PL-15-2935 Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-248194 Permit Number: PL-11-15-2935
Scheduled Inspection Date: January 21,2016 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: LAFRENIERE, KATHY Work Classification: Addition/Alteration
Job Address:1100 NE 91 Terrace
Miami Shores, FL 33138- Phone Number
Parcel Number 1132050010390
Project: <NONE>
Contractor: D&D PLUMBING CORP Phone: (305)979-0516
Building Department Comments
REPLACE EXISITNG PLUMBING FIXTURES WITH NEW infractio Passed Comments
IN MASTER BATH INSPECTOR COMMENTS False
spector Comments
Passed E9`0'
Failed
L !�
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
January 20,2016 For Inspections please call: (305)762-4949 Page 14 of 32
A3i P 3. 31 i` e04i':Yo PUO
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Miami Shores Village P6i?111r #t "lumbtnij -Res>i+denttai
10050 N.E.2nd Avenue NE
irkt�r. cadron:A+rl41t10nlAlterrtion
Miami Shores,FL 33138-0000 er
ti ° Phone: (305)795-2204 JHCtt77! t :
x � Aa
Expiration: 06/29/2016
s Issue nst� '1211�2i�15 p
Project Address Parcel Number Applicant
1100 NE 91 Terrace 1132050010390 KATHY LAFRENIERE
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Celt
KATHY LAFRENIERE 1100 NE 91 Terrace
MIAMI SHORES FL 33138-3404
1100 NE 91 Terrace
MIAMI SHORES 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
D&D PLUMBING CORP (305)979-0516
Total Sq Feet: 200
Type of Work:REPLACE EXISITNG PLUMBING FIXTURES Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
Top Out
Bond Return: Final
Classification:Residential Scanning:1 Rough
Review Plumbing
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20
Invoice# PL-1'a15-57835
DBPR Fee $3.38 11/20/2015 Check#:626 $50.00 $187.96
DCA Fee $3.38
Education Surcharge $0.40 12/01/2015 Check#:639 $187.96 $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 confo ' with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume respon 'lity for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBIN ,M ICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I cert' �at all t or oing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Fu r' e e above-named contractor to do the work stated.
December 01, 2015
Authorized Signet e:Owner /41 Appli nt / Contractor / Agent Date
Building Department Copy
December 01,2015 1
Miami Shores Village
Building Department Nov a 26%
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 – —__
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201 -1
BUILDING Master Permit No.RC-10-15-2656
PERMIT APPLICATION Sub Permit No.Pt -i5 - Zei 3 S
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑■ PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1100 N E 91 st Terrace
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:11-3205-001-0390 Is the Building Historically Designated:Yes NO
Occupancy Type: R Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Kathy Lafreniere Phone#:508-259-9793
Address:1100 N E 91 st Terrace
City: Miami Shores State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: D&D PLUMBING CORP. Phone#: 305-979-0516
Address: 3890 NW 2nd Terrace
City: Miami State: FL Zip: 33126
Qualifier Name: David Diaz Phone#: 305-979-0516
State Certification or Registration#: CFC1426173 Certificate of Competency#:
DESIGNER:Architect/Engineer: JCD ArchitectPhone#: 305-285-4343
Address:1385 Coral Way Suite 207 cit,. Miami State: FL Zip: 33145
Value of Work for this Permit:$$1,500 Square/Linear Footage of Work: 200 sq.ft.
Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/Replace ❑ Demolition
Description of Work: Replace existing plumbing fixtures with new in existing locations in Master bath.
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$
TOTAL FEE NOW DUE$ 15-1-61'6
(Revised02/24/2014)
P-
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: 1 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 b osted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absen of uch posted notice, the
inspection will not be approved and a reins on fee will be charged.
Signature `s Signature
G'
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
! day of a��J n-i 1>t- 20 J l ,by IL4 day of 00JJ1 Wj 1'C 20 /S by
1 h] I-(i2f ,who is personally known to is persona ly known to
me or who has produced L 'S'7 as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
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IUJCUI.VANDAb1A
f� MY COMMISSION S FF 028557
EXPIRES:October 18,2017
Sign: ZSig BwMdWw 7hru
Print: . avy Print:
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APPROVED BY , t ' Plans Examiner Zoning
Structural Review Clerk
(RevisedO2/24/2014)
CERTIFICATE OF LIABILITY INSURANCENST;1Dty"'
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 WANED,subject to
the terms ami conditions of the policy,certain policies may require an andoreemerd. A statement on tills certificate does not confer rights to the
certificate holder in leu of such embrsemerd(s).
PRODUCER WCTLudy Estreb
Accurate (308)226-8727 0; (305)226-8767
8300 West Flagler Suite 114 Rr- luctaestrett owlsouth.net
Miami,FL 33144 INSURER(S)AFFORDING COVERAGE NAIL 0
Phone (306)226-8727 Fax 226-8767 INSURER A: Unbd Stag USbft Insurance Comp
INSURED INSURERS: °
0&D Plumbing Corp 001URERC:
3890 NW 2 Terrace R=RER 0'
Miami,FL 33126 (305)979-0516 DISURERE,
INSURER F:
COVERAGES 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 CONTRACTOR 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.
L TYPE OF INSURANCE ADOLSUDIt POLICY NUMBER LIM"
GENERAL LIABILITY OCCURR B1CF_ 1,000,000.00
® COMMERCIAL GENERAL LIABILITY i E F e ,,.,. $ 5,000.00
A ❑ ❑ CLAIMSMADE ® OCCUR Y Y CLIG79197A 11/26/2015 11262016 MED° ( °fes S 100,000.00
❑ PERSONAL&ADV INJURY $ 1,000,000.00
❑ GENERAL AGGREGATE S 1,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 1,000,000.00
❑POLICY ❑ ❑ LOC $
AUTOMOBILE LIABILITY SINGLE LIMIT
p ANY AUTO BODILY INJURY(Per peman) S
❑ ED
ALL S m ❑ UT BODILY INJURY(Per so;R t $
❑ HiRED AUTOS ❑ AUTO D $
S
❑ UMBRELLA UAB ❑OCCUR EACH OCCURRENCE $
EXCESS UAB ❑CLAIMS-MADE AGGREGATE -— _$
❑ DED El RETENTIONS $
WORKERSCMTION
AND EMPLOYERS'LIABILITY YIN mtkrrs C) H __
ANY PROPRIETORIPARTNERIEXECUTIVEN A EL EACH ACCIDENT $
OFFICEiNMEMBER EXCLUDED?
IfRIPTION )o"Awtv in NNNILDiSEASE-EAEMPLO $
DESCOF OPERATION belay EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AUACORD 101,Addblonai Remarks Sotrednte,H more spm Is required)
State Plumbing Contractor
CFC 1426173
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AS POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE TI WILL BE DELIVERED IN
Miami Shores Village ACCORDANCE WITH NS.
10050 NE 2nd Avenue
Miami,FL.33138 AUTNORtaEO
Lucia Estrella
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010105)OF The ACORD name and logo are registered marks of ACORD
lots ain" Miami shoresVillage
" not '` Building Department
ZORI� 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
CONTRACTORS' REGISTRATION Fax: (305) 756.8972
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LICENCES
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. _COPY OF LIABILITY INSURANCE*
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 CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL
CONTRACTOR'S TAX RECEIPT.
D. COPY OF LIABILITY INSURACE*
E. COPY OF WORKERS COMPENSATION INSURANC * "
(Workers Compensation EXEMPTION must ha NOTICE TO OWNER form nd Contractor Affidavit)
*YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW
Certificate Holder:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
Certificate must specify the description of operations or contractor license number.
■■rr■rrrrrrrrrrrrrrrrrrrrrrr■rrrrrrrrrrrrrrrrrrerrrrrrrrrrrrrrrrrrrr�rrrrrrrrrrrrrerrrrrrr
BUSINESS NAME: -FI C
BUSINESS ADDRESS: N w Z"r,> �Qrrrn(f CIT( (Y),-q ry STATE L- ZIP 3312
BUSINESS PHONE: ( 13S ) 'Z�S S SAF FAX NUMBER C
CELL PHONE( >P,2 QUALIFIER'S NAME: PA\)) r) Q/ Z
QUALIFIER'S LIC NUMBER: C
001428
Local Business Tax Receipt
Miami—Dade County, State of Florida
` -THIS IS NOTA BILL - DO NOT PAY [LBT .I/
5268586
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
D&D PLUMBING CORP RENEWAL SEPTEMBER 30, 2016
3145 SW 19 ST 5505483 Must be displayed at place of business
MIAMI FL 33145 Pursuant to County Code
Chapter 8A-Art.9&10
OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED
D&D PLUMBING CORP 196 PLUMBING CONTRACTOR BY TAX COLLECTOR
Worker(s) 1 CFC1426173 $45.00 07/27/2015
CHECK21-15-105518
This Local Business Tax Receipt only confirms payment of the Local Business Tax The Receipt is not a license,
permit,or a certification of the holder squalifications,to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 6a-276.
For more information,visit www miamidade aovRaxcollector
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION :e�[I -Sr y
CONSTRUCTION INDUSTRY LICENSING BOARD
CFC1426173
The PLUMBING CONTRACTOR ..
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
DIAZ, DAVID
D& D PLUMBING CORP
3145 SW 19TH STREET i
MIAMI FL 33145-1927
o�
ISSUED: 08111!2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408110001168
JEFF AWpTER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
*=CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW
^,ONSTRUCTION INDUSTRY EXEMPTION from Florida Workers.Compensation law.
This certifies that the individual listed below has elected to be exempt
EFFECTIVE DATE: 3122/2014
EXPIRATION DATE: 3/21/2016
PERSON: DIAZ
DAVID
FEIN: 200604412
BUSINESS NAME AND ADDRESS:
D&D PLUMBING CORP
3145 SW 19 STREET
MIAMI
FL 33145
SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING
CONTRACTOR of election under I section
Purs,nt t.Chapter 440.05(74),F.S.,an otftcer of a oorporation who Gleclg exemption trap 7hts chapter�+fairte a certi(tca�
may not berhfl>s or 'PensaOon der�chapter Pursuant to Chapter 440.05(72),F.S..Certificates of election to be exempt.•apply only
my
t r c scope b the business co or trade Used on the notice of eleatkn to be exempt Pursuant to Chapter 440.05(13),F.S.,Notices of election to be
exempt and cotes of election to be exempt shall be subject to rev n if,at any time aftsr the tilin8 of the notice e.file fssuanoe of the certifioke
e e parson marred at etre notice�eerNflcata rw ioar9er meets the requkernem of this section for issuence of a certlrioete.The deParfine^t shell revoke a
QUESTIONS?(850)413-1609
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEArIPT REVISED 07-12
D & D PLUMBING CORP.
3890 NW 2M Terrace Miami,FL.33126
PH:305-979-0516 dndcorp@aol.com
CFC-1426173
November 11, 2015
State of Florida
County of Miami-Dade
Before me this day personally appeared David Diaz who, being of duly sworn,deposes and says:
That he will be the only person working on the project located at: 1100 NE 91s�Terrace, Miami
Shores, FL 33138.
s
Swore to(or affirmed)and subscribed this day of � , 20 CS
By
Personally know
OR Produced Identification
Type of Identification Produced
a, 7` •,,o, AUCIALVANDAMA
W COMMISSION i FF 028557
P ES:october 18,2017
Print, Type or Stamp Name of Notary
.... ,„nom Miami shores Village
r rue Building Department
[pR 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
1 mak. �h
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the constriction 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.
blSignature: ��2 `�, - -y/
O
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of N,)Q_'rn b4-- ,20_1fj
By L—A E FJE who is personally known to me or has produced
�- 1ci -aas identification.
Notary: t"AN nd,16M P.Wwm,A
wr
andro R Addino
v My Commission FF 929919
SES" or w0 Expires 10IM2019