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PL-15-3111 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number. INSP-249466 PermitNumber: PL-12-15-3111 Scheduled Inspection Date:January 05,2016 Permit Type: Plumbing - Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner. JONES,WILLIAM Work Classification: Sprinkler System Job Address:379 NE 94 Street Miami Shores,FL 33138- Phone Number Parcel Number 1132060136130 Project <NONE> Contractor. BERNIES SPRINKLER&LANDSCAPING INC Phone. (305)620-1111 Building Department Comments REPAIR HEADS AND LINES OF SPRINKLER. Infrectio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Eq/ Failed Correction Needed Re-Inspection a Fee No Additional Inspections can be scheduled until re-Inspection fee is paid January 04,2016 For Inspections please call:(305)76241949 Page 23 of 45 remit NO. Pik42-15-311 Miami Shores Village PEl7ltt "yp ;Plum _Rt3 +If +E:2tti€I 10050 N.E.2nd Avenue NE 6*aiassificadork S)fario r System `•'• ""'m Miami Shores,FL 33138-0000 Petr t� `tel'u �pROVEL1 Phone: (305)795-2204 issue ;12124/2n1 Expiration: 2`U21 Project Address Parcel Number Applicant 379 NE 94 Street 1132060136130 WILLIAM JONES Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell WILLIAM JONES 379 NE 94 Street MIAMI SHORES FL 33138-2842 Contractor(s) Phone Cell Phone Valuation: $ 1,200.00 BERNIES SPRINKLER&LANDSCAPIP (305)620-1111 Total Sq Feet: 0 Type of Work:REPAIR HEADS AND LINES OF SPRINKLER Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Return: Underground Sprinkler Classification:Residential Scanning:3 Review Plumbing Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# PL-12-15-58075 DBPR Fee $2.25 12/24/2015 Cash $ 121.70 $50.00 DCA Fee $2.25 Education Surcharge $0.40 12/16/2015 Cash $50.00 $0.00 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $171.70 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 construction and zoning. F herrn e,I authorize the above-named contractor to do the work stated. n v December 24, 2015 Authorized Signature:Owner / Applicant / (J_ontract / Agent Date Building Department Copy December 24,2015 1 �� Miami Shores Village .[ Building Department II ® c 2015 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 R Tel:(305)795-2204 Fax:(305)756-8972 �— INSPECTION LINE PHONE NUMBER:(305)762-4949 FOC 20 e`� QQ BUILDING Master Permit No., (--,L(5' :51 l PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING Ej REVISION EXTENSION DRENEWAL LUMBING F-] MECHANICAL PUBLIC WORKS [:] CHANGE OF CANCELLATION SHOP 7 ' CONTRACTOR DRAWINGS .7 JOB ADDRESS: � � AJ E � 6 C� City: Miami Shores County: Miami Dade Zia: 33139 Folio/Parcel#: &-3-2644 4 / -Cp/ L� Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: � OWNER: Name(Fee Simple Titleholder): �l�(i �J of Phone#: b�^ a //i s Address: 1/y✓ City: /� ��'// 5U ®sit-�Stater Zip: 3 1 Tenant/Lessee Name: Phone#: Email: k C �#: L /CONTRACTOR:Company Name: ( e S V � eefe4 hoVZO 2®� G / t Address: �'`� -- C23 q7 ity: L State: Zip: Qualifier Name: _�-• 11 Lo-,I, j��✓ Phone#: State Certification or Registration ) #: F �`i oo0:2,i40 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: Square/Linear Footage of Work: Type of Work: ❑ Addition Alteratio/nn ❑ New Repair/Replace ❑ Demolition Description of Work: i r 4;5� (�7f1 Specify color of color thru tile: Submittal Fee$ Permit Fee$ �` � CCF$ �. '�� _ CO/CC$ Scanning Fee$ q . Radon Fee$ DBPR$ Z) , c�'� Notary$ r Technology Fee$ (o 0 Training/Education Fee$ � H o Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 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 Signature OWN �rNT ONTRACTOR The foregoing instrument was acknowledged before me this The foregoing Inst umen�t was packnowledged before me this day /of� �� ,20�� by day of !'�1`°�i�'CC� 20 (S ,by Gf/ li. q yam— ,who is personally known to G�DH ?2�t� who is personally known to me or who wed `G�tG a3'�' me or who has produced l � T� - j Q;'Mt identification and who did take/an oath. � - identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign. Sign: Print: �'1 Print: Seal: L(407) ��_. JAMIE M ARDEN Seal' o,1eiic State of Florida MY COMMISSION#EE179925 °us Notary 49 yr Sindia Alvarez EXPIRES March 15,2016 y� Qg My Commission FF 156750 ptg3 FI + orc�oe Expires 09/03/2018 APPROVED BY /t Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) S�oRFs onto nntM Miami Shores Village Building Department RILDA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION 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 CONT TOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. C PY OF LOCAL BUSINESS TAX RECEIPT C. OPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. LC__OPY_QFllAB1L1T_Y__IAISUI3ACE*) E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER-form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ................ ............... ................ ... ................................ BUSINESS NAME: I rn S ��/ r,/tQ-S L BUSINESS ADDRESS: 9 C o A � 361)r CITY No,t A STATE ZIP �&4 BUSINESS PHONE: (3'0!i_) b"420 I C FAX NUMBER( ) CELL PHONE ( ) QUALIFIER'S NAME: rChT WV Lei- 'y' QUALIFIER'S LIC NUMBER: Constriction Trades Qualifying Board ' BUSINESS CERTIFICATE OF COMPETEf4CY 14P000240 BERNIES SPRINKLER&LANDSCAPING INC ;D.B.A. N�RG=ADY B Is certified under the provisions of Chapter 10 of Miami-Dade County 0003 LAWN SPRINKLER JugamMJAM Semet H.Salas P.E. �_o Secretaryof the Board `u / www.MeMdadegav/eco'romy NAaM-Dade Co retains aA d herein. Local Busi ness Tax Pecei pt Miami-Dade County, State of Florida -THIS ISNOT ABILL-DO NOT PAY BT 7195201 !_j BUSINESS NAM E/LOCATION RECEIPT NO. EXPIRES BERNIES SPRINKLER& NEW BUSINESS SEPTEMBER 30, 2016 LANDSCAPING INC 7477387 810 NW 186 DR Must be displayed at place of business Pursuant to County Code MIAMI GARDENS, FL 33169 Chapter 8A-Art.9&70 OWNER SEC.TYPE OF BUSINESS PAYM ENT RECEIVED BERNIES SPRINKLER& 196 SPECIALTY PLUMBING BY TAX COLLECTOR LANDSCAPING INC CONTRACTOR R/fl r;RAny I ANIFR 45.00 12/15/2015 Worker(s) 1 14P000240 0223-16-001808 Tins Local Business Tax IZem pt only con"ms paymerd of the Local Business Tax The Receipt is not a I icense, perrrit,or a certi^cation of the hol der's qual i"cations,to do bus!ness.Holder nest comply with any governments] ornongovernnental regulatory laws and requiremantswhich apply to the business. The REPT NO.above mist be displayed on all commercial vehicles-Miami-Dade Code Sec 8a-716. MLAM4 Fbr more information,visit www.mlarridade.govftwccolledor 0 Municipal Contractor's Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY M C CC NO: 14P000240 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES' BERNIES SPRINKLER&LANDSCAPING SEPTEMBER 30 2016 810 NW 186 DR INC 7477388 MIAMI GARDENS,FL 33169 Pursuant to County Code Sec 10-24 OWNER TYPE OF BUSINESS PAYMENT RECEIVED BERNIES SPRINKLER&LANDSCAPING SPECIALTY PLUMBING CONTRACTOR BY TAX COLLECTOR INC C/0 GRADY LANIER 175.00 12/15/2015 0223-16-001808 This receipt is not valid in the following Municipalities:Aventure,Doral,Hialeah,Key Biscayne, Miami Gardens,Miami Lakes,Pohne to Bay,Pinecrest.Sunny Isla Beach,Town of Cotler Bay. MAN For more infomn tion,visit www.miamidede.go hwoilector 1 _ , DEC-16-2015 02:27 FROM:CLOVERLEAF INSURANCE 3056550730 TO:3057568972 P.1 Ac Rn® CERTIFICATE OF LIABILITY INSURANCE F °12/1612015' THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMA'nON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVLFRAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13STMEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; It die cartincato holder is an ADDITIONAL INSURED,the policy([")must be endosSUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require all endorsement A statemant on this certificate dans not confor rights to the certificate holder In Ilau of such endorsomen e. GONTAGT PRODUCER NAME; C.MCCULLOM Clovedsaf Insurance Brokers "M'o pa). 305-655-1005 A +o5�A 18314 NW TM Avenue to-MAIL Miami,Florida 33188 candyr(NGlover��Ieaflnpurance.Com PR4 X751 INSURER(8)AFFORDING COVQRIE NA10 Y INSURED INSLIRERA. GRANADA INSURANCE BERNIES SPRINKLERS 8,LANDSCAPING,INC IN9URFR 0 810 NW 186TH DR MIAMI, FL 33169 INSURER c; INsuRF,R D•:_ (NSU,RER E• �_.. INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVC BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RSOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED AY THE POLICIE5 DESCRIBED HEREIN IS SUEWECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCtES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ADUL 1,110 lNea TYPE OF INSURANCII UMd9 NUM19ER LIQ 49NEPALLIABILITY GACHOCCURREN.F E 1,000.000,00 COMMERCIAL GENERAL LIABILITY -DXMArF TQ S 1Bo occ;w i 100.000.00 A CLAMS-MADE 0 OCCUR 0185'F1000773380 2/07/15 12/07/x6MFDFxp arsee=l6 5.000.00 PERSONAL A ADV INJURY 6 1,000.000.00 0FNERAL AGGREGATE .2.000.000.00 GERL AGGREGATE LIMIT APPLIF5 Fate. pRODUC18-COMp/OP ADG 5 1.000.000.00 POLICY T'• LOC 6 AUTOMeOea.0 LIADILITY COMBINED SINGLE LIMIT 6 (E0 momml) ANY AUTO BODILY INJURY(tsar peNOn) 6 ALL O{NNLDAUTOS BODILY INJURY(Por IlCpW") f SCHEDULED AU 1'03 FROPCRTYD - AGE HIREDALITOS (PermcadOnA_M S NON-OWNED AUTO 5 6 UMSRMJALrA6 OCCLIA EAC►+OCCURRENCE I excess Um CLAIMS-MADE AGGREGATE 5 DEDUCTIBLE i FTGNTION S 5 WORKERS COMPENSATION VVL „• AND EIWLOYMtS'LIABILITY Y I N ANY OFFI REMEMBER EACLUDW?MCPAICTORMARTNER/UWUTNE❑ NIA E L PJ1CH ACCIDENT Is � ClC�.,GI(Myaenadalay IN NH) E.L.DISWE•EA EMPLOYE 11 0WN9%FRAT19NS below E L DISEASE-POLICY LIMIT ; DESCRIPTION OF OPERArONS I LOCATIONS E VEHICLU(Attach ACORD 101,Additional RawxAm Schedule,a mare.Pete la mqulrnd) Law Sprinkler- Installation, Servicing or Repair.Dade County Contractor License 14P000240 CERTIFICATE HOLDER CANCELLATION Miami Shores Village 3HOUI.0 ANY OF THE ABOVE pIISOR1DED POLICISS flE CANCELLED BEFORE 10050 NE 2 Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shroes,EI 3$138 A DANCE WITH THE POLICY PROVISIONS, D TIVE chi 1888-2008 CORD CORPORATION. All rights raserve . ACORD 25(2009/09) The ACORD name and logo are ragistereCt marks of AC RD 1Zeport Viewer Page 1 of 1 t00% } 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" CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 2/10/2015 EXPIRATION DATE: 2(9/2017 PERSON: LANIER GRADY B FEIN: 461461775 BUSINESS NAME AND ADDRESS: BERNIES SPRINKLER&LANDSCAPING INC 810 NW 186 DR MIAMI FL 33169 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND AUTOMATIC SPRINKLER DRIVERS INSTALLATI PWwent to Chapter 440.08(14).F.S..an ot9om of a omporatlen who etecle W"npum fmmthls ch8 fOn9 a ceNHcs%of eteo urkar"secWn msr not recover OanePoe m eemPeneaUan urafmf ft chap -PummTdto Chapter040.W12).F.&.CertlHeatea of el.H to be exempt...apply ony wBldrl the scope ofihe buakress m trace BetaA mthe roNoe of eketlon to be szempL Purouamtto ChepDer440.05(13),F.S..Naftm mele�sn�n to ba thethe person nanred on Oreon tae rtotica mb aMU De auDJemto rewoatlon M,et airy tone eRmMe a8n9 of rhe notice mNe mare . bnemnreeta are regidiamen}s oftltla aegbn for tssuerwe of a eertiBmOe.The deparbrem shat revoke a DMF2-OWC-282 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED M13 QUESTIONS?MOr413.1608 haps://apps8.fldfs.com/crreportviewer/reportViewer.aspx?data—k... 2/18/2015 BERNIE'S SPRINKLER, INC. The Full Service Company That Caresi Licensed & Insured,' , 3531-NW 170th Street• - Opa Locka, Florida 33056 (305) 620.1111 �6LZ®1� --- --- Date:� --< _ y- ------ - _ - _ _ State ofl��t�� County of Mf&41 Before me this day personally appeared&Ab� WNbein>;duly sworn,deposes and says: That he or she will be the only personrking o:r e prg t locate6 i Z 99 W— T i Sworn to(or affirmed)and sub` - ke�� - re metes ,ftof 20 b by Personally know OR Produced Identifications Gro0, OZ 4t 9 C' Type of Identification Produced Stamp Name of Notary o40 c Notary Public State of Florida ? Sindia Alva= W < My commission FF 156750 ppp� Expires 09/0312018 Miami shores Village Building Department �toRl11 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 exemptthemselves 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 be 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 re workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors,quire verification of BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: /A lx—� 41- e State of Florida County of Miami-Dade The foregoing was acknowledge before me this 4f—day of ,20 /J By 9oZ '� who is rsonally own me or has produced as identification. ;,io��arry�`c Notary. JAMIE M ARDEN MY COMMISSION#EE179925 SEAL: '„o P'' ori`'•• EXPIRES March 15,2016 (407139&0153 Florldallotaryservice.com