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PLC-15-3064 Z— yc /'� — Z� Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-249977 PermitNumber: PLC-12-15-3064 Scheduled Inspection Date: December 30,2015 Permit Type: Plumbing - Commercial Inspector: Diaz, Osvaldo Inspection Type: Final Owner: , Work Classification: Repair Job Address:10500 BISCAYNE Boulevard Miami Shores, FL 33138- Phone Number Parcel Number 1122300010500 Project: <NONE> Contractor: BERGERON PLUMBING INC Phone: (561)445-2115 Building Department Comments REPLACE ELECTRIC WATER HEATER Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-249127. contractor called no one onsite to locate heater Failed �P 0J I Jq;?r - Correction Needed D 1,3 Re-Inspection ❑ �; Fee No Additional Inspections can be scheduled until re-inspection fee is paid. December 29,2015 For Inspections please call: (305)762-4949 Page 20 of 34 Permit n�o. 1 16. -'1>5- 064, �eH° tt Miami Shores Village e17 )ip8:I*�tltitE? 4- ot14t310 C g� 10050 N.E.2nd Avenue M Work Cfa atiow,Repair ""' Miami Shores,FL 33138-0000 yf g Phone: (305)795-2204 5tatu APPROVED tORtD a Issue 1 !11/ 0 ' ,, Expiration: 0812016 Project Address Parcel Number Applicant 33 10500 BISCAYNE Boulevard 1122300010500 ICUC HOLDINGS INC Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell ICUC HOLDINGS INC 10500 BISCAYNE Boulevard MIAMI SHORES FL 33138- 3009 N MAIN Street SANTA ANA CA 92705- Contractor(s) Phone Cell Phone Valuation: $ 600.00 , BERGERON PLUMBING INC (561)445-2115 ... Total Sq Feet: 0 Type of Work:REPLACE ELECTRIC WATER HEATER Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Classification:Commercial Review Plumbing Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee $2.60 Invoice# PLC-12-15-58014 DCA Fee $2.00 12/11/2015 Check#: 1499 $ 108.60 $0.00 Education Surcharge $0.20 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 constructizoning. Futherrtrore,I authorize the above-named contractor to do the work stated. December 11, 2015 Authorized S nature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 11,2015 1 _ . Miami Shores Village -- Building Department DEC fl 6 201 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 2014 BUILDING Master Permit NoT L�-- S -213 LfC1 PERMIT APPLICATION Sub Permit No. IS -s-3Qo� ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL QPLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: O S®� 131 S��Ns>U [RU�II) City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): GUL.� I � 0 �L. Phone#: C019—315" �1��- Address: I(D S 00 �1 S C.P.`1'Nom. �yr i� (—�') <V,73 City: tA. 51RWYr State: �'�— Zip: 3311e Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Bergeron Plumbing Inc Phone#: 5614452115 Address: 5562 Aspen ridge cir City: delray beach state:flodda Zip: 33484 Qualifier Name: David M Bergeron Phone#: 5614452115 State Certification or Registration#: cfc1427568 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ (Cco-uo Square/Linear Footage of work: Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/Replace ❑ Demolition Description of Work: replace lectric water heater Specify color of color thru tile: Submittal Fee$ Permit Fee$ il(fid. y CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ GO� (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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment Also,a certified copy of the recorded notice of commencement must be posted at the job site for the flrst inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this l day of � R—C— .20 IS by day of 20 IS— by rA I q1 WH U 0"41 who is rs who is personally known to me or who has produced ,,,ui uu,,, as me or who has produced as Identification and who did take a :,��0f8• identification and who did take an oath. NOTARY PUBLIC: ;� NOTARY PUBLIC: Sign: Sign: b" _�., '' S7—,STAN- "'S$� Print Print: �. Seal: Seal: •""""' JORGE CASTRO ,•�,a�p,,e,, +°. Notary Public-State of Florida c' : My Comm.Expires Nov 2,2018 �:� Commission#FF 146187 sssssssssss•ssssssrssssssssssssssssssssssssssssssssssssssssssssss ssstl+WlAl�ss sssssssss APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL.REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 - BERGERON, DAVID MICHAEL BERGERON PLUMBING INC 5562 ASPEN RIDGE CIRCLE DELRAY BEACH FL 33484 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. PROFESS_ IQIsIAL REGULATION Every day we work to improve the gray we do business in ori to CFC1427568 ISSUED: 06101/2014 serve you better. For Information about our services,please log onto www.nWflovidallcense.com. There you can tind more in niation CERTIFIED Pt liNWNC-CONTRACTOR about�divisions and tient ids You.sum BERGERON,D ID LlIJC AEL to department newsletters amore about the Department's BERGERON PL1� ..' initiatives. Our mission at the Department is:License Efficiently,Regulate Fairly. t We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! date:auc a,,2016 L1406010=472 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC142750 The PLUMBING CONTRACTORNamed below IS CERTIFIED lip Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 BERGERON, DAVID MICH -- BERGERON PLUMBING �` • 5562 ASPEN RIDGE CIRCLE DELRAY BEACH FL 33484 r i 1 ANNE M. G A N N O N P,p,Box 3353,West Palm Beach,FL 33402-3353 "LOCATED AT** a CONSTITUTIONAL TAX COLLECTOR www•Pbctax.com Tel:(561)355-2264 Serving Palm Beach County 5562 ASPEN RIDGE CIRCLE Serving you. DELRAY BEACH,PL 33484 TYPE OF BUSINESS OWNER CERTIFICATION# I RECEIPT#NATE PAID AMT PAID I BILL A 23WO9 PLUMBING CONTRACTOR BERGERON DAVID MICHAEL CFC1427568 I U15MU74-07/17/15 $27.50 1 B401376 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY- 83-800 OUNT Y- B3-800 204512016 LOCAL BUSINESS TAX RECEI BERGERON PLUMBING INC - LBTR Number: 200819386 BERGERON PLUMBING INC EXPIRES: SEPTEMBER 30, 201f 5562 ASPEN RIDGE CIR _ DELRAY BEACH,FL 33484-2582 This receipt grants the privilege of engaging in or �o I�n�Ileelea,Ilu In Iwlu I„I� ��I nln�Ia,! managing any business profession or occupation within its Jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. t • ' 1 100X+ 4 L 0 AM CHEF OFMCER STATEOFRA M NPAWFAElI OFFIMM&SERVICOS IMMMOMONOWC131111PIMAIM t:CgMWKMoFMM=MToMMMkWTFR=RANDAWOMB'C MPtDsATiON LAW t t CoKaTRUCT10N.Mff=-fRY 8MPTM This cer6 m that the W4%Wuml listed below has elected in be emopt from Flodde Wodcers'Compensation law. EFFECINEOM 31302014 6XPRATMOM 3292018 PHISM BERGERON DAMO M FEM 261841399 BIAS NAMEAND ADUMM SMGERON PLUMBWG INC 5862 ASPEN RIDGE Cot DELRAYBEACH FL 33484 SCOMOIFIMUSMIRSBORTIMAIM LICENSED PLUMBING CONTRACTOR ppb 4�0.a5{4g,FS,iaditrdam�oaim�adsb aaetllpa�rLsddea—im+a�er/bt bn� da fie.iLpml�mae�redd b6�siAi�4Pnroatb/7rpls +�1a.-,, �bs�ad V dadanbEee+sal��m j/rRraa �daryN�a�erMowopdtaM dMrmsfaP�as�edmfrte/oLa e�dm�iraAOartiwY�rriolir�as CsWL dsmrkssTlatlprLxets4im�L4amf4abstiq�hefr/iaedlM DFS 2 OMI,ZO COMWAM OF UEMM TO BE E W3FrRBWW 9712 ougs7toNm(85WIS-I e • �•� BERGPLU-01 LDEZIC ACORo CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) llh ' 12/9!2015 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 endomement(s). PRODUCER CONTACT NAME: Plastridge Insurance Agency PHONE FAX 820 NE 6th Avenue A/C No :(561)276-5221 q/C No;(561)276-5244 Delray Beach,FL 33483 ADDRESS:deiraydocs@plastridge.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:OId Dominion Insurance 40231 INSURED INSURER 13:Progressive Express Ins.Co. 10193 Bergeron Plumbing Inc. INSURER C: 5562 Aspen Ridge Circle INSURER D: Delray Beach,FL 33484 INSURER E: 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 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. ILTRR TYPE OF INSURANCE INSD WVD AUDLISUBRI POLICY NUMBER POLICY EFF MMIDD� LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE P(IQCCUR MPG94396 01/2212015 01/22/2016 PREMISES Ea occurrence $ 500,000 MED EXP(Any one Penson) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED tSINGLE LIMIT $ 500,000 B ANY AUTO 021116181-2 04/01/2015 04/01/2016 BODILY INJURY Ar person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR HOCCURCH EOCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER H- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETORlPARTNER/EXECUTIVE FNIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(ACORD 101,Additional Remarim Schedule,may be attached If more space Is required) VILLAGE OF MIAMI SHORES 10050 NE 2nd Avenue Miami Shores,FL 33138 Bergeron Plumbing License#CFC 1462568 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF MIAMI SHORES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ♦5 Is iami shores V Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to Owner- Workers' Com ensation 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 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. I. 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 ofthe 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,Iviianu 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: t� Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day 20 t S By who is ona lyewn me or has produced as identification. �S a Nota? :•346 s •c• '; SEAQ,: ®�f� N Com%1�459 •.oQ` y z BERGERON PLUMBING, INC. WE WON'T DRAIN YOU Date: State of Fl®r",; County of loalm Aecic Before me this day personally appeared .Davi V► who, being duly sworn, deposes and says: That he or she will be the oni erson working on the project located at: S orn to (or affirmed and subscJibed Before me this )0 day of 20 , by Y G Personally Know OR Produced Identificati n Type of Identification P odu e JORGE C:aST RO Notary Public-Sof Florida j • My Comm.Expireov 2,2018 Commission#� 146187BordedTf woNatiWayAm Print, b amp Name otary 5562 Aspen Ridge Circle • Delray Beach, F 3484 • Pho : (561) 445-2115 #CFC 1462668