAiI�S. TYPE OF INSURANCEI'MR R POLICY R. P LINBTS. t>'0MAL LL42R TY EACH RRENCC s 1000 000.00 r��Tts 9E{�iiIAL HpL UAMUTY 1 O E 100,000-00 LJ CI 1{iA1S MADE OCCURA tom+ IIS 1... S 000-.001000920141 0812M014 082215 PERSONAL&ADV MUM $ 1,000,000.00 i Q ItENERhLAtit3REtdaTE $ 2,0,000.00 PPL AGGRODATE LUT APPLMPER: PRODUCTS•COMPOP AGOG g 1,000,000.00 I LL!POLICY ❑ k t LOC S AUTOMOSWE LIMILrI ff i O LE L__i CIAdiT {� 1 4 AW^ffO BODILY Im"W(Per parson) SALLOWNE - I AUTOS ppSCHEDULED @LILYIAtAmY(Ptu=ww $ iMt3rlOVdtdE3 p w.... ...__.......U. i I mmo AUTOS lJ AUT()$' I l P ia1PF l t3A&tAQt $ 1_9 UtdQAELLA LUIS _ __..__ . . _—� �—p AGGREGATE 3 DED El RE7'BNTIOP11��— -- W 6MRPSrCtDNkENBlATaON �SC13 61 5 OtN __ i � }AMD' IPLOY `LIAfINi1'Y YIN'. ANY PROPMETOWPARTNEREXB;IJr E (EL EAQNACCIDENT - S ---- OFFICER>IVt MIM EXCLUDED? NIA I d I w�i t ELL,D%VEm•EAE 40LOY $ �� RI OPERATtObd3b81ouav_.__ _._�_ EL DISEASE POUGYUMIT $ I i DESCRU>TIOIM OP OPERATION)LOCATIONS I VEMLES(A1140 ACORO 101,AdttltAFW Remarks Scleetluk,It 06m space N relished) LIC 4 CFC1428027 [ RESIDENTIAL AND COMMERCIAL PLUM8INO CONTRACTOR t CERTIFICATE HOLDERLANCE ABOVE DESCRIBED POLICIES BE CANC LLED BEFORE E CITY OF MIAMI SHORES BUILDING DEPARTMENT THE TI N DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2ItiD AVE ACCO THE POLICY PROVISIONS. MIAMI SHORES FL 33138 N�nTIVE 1 8II10 D CORP6KATION. All rights reserved. ACORD 26(20100)CIF !# me and logo are reglatered,marim of ACORD 06-21-2013 JEFF ATWATER STATE OF FLORIDA CHIEFFMANCKOFFIM DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * CERTIFICATE OF ELECTION TO N EXEMPT FROM FLORIDA WORKEIIS' COMPS UTiON LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listad below has elected to be exempt from Florida Workers' Compensation 18w. EFFECTIVE DATE 08/22/3013 EXPIRATION DATE 08/2212013 PERSON: CUE HECTOR E FEiN 275301441 BUSINESS NAME AND ADDRESS: SUPREME PLUMBIINB CORP 840 E STH ST HIALEAH FL 33010 SCOPES OF BUSINESS OR TRADE: 1— PLUMBING NBC AND DRIVERS lW1111TANT: Pursuant to Chapter 448 . 051141 F.S.. an officer of a corporation who elects exemption from this chapter by filing a motcote of election ender this section may net recover bandits or compensation under this chapter. Pursuant to Chapter 448.06(12), F.S., Certificates of olectton to be exempt.— apply poly within the scope of the badness or trade listed on the notice of election to be exempt. parsawn to Chapter 440.851131 Fs., Natives of election to be exempt cud certificates of election to be exempt shalt he subject to revocation it at any time after the filing of the notice or the issuance of the cormleate, the parson awned on am notice or certificate as longer meats the rnairemem of this auction for issuance of a serwicam. The department awl revoke a cares ewe at gay time for hil— of do Person awned on the emtincete to meet tips requirements of liftseetlOIL (JUF.STIONS7 (850) 413- OWC-252 C131WICATE OF ELECTION TO BE MUNIPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT 0yfp COMFINJUKVI PO TM CES F Pursuant to Cuter 440.05(94), F.&, int officer of a Carparatinn who CONSTRUCTION INDUSTRY O eli:Cts exemption front this chAnter by MIN a certiflcM of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDAL under this section my trot recover benefits Cr compensation wider tiffs WORT EFS COMPENSATM LAW 9 D thopter, EFFECTiVE 08/22/2013 EXPIRATION DATE: 08/22/2018 Pursuaftt to Mepter 440,05112), F.S., Cerfificetes of election to be pERS0J* HECTOR E CUE H exwrgn-. oplily only within the scope of the business Cr true listed on FEj j* 275301441 E the notice of election to be exempt BUSINESS MANE AND ADDRESS: E Pursuant m Carr 44005(13), F S., Wce" of election to be exempt SUPREME Pluusaac CORP and ewdfit of election to be exempt shall be subject to revocation 840 E 5TH Sr if, at env time after the filing of the notice or the issuetce of the HKLEAK R 33010 cwtific te, the person named on the notice of tertifitmte n0 longer mef the requirements of this section for i9lum :e of a C011tifitrete, The pep on tenteshell fks a�certieft to Mew at 000 requirements of 11115 SCOPE OF BUSINESS OR TRADE 1- PUMILA HOC AMID DRIM RS Section. QUESTIONS? (850) 493-1601 CUT HERE * Carry bottom portion on the job, keep upper pion for your records. t OWC-252 CERMCATE OF ELECTION TO BE EXEMPT REVISED 01-11 Miami shores Village Into Building Department 2Fare�siN$o �10R1pA 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 // Contractor,0 Print Name: "140 Print Name: e CT0 c✓2 A4 Jrr 1J4E Z_ Signature: Signature: State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn tgjand subscribed before me this 15 Sworn to and sub c ' ed b r me this t 2 day of days e - _ /PF1 199 By COMM#FF092357 B��''��a�i �� .AAi� OT .-COM (SEAL) (SEAL) L . n . efla' tea— Type of Identification produced - �-d5�6 Type of Identification produced Miami Shores Village arms ""'1" Building Department 4p �Pi IrR' A 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. RC "2031 & PL- )q--ZqZ:I- Owner's Name (Fee Simple Title Holder): T0N AA- C- OU Phone#: � z- - Owner's Address: 55Z Kfe 1zlF City: State : L Zip Code: Job Address (Of where work is being done): �� • � �� City: Miami Shores State: Florida Zip Code: Contractor's Company Name: f LIM& N�"J �NC` Phone#: S �' 9 22— 361 Address: :s- Iv- W• Ix,--r—r—i City: GO'D fly" GIT( State: E-L— Zip Code: 'd ®2, Qualifier's Name: �� „'GAS Lic. Number. CrG ® Zi Architect/ Engineer of Record Name: Phone#: Address: City: State: Zip Code: Describe Work: ' N'�-W hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. 1 hold the Building Official and the iami Shores harmless of all legal involvement. Signature Signature WT 1 0 � er or Ageninowledged Contractor or Architect The fore ing ins rument was before me The fore ping instrument'was aknowledged before me this ay o ,20/�,by ex�ay. v�� this ) day of Pt-C.. ,20/ijby tW L* 76 Who is ersonally know to me or who has produced • who is persopally known to me or who has produced as indentification. _s _aW+ as indentification. Notary Public: Sign: SiI � ' Seal: NOTARY PIBIJCaa l: ®•® ► STATE OF FLORIDA ®�:� #8E 177299 J.'rr� Cpril11#FF08238T try®voided thNa®®��0 E>pka 2AZ 018 �,� +` No seer. gym® r Miami Shores Village 1 - r Building Department j NOV 04 2014 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 201 3 BUILDING Master Permit No. �� R PERMIT APPLICATION W&LPermit No. _242 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REV ;' SION ❑RENEWAL FE-]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ GE OF ❑ CANCE y ION [:] SHOP C RACTOR DRAWINGS JOB ADDRESS: 358 NE 94 ST City: Miami Shores Coun Folio/Parcel#:1132060136150 \ s the Buil Ily Designated ` NO X Occupancy Type: SGL FML Load: Construction T FFE: OWNER:Name(Fee Simple Ti ATHAN C. BU ND P Address:358 NE 94 ST MIL city: MIAMI SHORES FL Zi : 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Compa me\\` �- N� � ��°� Phone#: Address: Lt4 2-0 JN City: rj To-- State: �L� Zip: ame: +�a Phone#: State Ce or Registrati Certificate of Competency#: DESIGNER:Arc' ineer: F IDA INT E AL ENGINEERING Phone#: 305-378-1991 Address:7500 N SUI 41 city: MIAMI state: FL Zip: 33122 Value of Work for this Permi' ` D Square/Linear Footage of Work: Type of Work: ❑ Addition tion ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: INTERIOR RE ` ADD NEW BATHROOM, KITCHEN REMODEL, BATHROOM REMODEL, RELOCATE LAUNDR OM Specify color of color thru tile: 169k,5I, Submittal Fee$ Permit Fee p CCF$ 9 �� g �r� CO/CC$ Scanning Fee$ , "f ® DBPR$ `�i �J Notary$ Radon Fee$ 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 o 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. k�l Signature Signature g g OWNEor AGENT CONTRACTOR The foregoing instrument wa acknowledged before me this The foregoing instrument was acknowledged before me this day of 0CT ,20 t�-4 by lC- day of Cdt6j ,20 1-1 by N i-1. ..� C>> �G►1- r�>�rho is personally known to Al'-w 'Vn5'-0-.5 who is personally known to me or who has produced uLz� fie as me or who has produced rYL `fi b 1C, 2 2 0 cf410EC)as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: 2 _ Sign: Sign: /1 Print: a Print: ONDO LEON .au�nq Seal: K SlndiaAlvami Commission s EE 175035 My Commission FF 16676® Seal: My Commission Expires W-1-, Expires 09103/2016 � ��"•�� Match 30, 2016 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 11/03/2014 1,1:38 Page 111 OP ID:TR A�RQr CERTIFICATE OF LIABILITY INSURANCE `�;031220 4 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 Roebuck Associates Insurance PHONE FAx Exchange LLC E-W No: 5599 S University Drive,I;:301 ADDRESS: Davie,FL 313328 PRODUCER Roebuck Associates CUSTOMER IDs G&RPL-1 INSURERS AFFORDWGCOVERAGE NAICtI INSURED G&R Plumbing Inc. INSURERA:Federated National Ins.Co. 2785 NW 84th Terrace INSURER 0: Cooper City,FL 33024 INsuRER c INSURER 0: 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. NOTVATHSTANDING 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. -06UdV EFF LTR TYPE OF INSURANCE POLICY NUMBER MMIDONYM IMMMLIMTS GEiVEMLIUASIUTY EACH OCCURRENCE $ 11000,000 A X COMMERCIAL GENERAL LIABILITY L050401166500 0211912014 02/19!2015 PREMISES EaocCurrence $ 100,00 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 6100 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOPAGG $ 2,006,000 POLICY JECTPRC n LOC $ AUTOMOBILE UABB.ITY COMBINED SINGLE LIMIT $ (Ea--dent) ANY AUTO - BODILY INJURY(Per person) $ ALLOWNEDAUTOS BODILY INJURY(Per acddent) $ SCHEDULED AUTOS PROPERTYDAMAGE $ HIRED AUTOS (PER ACCIDENT) NON-OWNED AUTOS $ $ UMBRELLA L1AB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATU- OTH ANtDEMPLOYERS'LIABILITY YIN Y6 _. ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? NIA (Mandatory In N)) E.L.DISEASE-EA EMPLOYEE $ Ilya desedbe www DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,U more space Is required) Plumbing Contractor License # CFC033812 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE iMTH THE POLICY PROVISIONS. Building Department 10050 NE 2nd Ave AUTHORIZED REPRESENTATM Miami Shores,FL 33138 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD EPAR?MENT ESSIlcwAt E GUIAR' o t* CFC033812 ISSUED : 08!05/2014 CERTIFIED PLUMBING CONTRACTOR TORRES , NILO G 8 R PLUMBING INC � . . theuncle : -. - provisions of Ch . 489 FS . L1408050001651 " BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 DBA: ReC@Ipt :FLDMBINGILNJN SPRNRL/CONTRACTOR Business Name:G & R PLUMBING INC Business Type:(PLumBIIJ(i cowmcTOR) Owner Name:NTLO ToRREB Business Opened:o5/22/2007 Business Locatlon:4420 NE 20 AVE P Stste/County/CerUReg=C 033812 OAKLAND PARK Exemption Code: Business Phone:954-822-3614 Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Colledlon Cast Total Paid 27.00 0.00 0.00 1 2.70 0.00 0.00 29.70 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 Munidpafity planning WHEN VALIDATED and zoning requirements.This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not Indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: NILO TORRES Receipt #04B-14-00000065 2765 NW 84 TERR Paid 10/02/2014 29.70 COOPER CITY, FL 33024 2014 - 2015 I port Viewer Page 1 of 1 i �t1 �1IX/96 0 WXMCFRCER STATE R`►g FLQRIDA �� OF;POIAN{MALrSERVICES ►�*CER IrATE OF I TO BE EXEWF FRAM FL4RWA ON LAW" JV�f ON MQUS RY_ ON gl I wT VEDATE: SMW 4 EZMTMDATE' WnWI8 PERSOM KPIUM GAL Feft 202UV42 NUMM AND ADDRESIL G A RPUmfflNFtti MVC 2785 NW 84TH TERRACE coopERCdM F1. 33M SCOPES OF 8LqW4M DR TRADE: UCENSEMPUINGM CONTRACTOR MEN Isms +I�1 p. Ym�al�ar eltm s ame eia�aa menaa�or be�s ppi tlds �r[mwrr�ia 76i/ tlpsaYelsa adsay�osd�e p��of� xmwtm� VFM-Mr,W TEOFELEG MT0BEEIMUPTREVISED 712 QUEST10W05*13-m8 bfts://appsg lld£s cum/cncpodv ewcheportV>ewer asgx?d kdvp A7Q3gH6TER.6e::. 4/1/2014 gold MOM Miami shoresVillage Building Department R 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel:(305) 795.2204 Fax: (305)756.8972 Notice to Owner - Workers' Compensation ins urance Exemption ,,yet. prior Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers vin the construction industry to exempt themselves from this requirement for any construction project to ac 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 elewto be exempt if- I. 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,YQU M be personally liable for the worker compensation iniuries of m 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 Contractor Print Name: Print Name: kO 1o,.rA_5 Signature: Signature:n�1 ...k!,,�_ State of Florida State of Florida County of Miami-Dade) County of Miami-Dade Sworn to a4d subscribed before BRYAN OKOINYAN Sworn to and subscribed before me this Z b Sworn scribed before 's 4 day of CXAftr ENOTARY PUBLIC day of (tel OF FLORIDA By 8 1 ,/1; "lot ORLANDO LEON MEJlA Cmw*FF092307 B EVW98 21112=18 yry�yMY Commission Expires (SEAL) (SEAL) Marah .110, 2016 Type of Identification roduced Type of I MW ea on producea