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PL-15-2173 UZ - 56 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-242198 Permit Number: PL-8-15-2173 Scheduled Inspection Date: October 29, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: SWICK, KATHY ANN & BOB Work Classification: Addition/Alteration Job Address: 138 NE 92 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060133270 Project: <NONE> Contractor: ORIGINAL PLUMBING, INC Building Department Comments PLUMBING WORK FOR BATHROOM REMODELING Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failedc� Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. October 28,2015 For Inspections please call: (305)762-4949 Page 6 of 33 \ / � 4� Miami Shores Village 10050 N.E.2nd Avenue NE x Miami Shores,FL 33138-0000 F f f •`tia 'ate Phone: (305)795-2204 Expiration: 02/24/2016 Project Address Parcel Number Applicant 138 NE 92 Street 1132060133270 Miami Shores, FL 33138- Block: Lot: KATHY ANN&BOB SWICK Owner Information Address Phone Cell KATHY ANN &BOB SWICK 138 NE 92 Street MIAMI SHORES FL 33138-2814 Contractor(s) Phone Cell Phone $ 1,200.00 ORIGINAL PLUMBING, INC Valuation: Total Sq Feet: 0 Type of Work:PLUMBING WORK FOR BATHROOM REMODELI Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning: 1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# PL-8-15-56852 DBPR Fee $3.38 08/28/2015 Check#:802 $ 187.96 $50.00 DCA Fee $3.38 Education Surcharge $0.40 08/25/2015 Check#:801 $50.00 $0.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $237.96 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 AFFi AVIT: I certify that II the-foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructionzonin Futhermor I authorizethe above-named contractor to do the work stated. August 28, 2015 Auth rized Sign ure:Owner / Applicant / Contractor / Agent Date Building Department Copy August 28,2015 1 I Miami Shores Village Building Department AU �1 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 ..Y Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2010 BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No.?L.VZ_�7, ( ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION F-]RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP JOB ADDRESS: CONTRACTOR DRAWINGS 13� N� q 2 ^�°:5r City: _ Miami Shores 2 County: Miami Dade Zip: Folio/Parcel#: 3 206 O / 3 32-70 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: ff' Flood Zone: BFE: FFE: f OWNER:Name(Fee Simple Titleholder): y � Phone#: 80 _-)R j 0 `t Address: 3 1" P lite s T 3 IS 7 City: � State: Zip: 3� I Tenant/Lessee Name: Phone#: 11 Email: ( c't `�I� tt C�_C. ' 6' CONTRACTOR:Company Name: t lr� u cv� Y--�uv 'U�1 Phone#: 1 y Address: / C) �� D L.�. City: State: —Zip: �— Phone#: Qualifier Name: taaal EF State Certification Certification or Registration#: L b C7 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: r `� City: State: Zip: ---Value of Work for this Permit: ( �`� Square/Linear Foot ge of Work: Type of Work: ❑ Addition ❑ ,Alteration New Repair/Replace El Demolition Description of Work: Y 1 -- 00-4 f od W Specify color of color thru tile: ( -5d ol, ` k Submittal Fee$ Permit Fee$ Z7 CCF$ tg• CO/CC$ Scanning Fee$ t• J� Radon Fee$ DBPR$ Notary$ Technology Fee$t,, Training/Education Fee$_ u Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ '` ►` (RevisedO2/24/2014) Y � f 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. Signature Signalye tures cT NER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this '�da / of CT 20 t— by day of _:�/u Jr-X ,20 / 5 , by � iSTk 71 ScAI J w i�sonally known to AOX/S ,/ /� gwl"01,1 ,who is personally known to me or who has produced bt S Z bcSi s �i' '`? U• as me or who has produced -6-5-37 as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: P Sign: Sign: Print: Print: Seal: Public State of Fbrida Seal: *�' * MY COMMISSION#FF 151873 1 1 ous Notary EXPIRES:NOVemI)9f 21,2018 a° V. SindiaAtvarez ' � 4� BonWThro849Notary SoMm moo¢ MV commission FF 155750 o!,d Expires 09,10312018 ************* * ********************************************************************** APPROVED BY C�S 'L S S Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 HAUGHTON, HARRIS JESLIN ORIGINAL PLUMBING INC 18001 N.W. 2ND PL MIAMI FL 33169-4307 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range ; STATE OF FLORIDA from architects to yacht brokers,from boxers to berbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. _ s PROFESSIONAL REGULATION Every day we work toimprove the way we do business in order to CFC057806 ISSUED: 06/22/2014 serve you better. For irrfonrration about our services,please log onto www.myfloridalicense.com. There you can find more infomnation CERTIFIED PLUMBING CONTRACTOR about our divisions and the regulations that impact you,subscribe HAUGHTON,HARRIS JESLIN to department newsletters and learn more about the Departments ORIGINAL PLUMBING INC initiatives. Our mission at the Department is:License Efficiently,Regulate Fairly. We constantly strive to sere you better so that you can serve your customers. daW Thank you for doing business in Florida, IS CERTIFIED AU under the provisions of ChFS. and congratulations on your new license! &pi�aeon> = c a,,so,s �� 0622 �� DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD o1 CFC057806 The PLUMBING CONTRACTOR . gx Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 HAUGHTON, HARRIS JESLIN. ORIGINAL PLUMBING INC 18001 N.W.2ND PL. I ARAI rE OI]ACA won 5 p s NOW A 4447 g fypg F gUS S PALVNN B`Y 7'A7K 1 PWMB $4 .00 (fjj 0, - 4 c' 1E{ t 14-x4=2 _ tafietseal T ode - sm r — . y _ CERTIFICATE OF LIABILITY INSURANCE °ATE , YYYJ THIS CERTIFICATE IS ISSUED.AS A MATTER OF_INFORMAT)ON ONLY AND CONFERS.NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT J#FFitRMATiVEI.Y OR NEGATIVE:Y AlillfNO,EXTEND QE;ALTER THE COVERAGE AFFORBEt3 BY THE PQLtCIES BELOW. THIS CERTIFICATE OF;INSt/RANCE DOES t+IOT COI�lSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE.HOLDER.- IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed, 8 SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer dghts to the certificate holder In lieu of such endorsementis). PRODUCER CONT CT SHARON _ B C 8 D Insurance Specialists,Inc. PHo E Exit: (954)739-7119 F _0 j. (8-54)791-6563 1217 Sunset Strip glpg bcdinsOS@tive.aonl Sunrise,FL 33313 INSURER(S)AFFORDING COVERAGE NAIC# Phone (954)739-7119 _ Fax (954)791-6563 iNsuRERA: WESTERN WOLRO INSURANCE INSURED INSURER B: ORIGINAL PLUMBING INC. iNSURERC: 18W NW 2ND PLACE INSURER O: MIAMI GARDENS,FL.33169 fIdSUflER E; INSURER F. COVERAGE$ � r 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 ADD UBR POLI Y EFF POLICY ERP LIMITS LTR POLICY NUMBER MMID yyl, &I OIYYYY GENERAL LIABILITY �~ EACH OCCURRENCE 5 300 000.00 MAGE TO 1 000 COMMERCIAL GENERAL LiABILtrY -PREMISES Ea ur ql_. .S._... 04,.,01. ® ® CLAIMS-MADE ❑ OCCUR MED EXP(Any One person $ 5,OW.00 A NPP1378420 04/28f2015 0412$(20:8 DEDUCT B.1,-$SW PERSONAL a AoV INJURY $ 300,000.00 DEDUCT P.D-$540 GENERAL AGGREGATE $ 6tH?000.00 (GElft AGGREGj{�ATyyE LIMIT APPLIES PER' PRODUCTS-COMPIOP AGO S 3W,©80.� [K_{POLICY L.J JF d ❑ LOC $ AUTOMOBILE LIABILITY erdSINGLE LIMB a acct ❑ ANY AUTO BODILY INJURY(Per person) S ❑ AMS NEO ❑ AUTOS LOWSCHEDULED BODILY INJURY(Per accident) $ -- ❑ 14RED AUTOS ❑ ANOUTHOS NED PIMMI lYnt AMAGE $ - - n UMBRELLA LIAB , ❑OCCUR a^ EACH OCCURRENCE S �- ❑ EXCESSLI!!__ ❑CLAIMSMAOE AGGREGATE 5 ElOED ❑ RETEMION S _ $ WORKERS COMPENSATIOND we STATU- �OTH- AND EMPLOYERS`LtABfLITY YIN — ANY PROPRfETOR(PARTNER1EXECUTiVE E-L.EACH ACCIDENT $ OFFICER(MEMBER EXCLUDED? D N i A — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEJ S Hyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD tOt,Additional Remarks Schedule,if more space Is required) INTERIOR ALTERATION FOR PLUMBING. LICENSE NUMBER:CFC0578W CERTIFICATE HOLDER CANCELLATION .. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BLDG.DEPT. THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E.2ND AVENUE MIAMI SHORES,FL.33138 - AUTHORIZED REPRESENTATIVE SHARON N.FOSTER-AGENT ®1988-2010 ACORD CORPORATION, All rights reserved. ACORD 26(2010105)QF The ACORD name and logo are registered marks of ACORD Report Viewer Page 1 of 1 • �1 100% "l JEFF ATWATER CHS FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION a 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: 1122!2015 EXPIRATION DATE: 1/21/2017 PERSON: HAUGHTON HARRIS FEIN: 241030278 BUSINESS NAME AND ADDRESS: ORIGINAL PLUMBING INC 18001 NW 2ND PLACE MIAMI FL 33189 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pulwantm Chspfer44&05(14j F.9,an at&er ata eurpomUm van elaels exampGen km Bds tlwa oelkb 5raoleledion undue&sedion may cwt telwrdrkdaelb arnsavan under ft WaDfler.PwwantID Chapter 440.05{12),F.8,1=ofelu6on to be exempt_apply only veAfiln tlro sx�e of0xl6eakleas ortrnde lamed q�the rodaa�akc5onm ko exe�d.Pwmlantm r44405(13b F.B..Notices arakc�n m W esemptand arh7�tas orek�on m he eomnpt ahe0 be subjadmmoes9onm i�a[any Wne agerefe kSng ottl/a natlw arMe f=sua�snrffia ealti5eale, the psrmn rained oniho ladica oroedNn/e lm bla�ermeebihe regntremads orthh aedkm for tea oelt[rnde.She depm9neM afia9 revoke a OFSF2-D1M1r,-252 CERRTWICASE OF ELECTION SD BE EXEMPT REVISED 08-13 QUESTIONS?(650013-1844 �, ORIGINAL PLUMBING INC CFC057806 18001 NW 2ND PL ACE, MIAMI, FI-33169. 954-274-3041 Miami shores village, Building Department, Miami Shores, FL 33138, Date : August 15, 2015, RE : Affidavit statement regarding workers compensation insurance and hiring of workers, lobsite address : 138 NE 92nd ST, Miami Shores, FL 33138 . To Whom it may concern : This letter is to inform you that I will be the only one working thru my company on the propose project at the address listed above. Signed Harris Haughton State of FL 19 County of .4.A.=/ The foregoing was acknowledge before me this day of < 20 A' By'� a.,, WhopPre sonally k w or has produced z�L - � as identification Notary: "'PA PV�i HARRMARINE R. BEDESSEE Seal : ,'z°. «`� Notary Public-State of Florida •: :•_ My Comm. Expires May 8,2016 Commission#EE 191009 OF OFF O ......•` Bonded Through National Notary Assn. `yNORiEs �! ,,, ,,,,,� Miami shores Village ly �n V Building Department g 1 0 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 and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWI,,EDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: &Iveo44 Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this 2 day of who is personally known tome or has produced L �C E NSI as identification. Notary: opW r&e, Notary Public State o£Florida SEAL: Sindia Alvarez AQ My Commission FF 156750 OF f�oP Expires 09;0312018 -.