DEMO-15-1076 i �
Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-234123 Permit Number: DEMO-5-15-1076
Scheduled Inspection Date: June 09,2015 Permit Type: Demolition
Inspector: Diaz,Osvaldo InspectionType: Final
Owner: UKAZIM, UCHENNA Work Classification: Plumbing
Job Address:960 NE 97 Street
Miami Shores, FL 33138- Phone Number
Parcel Number 1132060143160
Project: <NONE>
Contractor: LEYVA PLUMBING SERVICES INC. Phone: (772)871-5893
Building Department Comments
PLUMBING WATER SHUTDOWN FOR DEMOLITION. tnfractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed Er
Failed
Correction ❑
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
June 08,2015 For Inspections please call: (305)762-4949 Page 18 of 37
Ptzirmit No, DEMO-5�-15-1076'"
Miami Shores Village `y Permit Type I�WnOIi�ioni° `•
10050 N.E.2nd Avenue NE
Work Ctotsiswtiort Plumbing
Miami Shores,FL 33138-0000
Permit 0848 AOROVED
his Phone: (305)795-2204 -
F`OExpiration: 1 0112015
Issue I614129
Project Address Parcel Number Applicant
960 NE 97 Street 1132060143160
UCHENNA UKAZIM
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
UCHENNA UKAZIM 960 NE 97 Street
MIAMI SHORES FL 33138-
960 NE 97 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 250.00
LEYVA PLUMBING SERVICES INC. (772)871-5893 (772)672-3673
Total Sq Feet: 10
Type of Demo:Plumbing Available Inspections:
Additional Info:PLUMBING WATER SHUTDOWN FOR DEMOLIT Inspection Type:
Classification:Residential Final
Scanning: 1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 Invoice# DEMO-5-15-55449
DBPR Fee $2.00
DCA Fee $2.00 06/04/2015 Check#:1807 $58.60 $50.00
Education Surcharge $0.20 05/06/2015 Check#: 1791 $50.00 $0.00
Permit Fee $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $108.60
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'certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
con d o ing. F hermore,I authorize the above-named contractor to do the work stated.
Ji 6 June 04,2015
thorizedl Signature: ner / Applicant / Contractor / Agent Date
Building Department Copy
June 04,2015 1
Miami Shores Village
RF,CFTX,r :L)
Building Department MAY 6 2015
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20(C)_ qb(b BUILDING Master Permit No. -DEM6'lJ
PERMIT APPLICATION Sub Permit No. EX0 - IS- IbR(�
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
ERLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOBADDRESS: �� U� '51
City: Miami Shores County: Miami Dade Zip: :3'75 1 -5 E
Folio/Parcel#: t3 2-o(a _ 0 �� -� 31 �0-is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): V G*1FW N hy Phone#:
Address: 01 to 0 we CY-+ 5'f
City: M t A*& ( 51k� State: - Zip: 33 1 ,
Tenant/Lessee Name: Phone#:
Email: \.K , k4';L-%.+n @ c."'j 1 .
CONTRACTOR:Company Name: L / V M�I to Phone#: �G Fir (7�q
Address: 5 ')- S W M
City: G(-^ State: Zip:
Qualifier Name: b91 iq4— Luuvo, Phone#: 7W. 5:K
State Certification or Registration#: rc fZ12,5 �� Certificate of Competency#: ..
DESIGNER:Architect/Engineer: N CbN SJ L-Tej.N s Phong#:
Address: IfA oo SVlZC UO City: t)L,&A state: Zip: 3l O
00
Value of Work for this Permit:$ 2.Jr'Q Square/Linear Footage of Work: to L-4
Type of Work: ❑ Addition �_: Alteration ❑ New ❑ Repair/Replace [Demolition
Description of Work:
is •
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCS.QZS CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TAL FEE NOW DUE$ f�b+�-C
(Revised02/24/2014) 1 ,�ro A
l
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 A Signature 414Z
OWNER or AGENTCONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instr ent was acknowledged beforermethis
day of � r, ,20 , by I_d y of
�1�QnSign: Sign: 20 p ,by
1A �• �Y.aZIM ,who is personally known to4� who is personally known to
�\V'
me or who has produced Cr CIOM3-P as me or who hspaduced 0 as
identification and who did take an oath. identification and wh did to e a o th.
e
NOTA PUBL NOTARY PUBL : 0 11111ra,,
~®'� •�••�
Print: .•`P"p, Print: LV
',r• S Notary Public-State of Florida •~
Seal: • •
,• ••' M Comm Seal: ��� � � � �•,�
MY Expires Jul 27,2018 'cr "A�•cj�.���
;#tests Commission i FF 145261
u«rrnmmun°°°p°
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
To: Page 2 of 2 2015-04-20 14:39:32(GMT) From:Yamilka Leyva
04
4a
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
" CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW e
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 4/30/2014 EXPIRATION DATE: 4/29/2016
PERSON: LEYVA ABNER
FEIN: 651046604
BUSINESS NAME AND ADDRESS:
LEYVA PLUMBING SERVICES
1502 SW MERIDIAN AVE
PORT ST LUCIE FL 34953
SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING
CONTRACTOR
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may
not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt. apply only within the scope
of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of eleotion to be 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 no longer meets 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 section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609
Leyva Plumbing Services Inc.
1502 SW Meridian Ave
Port Saint Lucie, FL 34953
April 28, 2015
State of Florida
County of Miami Dade
Before me this day personally appeared Abner Leyva who, being .duly sworn, deposes and
says
That he or she will be the only person working on the project located at 960 NE 97 ST, Miami
Shores, FI.
Sworn to and subscribed before me this 28 of April 2015 by LE \J
Personally Know
OR Produced Identifica el—
iony
Type of Identification Produced b i_ L-110 ,z,
Print, Type or Stamp Name of Notary
K,- MAGAMR777"mission 0 FF 079698
ea March 3,2018
ThM NY Fdn lneuronee 80038&7019
a Miami shores
Village
Building Department
�> 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to Owner- Workers' Compensation Insurance Exemption
W. NoW
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate oRcers 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 ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature: !/
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before WL
this f6 day of ,20 S.
ByJa �l I�( +1Q a i ►�L who is personally known to me or has produced
1 as identification.
JAVIER OLARTE
Notary: :tea°. B`�� Notary Public-state of Florida
My Comm.Expires Mar 5,2017
SEAL: '%'9r oc- Commission#EE 880835
�''.O