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PL-14-51398 Miami Shores Village Building Department 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 20 BUILDING Permit No. PL-4-14-51398 PERMIT APPLICATION Master Permit No. Permit Type: PLUMBING JOB ADDRESS: 1255 NE 93 Street City: Miami Shores County: Miami Dade Zip. 33138 Folio/Parcel#: 11-3205-0297-0090 Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder):Jeffrey Mayer Phone#:786-503-4297 Address:1255 NE 93 ST City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: oot s Phone#: 954-445-6418 Address. 1550 NW 79 Ave City: MIAMI e.IL Zip: 33126 Qualifier Name: Juan F Mendez Phone#: 954-445-6418 State Certification or Registration#: C C 057653 Certificate of Competency#: Contact Phone#: 954-445-6418 Email Address: John.mendez@rrsc.com DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$4000.00 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demo -7' Description of Work: Revision: replace approx 15 ft of building drain inside the us "m t e xxxmx�xxxxxxxxxxx�xx:xxxuxxxxxxxxmxmxxmxFees*�x��x�x�x�x:xxxxx�x���x��x�xxxxx��xxxxxx�xx� Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ .. a 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 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 Signa�� 1bwJer or Agent Contr The for `oing instrument was a4l wiled ed before me this The foregoing instrument was acknowledged before me this 1a ` day of� �'20 ,by day of ,2014-,by � � who is personally known to me or who has p oduced 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 PUBLIC: NOTARY PUBLIC: Sign: Notary Public 5tatsOf o Sign: Print: Marilys Lopez Print: M Commission Expires: V1.1 f Expire 1Commission /28 2014 tale d {g{g g g a My p My Commissi I x ' s., �II9610 �806i ave ®r�r aR 8�IO8a APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) RIECEIVED Miami Shores Village APR 2 X14 -�� Building Department By:cl 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 BUILDING Permit No. PERMIT APPLICATION Master Permit No Permit Type: PLUMBING JOB ADDRESS: 1255 NE 93 Street City: Miami Shores County: Miami Dade gip; 33138 Folio/Parcel#: 11-3205-027-0090 Is the Building Historically Designated:Yes NO X Flood Zone: OWNER:Name(Fee Simple Titleholder):Jeffrey Mayer Phone#: Address: 1255 NE 93 Street City: Miami Shores State: FL Zip. 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Roto Rooter Services Company Phone#: 954-445-6418 Address: 1550 NW 79th Ave City: Miami State: FL Zip: 33126 Qualifier Name: Juan F Mendez Phone#: 954-445-6418 State Certification or Registration#: CFC 057653 er? t/"Competency Competency#: 954-445-6418 . 'ohn.mende corn Contact Phone#. Email Address. 1 DESIGNER:Architect/Engineer: one#: '*4`000 Value of Work for this Permit:$1500.00 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New Mepair/Replace ❑Demolition Description of Work: repair sewer line �xx�x��xxx�xx���xx�xauxxxx�xx�xxxx�n�xxFees���x�x�x��xxxx��xx�xxx��:����������x����x������ Submittal Fee$ . ' Permit Fee$ -1 0, CCF$ MCC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE Bonding Company's Name(if applicable) Bonding Company's Address City I 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 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 of be approved and a reinspection fee will be charged Signature Signature O er or ent Contractor The foregoing mstrumen was ac wledged before me this Th oregoing instrument was acknowledged before me this day of t ,20 O,by—SP , day of ► ,20 by (Y_ p, who is personally known to me or who has produced \SCEr S� 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 PUBLIC: NOTARY PUBLIC: Sign: 412111 Q , _ w Zntar r` -��Y n �. Slgn: - . Print: Notary Pub0c ®/P& 3 �nPrint: M Commission Ex ires: r,° "° Expires+�v2 /i }oMy Commissi yWir En*"Wt lw�b17504 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) 212 345-5000 4/29/2014 3 : 19: 05 PM PAGE 2/002 Fax Server A CERTIFICATE OF LIABILITY INSURANCE 2MO14°YYYY' 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME MARSH USA INC. 525 VINE STREET,SUITE 1600 Ip CINCINNATI,ON 45202 Attn:cincinnati.cartrequest@marsh.com INSURERS)AFFORDING COVERAGE l"C# 400408-RRSC-OAUW-14-15 00044 INSURER A:Old Republic Insurance Co 24147 INSURED INSURER B: National Union Fire Ins Co Pittsburgh PA 19445 44-ROTO-ROOTER SERVICES COMPANY 1550 NORTHWEST 79TH AVENUE INSURER C:Midwest Employers Casualty Company 23612 MIAMI,FL 33126 INSURER D: INSURER E: INSLIRER F: COVERAGES CERTIFICATE NUMBER: CLE-004075726-01 REVISION NUMBER:2 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 OONTRACT 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 CONDMONS OF SUCH POLICIES.UMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM& INV TYPE OF INSURANCE POLICY NUMBS awd&M Awywr UN" A GENERAL LIABILITY MWZY60132 04/0112014 04/01/2015 EACH OCCURRENCE $ 2,000,000 X CONV ERCWL GENERAL LIABILITY MSE3 Ea oaarr, $ 750,000 C;LAAIN YNIADE M OCCUR NM EXP am $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GIENERALAGGREGATE $ 6,000,000 CENLAGGREGATELMTAPRJESPER. PRODUCTS-CaVP/OPAGG $ 6,000,000 X POLICY P LOC $ A AUTOMOBILEUABILITY MWTB21957 04/01/2014 04/01/2015 —161 t 5,000,000 X ANYALTI`0 BODILY INJURY(Per Persm) $ MJ PED SCHEDULEDBODILY INJURY(Per acdderd) $ X HFEDAUTOS LX ��ED er acd $ $ B X UMSIRELLAUAB X OCCUR 20562456 04/01/2014 04/01!2015 EACHOOCURRENCE $ 5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I REfE1,1flCIM 25,000 $ A WORKERSCONPENSATION MWC118264(AOS) 04/012014 04/012015 0 AND EMPLOYERS UASIUTif TMMBANY ER EXCLUDED? ECLrTIVE N/A MWC301934 00(TX) 04/0112014 04/01/2015 EL F�HAOCIDENT $ 1,000,000 OFFICER,CInNFn EWC0063808(XS OH) 04/012014 04/01/2015 EL DISEASE- 15 EAHv>PUJYE $ 1,000,000 I PERATICMlSbelow EL DISEASE-PIcucyUNIIT $ 1,000,000 DESCRPMC)N OF OPERATIONS/LOCATIONS/VEHCLES(Attach ACORD 101,AdWanal Remarks SOUP,"More specs is required) RE PI.1.I41BING CONTRACTOR CFC057653 CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED ON THE AUTCMCBILE POLICY FOR'BODILY UVJURY°OR°PROPERTY DAMAGE ARISING OUT OFTHE USE OFA C0VERED,AUTO, WHILE THE OCJERED°AUTO,IS BONG USED PUF&W TOA CCMRACI: CEFMFICATE HCLDER IS NAMED AS AN ADDMCNAL NSURED CN THE GBOOL LIABII.JTY PCLICY WHEFE REQUIRED BY INSUFED CONTRACT BUT ONLY WITH RESPEOTTO LWBILJTYAFUSING OUT OFTHE NAKED INSUREDS PI MMES,°WOFIf,FOR THE CERTIFICATE HOLDER,OR ACTS OR OMISSIONS OFTHE CERTIFICATE HOLDER IN OON`ECTTON WITH THE GENERALSUPEFMSION OFTHE NAMED INSUREDS-WW, CERTIFICATE HOLDER CANCELLATION 0OF MIAMI SHORES 10055 SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10D NE 2ND AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES,FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENrATIvE of Marsh USA Inc. � 11Aanashl NlUkhoee m 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1 �Zo ATE a� CERTIFICATE OF LIABILITY INSURANCE D03/21/201144D n 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 MARSH USA INC. NAME: 525 VINE STREET,SUITE 1600 IPA No Extl: aC No): CINCINNATI,OH 45202 ADDRESS: Attn:cincinnati.oertrequest@marsh.com INSURER(S)AFFORDING COVERAGE NAIC# 400408-RRSGGAUW-14-15 00044 INSURER A:Old Republic Insurance Cc 24147 INSURED -ROTO-ROOTER SERVICES COMPANY INSURER B;N/A N/A 1550 NORTHWEST 79TH AVENUE INSURER C:Midwest Employers Casualty Company 23612 MIAMI,FL 33126 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-003532806-23 REVISION NUMBER:I 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. INS�R TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MIOMIUDD EFF MPMOUDD EXP LIMITS A GENERAL LIABILITY MWZY60132 04/01/2014 04/01/2015 EACH OCCURRENCE $ 2,000,000 NCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 750 000 PREMISES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 6,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 6,000,000 X POLICY PFC RO LOCI $ A AUTOMOBILE LIABILITY MWTB21957 04/01/2014 04/01/2015 COMBINED SINGLE LIMIT 5,000,000 Ea acadent X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ XNON-OWNED PROPERTY DAMAGE I $ HIRED AUTOS X AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION MWC118264(ADS) 04/01/2014 04/01/2015 X I WCSTATU- OTH- AND EMPLOYERS LIABILITY Y/N DRY LI, S R C ANY PROPRIETORIPARTNER/EXECUTIVE MWC301934 00(TX) 04/01/2014 04/01/2015 E.L.EACH ACCIDENT $ 1,000,000 0 OFFICER/MEMBER EXCLUDED? N/A XS 0 (Mandatory In NH) EWC0063808( N 04/01/2014 04/01/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2ND AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES,FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR12ED REPRESENTATIVE of Marsh USA Inc. Manashl Mukhedee –XVL+tisaA01-%- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD