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PL-15-3063 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-249117 PermitNumber: PL-12-15-3063 Scheduled Inspection Date: December 15,2015 Permit Type: Plumbing - Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner: MAYER,JEFFREY Work Classification: Repair Job Address:1255 NE 93 Street Miami Shores, FL 33138- Phone Number (954)547-3357 Parcel Number 1132050270090 Project: <NONE> Contractor: ROTO-ROOTER SERVICES COMPANY Phone: (786)464-1080 Building Department Comments REPAIR SEWER LINE Infractio Passed Comments INSPECTOR COMMENTS False TO CLOSE PERMIT#PL14-861 Inspector Comments Passed ED/ Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid December 14,2015 For Inspections please call: (305)762-4949 Page 29 of 43 ltd: L-'12 -3063 ,ejPii r Miami Shores Village , /' mtit7N" plumbingResidence),• S� 10050 N.E.2nd Avenue NE I rkWassrF1040A a Repair .,...M -..,. Miami Shores,FL 33138-0000 orm Phone: (305)795-2204 " f8t7rit+�h1S:-API�RoVE© toxit�` M Issuotate.1l2t15, Expiration: 06111/2016 Project Address Parcel Number Applicant 1255 NE 93 Street 1132050270090 Miami Shores, FL 33138- Block: Lot: JEFFREY MAYER Owner Information Address Phone Cell JEFFREY MAYER 1255 93 Street (954)547-3357 MIAMI SHORES FL 33138- 1255 93 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 1,500.00 ROTO-ROOTER SERVICES COMPANY (786)464-1080 ....._..... __ Total Scl Feet: 0 Type of Work:REPAIR SEWER LINE Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Return: Review Plumbing Classification:Residential Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee Invoice# PL-12-15-58013 $2.00 015 12/14/2Credit Card $ 116.20 DCA Fee $2.00 $0.00 Education Surcharge $0.40 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $116.20 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 certify ha,all the egoing inf ion ' curate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futherm e, I a ori a the ractor to do the work stated. December 14, 2015 Authorized S gnature:Owe / Applicant / Contractor / Agent Date Building Department Copy December 14,2015 1 Miami Shores Village g Department ILEI; 10 2015 11 Building 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 i Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 ®` FBC 20 t-P BUILDING Master Permit N:PU'5— 306 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL OPLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: 1255 NE 93rd street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132050270090 Is the Building Historically Designated:Yes NO X Occupancy Type: Res Load: Construction Type: Plum Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder):Jeff Mayer Phone#:786-503-4297 Address: 1255 NE 93rd Street City: Miami Shores State: FI Zip: 33138 Tenant/Lessee Name: N/A Phone#:Same Email: Mayedwm@yahoo.com CONTRACTOR:Company Name: Roto-Rooter Services Phone#: 786-464-1080 Address: 1550 NW 79th Ave. City: Miami State: FI. Zip: 33126 Qualifier Name: Michael Story Phone#: 786-298-0091 State Certification or Registration#: CFC-1429187 Certificate of Competency#: N/A DESIGNER:Architect/Engineer: N/A Phone#: Address:N/A City: N/A State: N/A Zip: N/A Value of Work for this Permit:$ 1500 Square/Linear Footage of Work: 0 Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/ eplace ❑ Demolition Description of Work: Repair Sewer line. Vo Sc- TAEC-r-kvC Specify color of color thru tile: Submittal Fee$ Permit fee$ X6, CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ D (Revised02/24/2014) r Bonding Company's Name(if applicable) N/A Bonding Company's Address N/A city N/A State N/A Zip N/A Mortgage Lender's Name(if applicable) N/A Mortgage Lender's Address N/A city N/A State N/A Zip N/A 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. I Signature 6lt!A-4 SignatureAZ�wR.�G d W ER or AGEN CONTRACTOR The foregoing insrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 r7 ,by day of 20 by '3eC41-4tV M" ,who is personally known to Michael Story who is personally known to me or who has produced IGP(1S P as me or who has produced a as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: 000, Sign: Sign: Print: Print: Seal- Seal: Notary Publ�State of Florida Notary Public State of Florida ryLopez My Commission FF 164UM / MY Commisaalan FF 184894 Expires 10/2612016 ExP�s 10/28/2018 p. P APPROVED BY ( /� �� °� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ''e StloR V pi Miami Shores Village "" I ""'t" Building Department L��3- 01 �L�R1[DA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. //� Owner's Name(Fee Simple Title Holder): -'ecc 1'11'1 )cz' Phone#: -7,9�D-563-1t1 29 7 Owner's Address: 17,155 /V l° q5 St-raj i' City: M i Q,M i 5J%O e-eg State : F L Zip Code: 33 3 Job Address (Of where work is being done): I 2,55 NG q 3 S-�rc&-i . City: Miami Shores State:—Florida Zip Code: 33 ) 3g Contractor's Company Name: F.d to - 21pO-�-ee- Phone#: -79 le -44 LY-1090 Address: J1;'SO ASL /+Ve City: Yv% I Ar M i State: %:-L Zip Code: 3 :9 Qualifier's Name: Vv%i cAa-r,1 .S f D fy Lic. Number: CF+G j y A1 1$7 Architect/ Engineer of Record Name: �" Phone#: Address: City: State: Zip Code: Describe Work: C, 7(,>`/ Y1n Gl I rV 6e-W e 1'- / 7 AJ V hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal involvement. Signature �x-,AJI'kAISignature Ow�nei'�o Agent l Contractor or Architect The foregoing instrument as aknoledged before me The foregoing instrument was aknowledged before me this—q-day of�jlr/ ,20r->,b y 'YeFCrZf ht Yj?✓ this C&N day of��nn�xr,20nby t r Who is personally known to me or who has produced who is personally known to me or who has produced P Y P P Y 1 Ii?eon 5P as indentification. as indentification. Notary Public: Notary Public: Sign: Sign: Se � S state of da el My Ca Lopezfit►�,j Acatery Public State of My CoF6 a g mmission FF 184894 MBfityS Lopez a w Sxphs 1012612018 Aly Commission FF 184884 Q0, Expires 10/28!2018 305 10:27:56 a.m. 12-08-2015 1 /4 g 5�oie�s D "..�. ® ORM F„ `S:h.ores*VIYfiami . -age 4` Buildn" :D`e �artm�ent 10050;N E.2"d-A,vertue Miami,5h0*j:*Florida.33138 T61:(305) 795.2204 CONTRACTORS' REGISTRATION Fax; (305) 756.8972 IF CONTRACTOR'Is.A FLORIDA STATE CERTIFIED CONTRACTOR:. A. +r COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C, ✓ COPY OF:LIABILITY]NSURANCE* D. ✓ COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS.A MIAMI DADE COUNTY C80IFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGfSTERED CONTRACTOR LICENSE OR MIAMI DARE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY-'OF WORKERS COMPENSATION INSURANCE* (Worlters Compensation EXEMPTION must Have NOTICE TO OWNER form and Contractor Affitlavit) "YOUR.INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate.Holder: MIAMI SHORE$VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the.description of operations or contractor license number. rrrwrswrrsrrwrrrrsrwrswrsrrrrrsrwrrrrrrsarrwrwrssrsrrrsrrrsrrrrs■:rrr�.srwr�wrsrsrrsrrrrrrr BUSINESS NAME: o BUSINESS ADDRESS: I5 5n N W 7QYe CITY_ 1n�1vt ; STATE Zip-33L2b BUSINESS PHONE:LZt6J Y16 - Jpgp FAX NUMBER CELL PHONE(7Skj L9S—Vp91. QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: 111 197 O O 00 O RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTI",!NDUSTRY LICENSING BOARD CAC142ilB. The PLUMBING CONTRACTOR " "`} Najned bdlbW.lS CERTIFIED wu Und&the-provisions of Chapter 489 FS. td 'AUG 31,2016 'E ,�cpliatlarf da SMRY,,MICHA ELVANLOGM ' :*"",.;' IROTOR06TER_SERVICt8N Y 01 GREEN RW '' 'x:pEERFiELD:HEACF� .�FL 33064 ISSUED: 12107=14 DISPLAY AS REQUIRED BY LAW SEQ# L1412070000652 Ln v . rn 1a70&59 Ln N Local :Business Tax Receipt Miami.-Dade County, State of Florida o =TH�S'IS' NOTA BILL — OO NOT PAY i N 3455532. ... 9USINHSS:N�►MBILCCATtOtu .. 'RECt:iP.rNO. EXPIRES o ROTO ROORR5ERVICESCgMPANY :RENEWAL SEPTEMBER'30, 2016 NW. 9'AVE 3609436 Must be displayed at place of business ^' DORAL Fl.331 26. Pursuant to County Code Chapter BA—ArL B&t0 OWNER SEC.TYPE OF BUSINESS PAYMENT RECINVED ROTO ROOTER SERUM COMPANY 196 PLUMBING CONTRACTOR BY TAX COLLECTOR Worker(s) 30 CFC057653 $105.00 08/04/2015 FPPUDB-15-013941 Tk)s Local BaslnessTaii Receipt only conRrms paymeat of ilm Local BusiaessTas The Receipt is not a licanse, pamil ar a¢ald6ceBoa bl iha haidar.s gnaliGeatioin,m do blpiluoas.Iioldarmiml complywidl enygsvemmealai or aoegoven matal regulatory Ism mW inquire mots w"apply to the hosiri= The RECEIPT NO,above must be dhpfeyed on all eoaenerclal We Sec lla-276. Far more Information.visiiwww.miemidede.aev ntallociar Ln 0 m 305 04:40:04 p.m. 12-08-2015 1 /1 DATE(NIMIDDA-M) CERTIFICATE OF LIABILITY INSURANCE 12=12015 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 A13DMONAL INSURED,the policy((es)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 NA MACT MARSH USA INC. PHONE FAx 525 VINE STREET SUITE 1600 CINCINNATI,OH 45202 MO. Atin:Cincinnati.CertRequest@mamh.com I F.212-946-0785 INSURER(S)AFFORDING COVERAGE MAIC 0 00M INSURER A:Old POPUbGC WUrSnW Company 24147 INSURED INSURER IS:Nacional Union Fire Ins Co PIUSIXIMh PA 19445 44-ROTO-ROOTER SERVICES COMPANY 15M NORTHWEST 79TH AVENUE INSURER c:Midwest Employers Casualty Company 23612 MIAMI,FL 33126 INSURER D: INSURER E INSURER F, COVERAGES CERTIFICATE NUMBER: CLE-005035667-Di 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 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 POLICY NUMBER POLICYMM1OERP MMMAI EXP LIMITS A X COMMERCIAL GENERALLIA13UM MWZY6013215 04/01/2015 04/01/2016 EACH OCCURRENCE $ 2,000,000 CLAIMS MADE M OCCUR PREMISESDAMAGE TO RENTIEV Ea occurrent $ 750,000 MED EXP Arty ane arson $ 5,000 PERSONALS ADV INJURY $ 2.000,000 GEWL AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE $ 6,00,000 X POUCY[D JECaT F—]LOC PRODUCTS-COMP/OPAGG $ 6,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWTB2195715 04MV2015 04/0101016 BINED $ 5,000,000 X ANYAUTO BODILY INJURY(Per person) $ X AL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Par accident) $ X HaiED AUTOS X RONN-OWNED PR GE $ X UMBRELLA UAB X OCCUR 19961670 04/01/2015 041018016 EACH OCCURRENCE S 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,00(1,000 01U3 X RETENTION$25 000 $ A WORKERS COMPENSATION MWCi 1626415(AOS) 0410112015 D4101/2016 XOTH• AND EMPLOYERS'LIABILITY STA EER C Y 1 N ANY PROPRIETORIPARTNERIEXECUTIVE MWC301934 00(TX) 0410112015 04101/2016 OFFICERIMEMBER EXCLUDED? FN-1NIAE.L EACH ACCIDENT $ 1,000,000 C (Mandatary In NH) EWC00638M IXS OH) 04/01/2015 04101/2016 EL DISEASE-EA EMPLOY $ 1,000,000 Mascdbeundor IPTION OF OPERATIONS below EJ—DISEASE-POLICY LIMIT $ 1,000,000 DESCRiPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addttlonal Remarks Schedule,may be anached U mom space Is required) PLUMBER CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY POLICY WHERE REQUIRED BY INSURED CONTRACT,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE NAMED INSUREDS PREMISES,'WORK'FOR THE CERTIFICATE HOLDER,OR ACTS OR OMISSIONS OF THE CERTIFICATE HOLDER IN CONNECTION WITH THE GENERAL SUPERVISION OF THE NAMED INSUREUS'WORK'. CERTIFICATE HOLDER 15 NAMED AS AN ADDITIONAL INSURED ON THE AUTOMOBILE POLICY FOR'BODILY INJURY'OR'PROPERTY DAMAGE'ARISING OUT OF THE USE OF A COVERED'AUTO,WHILE THE COVERED'AUTD'IS BEING USED PURSUANT TO A CONTRACT.UMBRELLA IS FOLLOW FORM AS REQUIRED BY WRITTEN CONTRACTOR AGREEMENT AND PER THE UMBRELLA POLICY TERMS CONDITIONS REGARDING THE ADDITIONAL INSURED WORDING. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES,NE 2ND FL 3E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI 6HORES,F7 33136 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashl Mukhe4es M0.titPpl.i O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2614101) The ACORD name and logo are registered marks of ACORD �J� e AA e c i/ Fd© �007- eo'-- 6- r 15,57t) N t3 77'4�1& (+Y71 kvre'—� PCf-, -1 F-1 _ �PU-44n /Y 1(;,-,e- el MAY 13 2014 , Y: k dI sHcR ES VILLAGE APPROVED By DATE /�N%b ZONING STRUCTURAL ELECTRICAL PLUMBING MECHAWCAL BLDG. I L-l� SU3JECT TO COMPLIANCE WITH ALL FEDERAL, STATE FIND COUNTY RULES AND REGULATIONS. '77.�-- OFFI, .4 CIULE ILLAGE li yIj �PVRUVED BY DATE ZO N-iNG A � � ,1 STRUCTURAL ri ELECTRICAL PLUMBING �MECHANI'�AL I GLDG- ki TO C' M`LIAN,r 4,'lllh ALL FEDERAL,I L STATEL A14D COUNTY RULES AND REGULVIOINS M4 PR Y*