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PL-15-2907 \ 2 Miami Shores Village x 10050 N.E.2nd Avenue NE #t1 Miami Shores,FL 33138-0000 Phone: (305)795-2204u Project Address Parcel Number Applicant 126 NE 108 Street 1121360090060m � ..e_W RONALD COX Miami Shores, FL Block: Lot: Owner Information Address Phone Cell z RONALD COX 126 NE 108 ST MIAMI SHORES FL 33161-7038 Contractor(s) Phone Cell Phone LASSETER PLUMBING CO INC 305 525-5075 Valuation: $400.00 ( ) (305)893-7180 _.. �..�. m . ...._._ . ®.. Total Sq Feet: Type of Work:REPLACE EXISTING FLUE PIPE Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification: Residential Scanning:3 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# PL-11-15-57794 $2.00 11/18/2015 Credit Card $64.60 $50.00 DCA Fee $2.00 Education Surcharge $0.20 11/17/2015 Cash $50.00 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 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 cern that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructiond z ing. Fut rmore, I authorize the above-named contractor to do the work stated. "v November 18, 2015 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy November 18, 2015 1 77J (3 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-247979 PermitNumber: PL-11-15-2907 Scheduled Inspection Date: November 19, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type- Under Owner: cox, RONALD Work Classification: Addi ' Iteration Job Address: 126 NE 108 Street Miami Shores, FL Phone Number / Parcel Number 1121360090060 Project: <NONE> Contractor: LASSETER PLUMBING CO INC Phone: (305)525-5075 Building Department Comments REPLACE EXISTING FLUE PIPE 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. November 18,2015 For Inspections please call: (305)762-4949 Page 19 of 30 Miami Shores Village Building Department �'vu1�' 17201 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305)795-2204 Fax: (305)756-8972 4 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2014 BUILDING 0C4 BUILDING Master Permit No.�_'F�S- L'::� PERMIT APPLICATION sub Permit No. TL IS- 290-4- ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I Z `0P-n City: Miami Shores County: Miami Dade Zip: tb, Folio/Parcel#: Is the Building Historically Designated:Yes NO �--� Occupancy Type: Load: Construction lType: Flood Zone: BFE: FFE: "� OWNER: Name(Fee Simple Titleholder): & 1�C Phone#:_ 30 __7�' !�j 71 Address: City: State: Zip: /C J Tenant/Lessee Name: Phone#:�_ Email: fl hf ISN 'V� A�qq CONTRACTOR:Company Name: 1 Phone#: ��� Address: ��n City: I, J /"�` /! State: ' C.. Zip: 3f�� Qualifier Name: i/i ✓l Phone#: ll State Certification or Registration#: ��1�G d� C�5V=kertificate of Competency#: DESIGNER:Architect/Engineer. Phone#: Address: City: — State: Zip: Od Value of Work for this Permit:$ Square/Linear Foot: of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: P66 V%>/i' r 00 �2 e, :D ', l; I 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$ 1 TOTAL FEE NOW DUE$ ()LI (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. r Signature P/POK Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of ��fin '- 20 > by �b day of � + �`�r * 20 F? by I QPJP4-bVST'. ��who isis-,personally known to �f}rl I�� - who is personally known to me or who has produced tJQ� �L 1��k(` as me or who has produced L� as identification and who did take an oath. identification and who did take an oath. NOT4PUBLI NOTARY PSign: Sign. �,LU Print: I (��/PrintAc,�-y Seal: Seal: MEE io State of Florida bORY Vy.® Notary Public State of Florida rez ; Sindia Alvarez sion FF 136750 y o� Idly Commission FF 156750 3/2018 ? of x i s69.10* * ********** *** >Y ***E*R# *** * ******** ********** APPROVED BY s���'� 715 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Nov 17 1511:27a p 1 AC�® DATE JMMMDfYY'YV) CERTIFICATE F LIABILITY INSURANCE 11/17/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM kTION 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 iN WRED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may equire an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)_ PRODUCER - - CONTACT Melissa Rihm NAME: Mack, Mack & Waltz Insurance Group, Inc. PHONE (954)640--6225 All NC:I95<7 6�0-6226 1211 S Military Trail MAIL ADDRESS:mrihm@mackinsurance.com Suite 100 INSURE S)AFFORDINGCOVERAGE MAIC# Deerfield Beach FL 33442 _ INsuReRA:Ohio Security Ins. Co. INSURED INSURERSM=idcTefield Employers Ins. Co. 10701 Lasseter Plumbing Company, Inc INSURER C;Berkley National Ins. Co 865 N.E. 130 Street lNSURERD: INSURER E: North Miami FL 33161 INSURER F, CERTIFICATE NUMBER. 1582833610 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM O CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE €NSU CE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHO MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL7RR TYPE OF INSURANCE A"q R PO ICY NUMBER MWDD( EFF POLYYYYI DDrY� LIMITS X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A CLAIMS-MADEX OCCUR DAMAGE T REN EY 9 PR MI ESE cccurre S 100,000 BLS 56272457 9/1/2015 9/1/2016 M ED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY _$ 1,000,000 (GEN'L AGGREGATE LIMIT APPU ES PER: GENERAL AGGREGATE $ 2,000,000 X: POLIC'E] PRO-PRO- CLoc PROOUCTS-COMPIOPAGG $ 2,000,000 OTHER: �AUTOMOBRFLIABILITY COM =0 SINGLE LIMIT $ 1,000,000 accident A L X- ANY AUTO BODI LY INJURY(Per person} $ ALL OV^ED AUTOS AUTOS 13S 56272457 9/1/2015 9/1/2016 BOD'LYINJURY(Peracrldenl) $ AUTOS HIRED AUTOS NON-OWNED AUTOS PRODAMAGE $ AUTOS (-Per accident € Uninsured motorist combined S 1,000,000 UMBRELLA UAB EXCESS �OCCUR EACH OCCURRENCE $ LWB CLAIMS-MAGE AGGREGATE= $ DED �RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X $A ERH" ANY PROPRIETORIPARTNERIEXECUTIVE YIN -' OFFICERIMEMBER EXCLUCED? NIAI E.L.]EACH ACCIDENT $ 500,000 B (Mandatory in NN)and 83021471 5/25/2015 5/25/2016 E.L.OISEASE-EA EMPLOYE $ 500 000 H yes,describe under i DESCRIPTION OF OPERATIONS below ( E.L.DISEASc-POLICY LIMIT $ 500 000 C Equipment: Floater i IMMIaO02289/1/2015 9/1/2016 Scheduled Equipment Limit 5,430 i r Unscheduled Equipment Limit 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS]VEHICLES IACORD 101,Addrdorw 1 RemaMs Schedule,may be attached)rmore space Is required) CFC-041696 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Departanent ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue 12iam, Shores, FL 33138 AUTHORIZED REPRESENTATIVE Greg Waltz/MELISS ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD na and logo are registered marks of ACORD INS025 epnt4mi Nov 171511:11a P1 r Local Business Tax Receipt Miami-Dade County, S--ate of Florida -THIS IS NOT ABILL-DO NOT PAY LBT�/ 922097 p BUSINESS NAMN NAME/LOCATION RECEIPT O_ EXPIRES LASSETER PLUMBING CO INC RENEWAL SEPTEMBER 30, 2D1S 865 NE 130 ST 922097 NORTH MIAMI, FL 33161 Must be displayed at place of busiress Pursuant to County Code Chapter SA-Art.9&10 OWNER iEC,TYPE OF BUSINESS LASSETER PLUMBING CC)INC 196 PLUMBING PAYMENT RECEIVED 8Y TAX COLLECTOR CONTRACTOR 45.00 0711312015 Worker(s) 7 FC041696 CHECK21-15-089048 This Local Business Tax Aeceipt my confirms payment of the Local Business Tax.The Receipt is not a license, permit,are certification of the he der's qualifications,to do business.Holder must comply with any governmental or nongovern mental regulatory]a mrs and requirements which apply tothe business. The RECEIPT N0.above mus be displayed on all commercial vehicles-Miami-Dade Code Sec So-276. 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