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PL-15-5 71 / 6 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-237379 Permit Number: PL-1-15-5 Scheduled Inspection Date: June 23,2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: HADDAD, DILCIA Work Classification: Addition/Alteration Job Address: 12 NE 111 Street Miami Shores, FL 33161-7047 Phone Number (786)399-6979 Parcel Number 1121360040020 Project: <NONE> Contractor: SUPREME PLUMBING, CORP Phone: (305)316-1164 Building Department Comments NEW PLUMBING FIXTURES NEW DRAIN PIPE AND NEW Infractio Passed Comments SUPPLY LINE FOR KITCHEN AND BATHROOM INSPECTOR COMMENTS False nspector Comments Passed V� Failed Correction ❑ Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid. June 22,2015 For Inspections please call: (305)762-4949 Page 33 of 38 Miami Shores Village JAN ® 5 201A i Building Department BY 1WSO N.E.2nd Avenue,Miami Shores,Florida 3313= Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 20 D® BUILDING Master Permit No. 15® SII PERMIT APPLICATION Sub Permit No.2L- 15" 5 ❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [PLUMBING ❑MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP JOB ADDRESS: /Z /v E 11A)4- CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zia: -33/6 l Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: 6 OWNER:Name(Fee Simple Titleholder): ®L C,,,4 ,"4J- Phone#: ynq 322 "9 Address: /:2 /// City: A4/ 404e .s,4094!�s+ State FL Zip: /( Tenant/Lessee Name: Phone#: Email: P /f,,� CONTRACTOR:Company Name: 0.. &i -Pta , �-� Phone#: 305 5`? �, K Address: 13 ® City: `p ry^ A State: Zip: Qualifier Name: l Phone#: .3(9 State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for-this Permit: Square/Unear Footage of Work: A�01,0 Type of Work: ❑ Addition ElAlteration ❑ New ElRepair/Replace E] Demolition Description of Work: W 4/ °f c et A0) Sa ^F'CAU�, 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$ 25�• O (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 m •be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the a en o ed notice, the inspection will not be approved and a reinspection fee will be charged. Signature L� Signature OWNER or AGENT C NTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this --E�day ofd 4 2015 by ` day of .�Av "wry 20 I� by who is personally known to H Q L-i3 r C J �. ,who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification a who did take a a NOTARY P NOTARY PU IC: o" Notary Public State of Florida 7NOtaryic State of FloridaJavier Fajardo ardoMy Commission EE1346 3 Sign: sion EE1346;3 OF pub ExPir@s 09!2912015 15 Sign:_ Print: Print: Seal: Seal: APPROVED BY /� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Noun UMN Miami shores Village Building Department ��ORiDA 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 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: OP VeIY77 e- _V) 0 C0 BUSINESS ADDRESS: 0 ST- CITY [w'q STATE ZIP,�O- BUSINESS PHONE:( 305) 3 FAX NUMBER( �� 87,3E CELL PHONE Q 1 �!�• 116V QUALIFIER'S NAME: f4ect2r C�,� QUALIFIER'S LIC NUMBER: CF-C — RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1428027 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 0 Run IN CUE, HECTOR EDUARDO SUPREME PLUMBIING,CORP 1 840 EAST 5 STREET HIALEAH FL 33010 a ISSUED: 08/21/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408210001429 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT ABILL-DO NOT PAY '� LBT_) 6857628 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES SUPREME PLUMBING CORP RENEWAL SEPTEMBER 30, 2015 840 E 5 ST 7132251 HIALEAH, FL 33010 Must be displayed at place of business Pursuant to County Code Chapter BA-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED SUPREME PLUMBING CORP 196 PLUMBING BY TAX COLLECTOR CONTRACTOR 45.00 09/18/2014 Worker(s) 1 CFC1428027 CREDITCARD-14-038344 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,ora certification of the holders qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec So-276. MIMI®DADE For more information,visit wwwmiamidadeaovAoxcollector 06-21-2013 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION ft * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW � CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers Compensation law. EFFECTIVE DATE: 08/22/2013 EXPIRATION DATE: 08/22/2015 PERSON: CUE HECTOR E FEIN: 275301441 BUSINESS NAME AND ADDRESS: SUPREME PLIIING CORP 840 E STH ST HIALEAH FL 33010 SCOPES OF BUSINESS OR TRADE: 1- PLUMBING NOC AND DRIVERS IMPORTANT: Pufsaabt to Chapter 440 . 05114►. F.S., an officer of a corporation vibe elects exemption from this chapter by tiling a certificate of election only under this section may not recover benefits or compensation ander this chapter. Pursuant to Chapter 440.051121, F.S., Certificates of election to be exempt.. apply n the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113). F.S., Notices of election to he exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate ao longer meets the requirements of this section for Issuance of a certificate. The department shall revoke a certificate at any time far failure of the person named an the certificate to meet the requirements of this section. QUESTIONS? (850) 413- OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who DIVISION OF WORKERS'COMPENSATION CONSTRUCTION INDUSTRY O elects exemption from this chapter bfiling a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover bee nefits or compensation under this WORKERS COMPENSATION LAW io D chapter. EFFECTIVE 08/22/2013 EXPIRATION DATE: 08/22/2015 PUI-scant to Chapter 440.05(12), F.S., Certificates of election to be PERSON HECTOR E CITE H exempt- apply only within the scope of the business or trade listed on FEIN 275301441 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.&, Notices of election to be exempt SUPREME PLUMBIING CORP and certificates of election to be exempt shall be subject to revocation 840 E 5TH ST if, at any time after the filing of the notice or the issuance of the .kLEAK FL 33010 certificate, the person named on the notice or certificate no longer met the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this SCOPE OF BUSINESS OR TRADE section 1- PLUMBING NOC AND DRIVERS QUESTIONS? (850) 413-160 CUT HERE +� Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 5y►tOR Es .... .....� Miami Shores Village Building Department R1DA 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 carver 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 II Contractor Print Name: 14 a Print Name:—# C tfe, _Signature: Signature: T a F=,2AO Public state of Florida State of Florida) �`j91 `°% Notary Public State of Florida State of Florida) r Fajardo Coup of Miami- Javier Fajardo Coun of Miami-Dan EE Cornmi commission �' � My Commission EE134673 s 09/29/201516 3 Sworn to and su e e 1fn*k&9/29/2o1s Sworn to and subscri151dayof �, ti , day of a By , �o ��d��► , By �g ,� (SEAL) (SEAL) Type of Identification produced Type of Identification produced