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PL-15-1957 v Miami Shores Village 10050 N.E.2nd Avenue NW r "' Miami Shores,FL 33138-0000 F' Phone: (305)795-2204 T, k3' '' Expiration: 02/10/2016 ' 1 �; •• is` w.,, �-A'` Project Address Parcel Number Applicant 6 NW 107 Street 1121360070010 ROBERTO MARTIN Miami Shores, FL 33168-4307 Block: Lot: Owner Information Address Phone Cell ROBERTO MARTIN 6 NW 107 Street MIAMI SHORES FL 33168-4307 6 NW 107 Street MIAMI SHORES FL 33168-4307 Contractor(s) Phone Cell Phone Valuation: $ 850.00 R&I PLUMBING SERVICES (305)823-6911 (786)413-6365 Total Sq Feet: 00 Type of Work:GAS LINE FOR A NEW RANGE Available Inspections: T of Piping:Type P 9 Inspection Type: Additional Info: Final Bond Retum: Press Test Classification:Residential Scanning:3 Review Plumbing �® Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# PL-8-15.56582 DBPR Fee $2.25 08/14/2015 Credit Card $115.10 $50.00 DCA Fee $2.25 Education Surcharge $0.20 08/04/2015 Cash $50.00 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $165.10 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 informati accur t and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-na a do the work stated. August 14,2015 Authorized Signature:Owner / Applicant ntractor / Agent Date Building Department Copy August 14,2015 1 ' Miami Shores Village CSD Building Department AUG 04 2015 V01 � 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201y�" BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP 'f (� CONTRACTOR DRAWINGS JOB ADDRESS: �t/ �v� ] City: Miami Shores County: Miami Dade p ZiK): Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: J OWNER:Name Fee Simple Titleholder): L (C*kt e x,&446 O bA F1g re4 Phone#: 4 308- X55 Address: City: ( S'bTo State: Zip: 33/� Tenant/Lessee Name: __ Phone#: Email: M &6-T[ S j zd 0041,ccp rLt--N—e-:S ATXF"4L) .E CONTRACTOR:Company Name: ' Phone#: Address: '2 -9q<3 A41`�� X4,06<- v.. City: /'�!` State• Zip:n2<9/'I Qualifier Name: F e-&AZV-4 4-,? Phone#: ��Z'S eT Z State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ �4-- Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: �O ��/yam �' '��� ��•t>�� Ay'af�" 1illi ufy d•wai ". Specify c llalrief ccoF,lile. "�`'e a �, - r .r,�4•:"owl.3 lame`eAq ' �- Submittal F er '° .r �• CF$ CO/CC� i* Scanning Fe DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ � 4 (RevisedO2/24/2014) 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 OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 3 d day of J U 1 $ ,20 18 ,by Z day of �y ✓L, ,20 15 ,by Cgo YO 1 t rq (Lo m GI'Lvho is personally known to �e9d� ,who is personally known to me or who has produced Mi CJ1-G11'C ib crk SAs me or who has produced 2�`�'7� as� id�3a3- ntification and who did take an oath. identification and who d' ke an oath. NOTARY PUBLIC: NOTARY PUB Sign* Sign: Print: C CJI i( It Y10 P.CXIn C1V 1 Print: C'0. '1;: /-I Seal: +�-� �`' Seal: FA ��inuiii =20-104ft kift As�I > �a ���r�e**���*«*a a �i�a* �k����;�x �a�•w*���*er�� • ! . APPROVED BY y �` Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) .: DRIVER CENSE G255--2n �7I"i8 q RENE GUZMAN 7898 NW 174 TER MIAMI.4, 334"6-36= DOR 10-08-1957 SEX 11411-2043 t�S' M a+wior wPecroonAnw.;,cr�e+rt in.nv soMrty srst rpgeerrrei".'w. CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENC 03P000074 AIJ&R & I PLUMBING SERVICE CORP D.B.A.: GUZMAN RENE Is certified under the provisions of Chapter 10 of Miami-Dade Count VALID FOR CONTRACTING UNTIL 09/30/201: STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION a CONSTRUCTION INDUSTRY LICENSING BOARD RF0067119 The PLUMBING CONTRACTOR Named below HAS REGISTERED O.k Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2015 (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) GUZMAN, RENE INDIVIDUAL l 7898 NW. 174TH TERR. MIAMI LAKES FL 33015 VIVA RORIDA RICK SCOTT ISSUED: 09/08/2013 SEQ# L1309080002688 KEN LAWSON GOVERNOR DISPLAY AS REQUIRED BY LAW SECRETARY Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY LBT 5007653 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES R&I PLUMBING SERVICES RENEWAL SEPTEMBER 30, 2015 CORP 5228945 7898 NW 174 TERR Must be displayed C place business MIAMI, FL 33015 Pursuant to County Coo de Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED R&I PLUMBING SERVICES CORP 196 PLUMBING BY TAX COLLECTOR CONTRACTOR 82.50 10/22/2014 Worker(s) 1 03P000074 0224-15-000255 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's qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO.above must be displayed on all comme,cial vehicles-Miami-Dade Code Sec 8a-276. MIAMI, ADE For more information,visit www.miamidade.gov/taxcollecto, Muni ci pal Contractor's Tax fecei pt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY M C CC NO: 03P000074 BUSINESS NAM EILOCATION RECEIPT NO. EXPIRES R&I PLUMBINGSBWCESCORP NEW BUSINESS SEPTEMBER 30, 2015 7898 NW 174 TERR 7457007 MIAMI,FL 33015 Must be displayed at place of business Pursuant to County Code Chapter 8A-Art.9& 10 OWNER TYPE OF BUSINESS ED R&I PLUMBING SEIWCES COW PLUMBING CONTRACTOR BY TAX COLLECTOR BY TAX COLLECTOR 200.00 10/22/2014 0224-15-000255 M IAM I DADS for more information,vi sit www rri ani dade oovitaxcolI ector =Nor A CER1 __ JI.r.TE OF LIABILITY IMS Z --ICE „ , 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: H the eertillcabe holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain Polkdes may require an endorsement. A statement on this certificate does not corder rights to the certlflcabe holderin Hou of such endorsement(s). PRODUCER =AVr JORGE CASTILLO World Of Insurance Agency (305)231-1111 No (3051231-0711 18604 NW 87 Ave Unit 113 iffilL& workwi118Ura<Vaknet Miami Lakes,FL 33015 S AFFORDING SAGE MAIC O Phone (305)231-1111 Fax (305)231-0711 dNSURER A: STARR INDEMINTY AND LIABILITY INSURANCE COM INSURED INBIIRER B: R&I PLUMBING SERVICE CORP vd1URER C: 7898 NW 174 TARRACE 00RUM D Miami Lakes,FI 33015 305 INSURERE' SURER 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 PERF 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. ADDLBUSR TYPE OF INSURANCE vm POLICY NUMBER Lem GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED ,���� ® COMMERCIAL GENERA.LIABILITY IS F oeu ffi A F-108/07!2014 08/07/2015 ❑ cLAIMs-MADE © OCCUR 1000051665131 MED EXP(Any ale $ 1,000,000•00 1-1 PERSONAL a ADV INJURY $ 5,400.00 ❑ GENERA.AGGREGATE $ 1,000,000.00 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,004.00 ❑POLICY ❑ PRO- ❑ LOC $ AUTOMOBILE LIABpJTY ar= INGLE LIAR 1 ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ LL OOWNED S ❑ AUTO� pB�ODILY INJURY(Perc $ F1HIRED AUTOS El ��D P SERAGIE $ ❑ ❑ $ ❑ UMBRELLA LIAR []OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ y0RKERS COMpENSATION ❑WCSTAT I- ❑OTH- AND EMPLOYERS'LIABILITY Y/N ITS ER ANY PROPRIETORIPARTNERIEXECUTNE N!A EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatoy M NH) E.L.DISEASE-EA EMPLOYEE$ DESGr��TION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/NEHXA.ES(Attach ACORD 101,AdMand Rem Sd ,If orae space Is re ) PLUMBING CONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICI E CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL ELIVERED IN 10050 NE 2ND ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES FLORIDA 33138 AUTHORIZED REPRESMArnE I JORGE CASTILLO ®1988-2010 ACORD TION. All rights reserved. ACORD 25(2010/05)QF The ACORD name and logo nglebered marks of ACORD 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 certiftes that the individual listed below has elected to be exempt from Florida Workers`Compensation law. EFFECTIVE DATE: 413!2015 EXPIRATION DATE: 4/212017 PERSON: GUZMAN RENE FEIN: 611433275 BUSINESS NAME AND ADDRESS: R&I PLUMBING SERVICE CORP 7898 NW 174 TERRACE HIALEAH FL 33015 SCOPES OF BUSINESS OR TRADE: PLUMBING NCC AND DRIVERS Pursuant to Chapter 440.05(14).F.S.,an offer of a corporation vrho elects exempts from this chapter by MM a certificate of election under Ws section --may not recover benefits or compensation ureter this chapter.Pursuant to Chapter 440.05(12),F.S..Certificates of election to be exempt...apply only vrfthin the scope of the(wetness or trade Usted on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S..Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation It.at any time after the filttg 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 cerdficate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1809 NINE N Miami shores Village Building Department �lpRYpA 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 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 OW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. 17 Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of ��. ,20 By A 1 CRKU, '���+�"""'����� who is personally known tome or has produced Notary: � •`'o`�°S� � •—, i co SEAL: gti�5a� r Date: 7- 1 State of �4 fZ(.DA County of Before me this day personally appeare,a/,i;)Q, t0 AeA who,beind duly sworm,deposes and says: That he or she will be theonly person working on the project at: Sworn and subscribed before me this day of L) _201 by Personally know Or produced Identification Type of 1dentificationT)(e%xA3 L4'%-Ax +�� SRIU�fil►GU UIN NO"PWAft-SM of Ftortdo Print, y MISS Aeon. 1 Yat NZ,. 13efia.ev� t7ri.a+ AL FLORIDA SHORT-FORM INDIVIDUAL ACKNOWLEDGMENT F.S.695.25 State of Florida County of"i A AM The foregoing instrument was acknowledged J before me this ' day Date of �U t�i , '201s- , onth Year by Name of Person Acknowledging who is personally JJknown to me or who has produced Foy- q o-- 'by,it Ve o Type of Identification as identification. NMI Pofs-ftft of FWW d •FF 245474 Sign tune of No ary Public My Com.E*=J0 30.2019 Name of Not4 Typed, Printed or Stamped Place Notary Seal Stamp Above Notary Public—State of Florida OPTIONAL Though the information in this section is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document Description of Attached Document Title or Type of Document: kAiQ;�i ShoYe.,,�, OASAyodto-n work- Pyrty\i4 Document Date: �� J, / Number of Pages: Signer(s)Other Than Named Above: 0 2013 National Notary Association # NationalNotary.org 9 1-800-US NOTARY(1-800-876-6827) Item#5181