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PL-15-2965 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,Fl- Phone: LPhone:(306)796-2204 Fax:(305)756.8972 inspection Number. INSP-248399 PermitNumber: PL-11-15-2995 Scheduled Inspection Date:March 30,2016 Permit Type: Plumbing - Residential Inspector. Hernandez,Rafael Inspection Type: Final Owner VILLARREAL,LEANA Mork Classification:Addition/Alteration Job Address:163 NISI 101 Street Miami Shores,FL 33150-1213 Phone Number (70663-1534 Parcel Number 1131010230150 Proms <NONE> Contractor. K.A.STAR CONSTRUCTION INC Phone:(786)260-9420 Building Department Comments KITCHEN PLUMBING Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comrnents Passed 5a— Failed Correction Needed Re-inspection Fee No Additional inspections can be scheduled until re-inspection fee is paid. P....0—____a-_-- — ____ __.a. iwwsn.sww �w•w Miami Shores Village 10050 N.E.2nd Avenue NW Miami Shores,FL 33138-0000 Y Phone: (305)795-2204 a � � i ? Expiration:05/28/2016 Project Address Parcel Number Applicant 163 NW 101 Street 1131010230150 Miami Shores, FL 33150-1213 Block: Lot: LEANA VILLARREAL Owner Information Address Phone Cell LEANA VILLARREAL 163 NW 101 Street (786)553-1534 MIAMI SHORES FL 33150-1213 163 NW 101 Street MIAMI SHORES FL 33150-1213 Contractor(s) Phone Cell Phone Valuation: $ 350.00 K.A.STAR CONSTRUCTION INC (786)260-9420 Total Sq Feet: 00 Type of Work: Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Retum: Final Classification:Residential Scanning:3 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# PL-11-15.57870 DBPR Fee $2.00 12/01/2015 Credit Card $64.60 $50.00 DCA Fee $2.00 Education Surcharge $0.20 11/24/2015 Credit Card $50.00 $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 AF (DAVIT: I certify that a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction find zoning. Futhe re, thorize the above-named contractor to do the work stated. December 01,2015 orize re:Owner / Applicant / Contractor / Agent Uate Buil ing Department Copy December 01,2015 1 G Sm" �n 4 £ � F �,aa, �,jit� g Pin 1041 e t s xE bLq A�gg7p.��7+bL+�►.yVq 7 WW�wQy i s �A W. 1 Y 040 IONE PCNAi9WASOIA:'� + a' `/ NNY= RC: 1549119� r IM MMAI Afv Lj lk Uwe a a 1 ^moi WORD C ANdE OF 0 CANCEMMO �IA� G * YS 3 ,k±i'-�T a ✓ x v: e r :� � y s w,wrx ;;,x00 h fl �� wools ot 01 a u .r Q A ik RIM ..N,k#e + a16 zz� f"q'SSF `ice`• �',f 'i Ddu _ 3 k x � _ i lr r r r F it rbc Y 9 3 m vF r , • 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 4;: / , OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 0 day of Na VGMbt°r .20 1 J4'** ,by day of// 20 f' by Una VjJk!J!e2 n .who is personally known to (`�Jiv� weyf ttwho is personally known to me or who has produced I /i/ -r /� .f LS�as me or who has produced � n/Q� +�fP,�d►s as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Paw I"of Plow J Caret Sign: / c� Sign• l �� Print: Print Seal: Seal: 401SH MA.Wq�01rt MYW A11SM#FF244 V 1�3:Oa�et28,2018 APPROVED BY _7=11404 S Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) CFC 142g9 O ESS/pNT OF& 24 SER T/F�Bp P �q�REGUCgT�A ND KA" s gvDE2 KA BtN��D SUE ' 08/��/ CONS CT/oNNTRACToR 20'4 SNC Fpira�b dalF/EC u . e A(/G37 2p s the prods/ons Of Ch,488 040817o002 42 "w v AV STATE OF a : '.� DEP FL { CGC PROFESS EN�p�B r 5X2272 ONq�REGUTSSgND "s M ER A JE8 GENB /SSUE p 05 pN T ry"•rti STAR Co, STV/N L CONTRACTOR 3/2p14 RUG TION �Ne ,r . I S CFRTIFI ExPiratior,.dw. .L 0/1d er "4UG31,201s the pr0yisiOns Of Ch,48g S. L14051300pp 26 i axoftceipt Miami-Dade County, State of Fforida Tt d 13 fv 07 a lliL ..l: IN, t~A r MW 7161311 N�3 r WISINE NAME/LOCATION FIECEIP'T"NO- A���° A STAR CONSTRUCTION INC: RENEWAL SEPTEMBER 30, 2016 '12640LC NCLUBN i 8 Haus€be displayed at place of business MIAW FL 33167 pursuarit to coonty Code Chapter 8A-Art,9 1 OWNER SEC. TY'P'E.' OF WU tNES #STARC J i Tf UCTIC N, INC 196 RE IVED 155 PLU#v1 N BY TAX COU.ECTOR aU KEVIN HERNANDE , CONTRACTOR rr� In riT 82,50 101 112015 l<;afkE?I!s} 1 CFC 1428924 0221-16-000036 This Local flusinoss Tax R +eipt only confirms payment of the Local Business i ax,The Receipt is not a license" pwmi4 or a evid6cation ofte Wder's quat ficatio4s„'to,do bossiness.Holder must comply with any%overnmontal opprare►znaittai regulatory laws and requimmnts which apply to the buslaoss, The RECEIPT NO.above mw be displayed on all comatercial vehicles-Miami-Dade Code Sec -276. for mom information.visit W" j e ,.�•• ofItcm w• u, � 4 Ta " Receipt xcal Bustness x State of Florida 'itT PAY l BUSINESS NAtIRI«ILOCATION 1�1 C +L"a **PIRES ,AiRtONSTRUCTICIN INC REN 2W', CA NT I�f J . , 201 �.. 15T, iw. SEC. TYPE OF BUSINESS PAYMENT RECEIVED INC 196 GENERAL BUILDING BY TAX COLLECTOFt CONTRACTOR r C C1 ;272 0221-1&000036 Tax Rtiesip oa O p � _ al 8rusiress Tax.The e'spt is not a lige , Of tk ld 's Q � ar is s.�1Wt er gust r, girt►any gstvetasr sttai tv"fr4 tr laws artd re a J0 a t to 0M b , NO a be displayed on all rt ia!v�tti� � Gcu3�Stfc1 -� . iu 3tt titfsit E ti \ :' isi � yii S kr. 1 ~F JEFF ATWATER STATE OF FLORIDA CHIEF'FINANCIAL t3FFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION Thisrtltiws that the individual listed below has electr ci to be exempt from Florida Workers compensation law EFFECTIVE DATE 61812014 EXPIRATION DATE: 615/2016 PERSON: •iERNANDEZ KEVIN FEIN 463522403 BUSINESS NAME AND ADDRESS: K A STAR COSTRUCT ION INC 12640 COUNTRY CLUB LN MIAMI FL 33167 SCOPES OF BUSINESS OR TRADE. ICFNSED GENERAL LICENSED PLUMBING CONTRACTOR CONTRACTOR '�!-suanf to CnaCder 440.05114).F S an rFu)ff of a ccAporahon who erE3c:ts etemptirm hmi this chapter by Ming a certif"le of r mn under M,5 sedan may •ecr,,er benetiits or swrtoens3tion urWpf ttxs Chapter.Pursuant to Chapter 440 05112),F S.CerMxaies of eAecbon to tie exempt. apply only vnthin the soom me hu s rtm or trade listed on the notice of eledaot to be exempt Pursuant to Chapter 440 05('.3),F S.Nobc-as of election to be:exempt and oerfAicaies of e40(ilor,fo be exempt snalf be sutieot to revocation if,at any time after the hf"of the notice o,the issuance of the certificate,the person named on the notice or rerjf tate no fiercer meets the requirements of thts secbun tee issuance of a certdwate the deoafiment shall revoke a certlfic:ate at any bra for failure of ihr person named on the certiti-ate to meet the requirements of this sedan DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1 A�'�' CERTIFICATE OF LIABILITY INSURANCE DATE 0/26D/YYYY) 10/26/15 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. N 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 endorsement(s). PRODUCER CONTACT NAME: MARTA ALONSO Florida Bankers Insurance PHONE (305)266-6493 AI , No): (305)262-0679 7278 SW 8 Street AE-MAILDDRESSO marta@floddabankersinsurance.com Miami,FL 33144 INSURER(S) AFFORDING COVERAGE NAIL# Phone (305)266-6493 Fax (305)262-0679 INSURER A: ACCIDENT INSURANCE COMPANY INC INSURED INSURER B: KA STAR CONSTRUCTION INC INSURER C: 12640 Country Club Dr INSURER D: Miami,FL 33167- 305 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 ADD UB POLICY NUMBER MMMIIDDDY EFF PMIDDY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 COMMERCIAL.GENERAL LIABILITY DAMAGE TOMe RENTED occurrence) $ 100,000.00 ❑ ❑ CLAIMS-MADE O OCCUR CPP0010255-02 MED EXP(Any one person $ 5,000.00 A 10/01/2015 10/01/2016 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00 D POLICY ❑ JECT PRO- ❑ LOC $ AUTOMOBILE LIABILrrYMBINEntD INGLE LIMIT Ea accide ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ❑ AUTOS ❑ AUTOS ❑ HIRED AUTOS ❑ AUOTOSWNED (�O%%71)AMAGE $ ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATIONI l WC STAT^'U- El OTH- AND EMPLOYERS'LIABILITY Y/N LI ANY PROPRIETORIPARTNER/EXECUTWE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ Ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,K more space is required) PLUMBING CONTRACTOR NO.CFC1428924 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2 AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights Deserved. ACORD 25(2010/05)QF The ACORD name and logo are registered marks of ACORD Miami Shores Village Room umv" Building Department R 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 �f � � V Fax: (305)756.8972 ��rr`J 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, -. ees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the onlypart n allowed o work on your project.In these circumstances,Miami Shores Village does not require verification of workers'co nsation ins ce coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIG G BELO U ACKN GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENT . Signa Owner State of Florida County of Miami-Dade L The foregoing was acknowledge before me this day of 7 ,201 . By/ who is personally known to me or has produced —ter as identification. viiD a Notary: pt* aoo3 SEAL: KA :TART' 0011 UOT1011. IAC. 12640 COUNTRY CLUB LANE MIAMI, FL 33167 Tel . 786-260-9420 November 13,2015 State of FLORIDA County of MIAMI-DADE Before me this day personally appeared KEVIN HERNANDEZ who,being duly sworn, deposes and says: That he or she will be the only person worldng on the project located at 163 NW 101stStreetrMiami Shores.FL 33150. X Swor to (or affirmed) and subscribed before me this 13 day November 2015 By KEVIN HERNANDEZ Personally know OR Produced Identification H-655500773470 Type of Identification Produced Driver License Nftn�No Ift at AW J QFw �, [►�n��int f otn��®9e