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PW-15-2583 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-245510 Permit Number: PW-10-15-2583 Scheduled Inspection Date: February 23,2016 Permit Type: Public Works Inspector: Hernandez,Rafael Inspection Type: Final Owner: ROY,WILLIAM Work Classification: Public Works Job Address:1280 NE 101 Street Miami Shores, FL Phone Number Parcel Number 1132050210010 Project <NONE> Contractor: TECO PEOPLES GAS SYSTEM Phone: (305)957-3857 Building Department Comments REPLACE THE EXISTING GAS SERVICE AND INSTALL A Infractlo Passed comments NEW GAS SERVICE LINE BY DIRECTIONAL INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re-Inspection a Fee No Additional Inspections can be scheduled until re-inspection fee is paid Permit l4 -1 E -'1 X283 Miami Shores Village PenrJ#Type:Public Works 10050 N.E.2nd Avenue NE a c+ I�ork:Gtassittratiart;Public Wolrkss Miami Shores,FL 33138-0000 Pe'"� i yep a Phone: (305)795-2204 Permit Status:APPRO �} '�toRNp z ruoDatte.= WIV2015 Expiration: 01120/2016 Project Address Parcel Number Applicant 1280 NE 101 Street 1132050210010 Miami Shores, FL Block: Lot: WILLIAM ROY Owner Information Address Phone Cell WILLIAM ROY 1280 NE 101 Street (305)793-5050 MIAMI SHORES FL 33138- 1280 NE 101 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 1,000.00 I` TECO PEOPLES GAS SYSTEM (305)957-3857 (305)970-1783 Total Sq Feet: 0 Scanning:3 Available Inspections: Inspection Type: Final Excavation Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# PW-10-15-57391 DBPR Fee $2.00 10/13/2015 Check#:5854 $50.00 $64.60 DCA Fee $2.00 Education Surcharge $0.20 10/22/2015 Check#:5912 $64.60 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 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 construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. itup" / ,�,,/>,_ October 22,2015 Authorized Signature: ner / Applicant / Contractor / Agent Date Building Department Copy October 22,2015 1 ., to �. Miami Shores Village Building Department OCT I 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 No. VW PERMIT APPLICATION sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL OPUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1280 NE. 101st ST. Com: Miami Shores County: Miami Dade Zia: Folio/Parcel#: Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):.RIGHT OF WAY Phone#: 9S-1-(q&-_3 Address: c16- /® ✓ °ycij 7 �C City: 0 c c State: i G Zip: -_K336 '9 Tenant/Lessee Name: Phone#: Email:_ 12,,0tCs)4 Z c�c� /�®G CC,i", CONTRACTOR:Company Name: TECO PEOPLES GAS Phone#: 954-453-0806 Address: 5101 NW 21 AVE. STE. 460 City: FT. LAUDERDALE State: FL Zip: 33309 Qualifier Name: JESUS VEGA Phone#: 954-453-0806 State Certification or Registration#: E1608 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 1000 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Q New ❑ Repair/Replace ❑ Demolition Description of Work: REPLACE THE EXISTING GAS SERVICE AND INSTALL ANEW GAS SERVICE LINE LINE BY DIRECTIONAL DRILLING Specify color of color thru tile: Submittal Fee$ Permit Fee$ CQ� CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ � (Revised02/24/2014) r �T 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 J - A, OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 by `® day of �J s® by who is personally known toyg�-%— 4- wh . ersonally known me or who has produced as me or who has ced as identification and who did take an oath. identificatio and w o did take an oath. NOTARY PUBLIC: NOTARY P BLIC: Sign: Sign- e Print Print a�P��, HUBERT NUNEZ e� f Florida My Comm. Expires Sep 11,2017 Seal: Seal: ,; ? Commission #FF 043679 1( Bonded Through National Notary Assn.�..' APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application- Miami-Dade County Page 1 of 8 r r` x, 1 r Nk :.., , Address Owner Name Folio SEARCH: 1280 NE 101 ST Suite Q J _........__.� PROPERTY INFORMATION Folio: 11-3205-021-0010 Sub-Division: MIAMI SHORES SEC 8 AMD IN PB 42-40 Property Address 1280 NE 101 ST Miami Shores, FL 33138-2609 Owner WILLIAM R ROY SUSAN P KELLEY Mailing Address 1280 NE 101 ST MIAMI SHORES, FL 33138 Primary Zone 1100 SGL FAMILY-2301-2500 SQ Primary Land Use 0101 RESIDENTIAL-SINGLE FAMILY: 1 UNIT Beds/Baths/Half 5/3/0 Floors 2 Living Units 1 http://www.miamidade.gov/propertysearch/ 10/13/2015 TE CERTIFICATE OF LIABILITY INSURANCE DA 6/3020115 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 terns 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 CONTACT MCGRIFF,SEIBELS&WILLIAMS,INC. HAMS. IF P.O.BOX 10265 PHCHNo Ext;800 476 2211 A/C No): Birmingham,AL 35202DARE LLQ: INSURERS AFFORDING COVERAGE NAIC# INSURER A Zurich American Insurance Company 16535 INSURED INSURERS:Associated Electric&Gas Ins.Svcs. Peoples Gas System TECO Energy,Inc. INSURER C:LM Insurance Corporation 33600 702 North Franklin Street Tampa,FL 33602 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:KUPY3T4E 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. INSR TYPE OF INSURANCE ADD SBR POLICY EFF POLICY EXP LIMITS LTR INSD POLICY NUMBER MMIDD MMIDD B X COMMERCIAL GENERAL LIABILITY XL5129405P 07/01/2015 07/01/2016 EACH OCCURRENCE $ 1,000,000 Self-Insured Retention X CLAIMS MADE F—IOCCUR $1,000,000 PREM SES Ea occurrence $ MED FRCP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY D jECT F-1 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ B AUTOMOBILE LIABILITY XL5129405P 07/01/2015 07/01/2016 COMBINED SINGLE LIMIT 1,000,000 Self-Insured Retention Ea accident X ANY AUTO $250,000 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident 1 B UMBRELLA LIAR OCCUR XL5129405P 07/01/2015 07/01/2016 EACH OCCURRENCE $ 1,000,000 X EXCESS LJAB Hx CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ I I $ A WORKERS COMPENSATION Excess Workers'Com nsation: 07/01/2015 07/01/2016 X STAT ER IOTH- B AND EMPLOYERS'uABILTrY Y/N EWS9318597-04(Statutory Limit is ANY PROPRIETOR/PARTNERIEXECUTNE excess of$35,000,000 Insured by LM E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED? NIA Insurance Corporation) 1,000,000 (Mandatory In NH) Employer's Liability:XL5129405P E.L.DISEASE-EA EMPLOYEE $ If yes describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Excess Workers'Compensation EW5-64N-004918-125 07/01/2015 07/01/2016 Each Accident or Each Employee for Disease $ 35,000,000 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more space Is required) Excess Liability policy provides insurance in excess of Peoples Gas System's Self-Insured Retention as stated above. Jesus Vega is the qualifier for TECO Peoples Gas. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Miami Shores AUTHORED REPRESENTATIVE 10050 NE 2nd Ave Miami Shores,FL 33138 P iil/. Page 1 of 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD C�orrsl��^���I�pM�ETENCY` BUSINESS CERTIFICATE OF C 0 608 PEOPLES GAS SYSTEM INC D.B.A.: 1 VEGA JESUS 9®�t�►� eeuMY 1� fled ung go OCT 13 201 • ... ..• - � � � � W ®�®W • • f W � W • • • � see 4 00 0 ag 3 • .a.�`i B 13 ■■ {y N ■ NNS � ■ 4 guy h ■ es p IUI N o #a 0`0 0 8'IIO:a�i1Pn ess 7 K Soe f• �Sw i,9 gel a it ; Q IOCG V 919i� �5 �l � U) � gIwo Ila 4® CD c ZO S if�Il-0 1 C+9 * 3 '.���r p� , N — 9!D�C:? g DATE 1 i CF-M coMPLIANCF wiTH ALL FF-DFRAL f3 fs) !x' q{ y 2 C -, rn P, Yf p O rr ii ,1 II '0 IG j. 0 z mrt- - 1 f IF � z cn Am , uN / F m in O — — Y. —n -nO • N i > I, 1 �! cn I - , 1 t s I M e, ♦ � .. -- -- O.P. t °v, ♦ NE. 13th AVE WI > �I -4m ! - z w �, • . • • • • s • � � III ,.'� • • •. • • s* . I� y" �( . . -- .. . . • •• • • ••• •• IL II `� ••• • •�• s • . PMpjWM =AWN BST: �SDI/ s amr wmau�amcaa�a �.VfSIONB • • • •• • �� „�„�� ` • • • • • • s$ mm •ft • • ••• • • • r •• • • • PEOPLES GAS IL • • •• DRUM= I 9Affi9A�tlA8BP. r 15779 W,OM HIGMAv q�$ 11 CABAERA 10-08—=16 -S4Q-� 2-d7lo N.MAM BEACH,FL. •• • • • • • ••• •• • ••• • • • • •• • • • • • • • • •• • • •• • •• • • • • ••• • ••• • • • • • • • • • • •• •• • 900 •• •• •