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PL-14-1149 Per / 3 -2_ 334-- Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-213488 Permit Number: PL-6-14-1149 Scheduled Inspection Date: December 11, 2014 Permit Type: Plumbing - Residen ' I Inspector: Diaz, Osvaldo Inspection Type;,Xe; Owner: BOURNE, ROBERT Work Classification: Addition/ er tion Job Address:490 NE 101 Street Miami Shores, FL 33138-2449 Phone Number Parcel Number 1132060170430 Project: <NONE> Contractor: AA MASTERS MECHANICAL AIR MOVING AND ENGINEERIN Phone: (305)559-7004 Building Department Comments PLUMBING FOR BATHROOM ADDITION 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. December 10,2014 For Inspections please call: (305)762-4949 Page 3 of 22 Miami Shores Village CEIVED Building Department JUN 0 3 2014 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 201 C BUILDING Permit No. PERMIT APPLICATION Master Permit No. g c 13 r Permit Type: PLUMBING JOB ADDRESS: /4Lo ME Ic`I 'atrett City: Miami Shores County: Miami Dade Zip: 3 Folio/Parcel#: 1 I - 62()(0-®1 - Qq 3 C ,p Is the Building Historically Designated:Yes NO Flood Zone: C) OWNER:Name(Fee Simple Titleholder): QU Phone#: 6(0) 2 �� _ ���(0 Address: ® N E A o I smofLi City: 6�-�tom` ��State: 1— Zip: 3310-3 Tenant/Lessee Name: Phone#: Email: ,, � I AW, �OVcv S CONTRACTOR:Company Name: AA Ba l &� 1'®�ecq o_,n!(, oA Phone#: ) 2-IM 0 0&4 Address: 15:501 5LIJ 10+ Tefracle City: State• Qualifier Name: ,Q 5, t ewr—q Phone#: (305-) 2.4 -0 (6(0- State Certification or Registration#: Of: C 14_.2&1 (o 9 Certificate of Competency#: _e Contact Phone#: Email Address:�O� Q AA�1��� ��e Un®-n lLM- (,O✓Yl DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$. �` �� Square/Linear Footage of Work:_�0 4_�_T Type of Work: OAddress `Alteration ONew L_JXRepair/Replace ODemolition Description of Work: ® c c, t -6:> o Submittal Fee$ Permit Fee$ .A y CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 0S ` Bonding Company's Name(if applicable) Rwffi g Company's Address City State 4A 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 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 Signatur Owner or Agent � Contractor The foregoing instrument was acknowledged before me this The forego' instrument was acknowledged before me this day of ,20�,by e,Ja; n c , day of tq A f ,20 Lf,by �� � M who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLI ,� Nary p �Smbs Florida NOTARY PUBLIC: ' ; Cristiane C Leon My Commbsion EE119033 ' Expires OMW2015 Sign: Sign: I 111i/e Print: t ' Print: My Commission Expires:(A 014�1,016 My Commissipires: y X01 APPROVED BY 6­fPlans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) L i Lo VN I. d A CERTIFICATE OF LIABILITY INSURANCE DA�05/28/14 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 ondorsement(s). PRODUCER CAME:ONTACT GRETELL GONZALEZ N Use General Insurance PNCN;Etl: (305)386-3305 A No): (886)330-1123 5841 S.W.137th Ave. EADDRESSO-MAIL gretellgonzalez@yahoo.com Miami,FL 33183 INSURER(S)AFFORDING COVERAGE NAIL# Phone (305)386-3305 Fax (888)330-1123 INSURER A: GRANADA INSURANCE COMPANY INSURED INSURERS: AA MASTERS MECHANICAL AIR MOVING&ENGINEERING SYSTEMS INSURER C: 15591 SW 105 TERR #525 CONTRACTOR LICENSE#:CFC 1426169 INSURER D: Miami,FL 33196 (305)244-0667 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. 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 ADDL UBR POLICY F_FF POLICY EXP LTR POLICY NUMBER MPWCD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 Q COMMERCIAL GENERAL LIABILITY PREEMMISES(Ea occurrence)GE TO RENTED $ 100,000.00 F-1 ❑ CLAIMS-MADE Q OCCUR 0185FL00045507 MED EXP(Any one person $ 5,000.00 A ❑ N N 05/06/2014 05/06/2015 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000.00 ❑ POLICY ❑ JECI PRO- ❑ LOC $ AUTOMOBILE LIABILITY Ea acdMBINEDdent SINGLE LIMIT ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ �OOW NED E:] SSCCHf EESDULED BODILY INJURY(Per acddent) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ ❑ ❑ AUTOS Per aocldent ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑wcRYLA ❑REN" AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) ❑ E.L.DISEASE-EA EMPLOYE $ If yyes describe under I ESLI JPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mora spaee la requtred) PLUMBING-RESIDENTIAL OR COMMERCIAL AIR CONDITIONING EQUIPMENT-INSTALLATION,SERVICING,OR REPAIR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BLDG DEPARTMENT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES FL 33138 AUTHORUM REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights(reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD s �RFs ones M Miami shores Village per. Building Department �ORiUA 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 Con actor Print Name: Print Name: �, nn Signature: Signature: T` State of Florida) State of Flori County of Miami-Dade) County of '� e Sworn to and subscribed before me this Sworn to d e e day of G�, ,20—Lq_. day of , •�° CMMIS Ss�4 By $y (407) ""� ©CPIq NFF1 r NOWY Public SM,of Rod" (SEAL) agatre C Leon (SEAL) Type of Identificatio MY eamm Type of Identification produced , R z X x g �13 y 9y r w t�" 7 � p sat �a IbeN �� i 7 ; n y, ynC h�; a.. � V �xvAA:\YVAVvvpanVA \