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DEMO-15-3024 p - 2 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-249411 PermitNumber: DEMO-12-15-3024 Scheduled Inspection Date: December 17,2015 Permit Type: Demolition Inspector. Diaz,Osvaldo Inspection Type: Final Owner. GOSLIN,SIMON JAMES Work Classification: Plumbing Job Address:1155 NE 100 Street Miami Shores,FL Phone Number (305)766-9635 Parcel Number 1132050190331 Project: <NONE> Contractor: JB WATERWORKS CORP Phone: (305)7664306 Building Department Comments REMODEL BATH AND KITCHEN SINK ICE MAKER LINE Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-248804. NO ONE ONSITE please call 15 minutes before arrival JAKE(305)7664306 Failed CorrectionN`�� Needed Re-Inspection Fee ❑ z 1� �� L No Additional Inspections can be scheduled until re-inspection fee is paid December 16,2015 For Inspections please call: (305)762-4949 Page 28 of 39 Miami Shores Village i 10050 N.E.2nd Avenue NE ••^ Miami Shores,FL 33138-0000 Phone. (305)795-2204 Expiration: 06/0812016 Project Address Parcel Number Applicant 1155 NE 100 Street 1132050190331 SIMON JAMES GOBLIN Miami Shores, FL Block: Lot: Owner Information Address Phone Cell SIMON JAMES GOSLIN 1155 NE 100 Street (305)766-9635 MIAMI SHORES FL 33138- 1155 NE 100 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,500.00 JBWATERWORKSCORP (305)766-4306 _ Total Sq Feet: 00 Type of Demo:Plumbing Available Inspections: Additional Info:REMODEL BATH AND KITCHEN SINK ICE M Inspection Type: Classification:Residential Final Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 Invoice# DEMO-12-15-57955 DBPR Fee $2.00 12/04/2015 Credit Card $50.00 $67.80 DCA Fee $2.00 Education Surcharge $0.80 12/11!2015 Credit Card $67.80 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $117.80 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 info accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the abov named tra to a work stated. December 11,2015 Authorized Signature:Owner ! Applicant ! ZogActor ! gent Date Building Department Copy December 11,2015 1 Miami Shores Village C� g 4 2d1� DEQ � Building Departmentn�c g Y. 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 B Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBc 2oly�- BUILDING Master Permit NoL6= 14 Z 797 PERMIT APPLICATION Sub Permit NoAolne),l 4-- 9 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: �� D� r o S T !u i'd1l., / S A,,,tee -s 3 7 d" City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: �2 FFE: OWNER:Name(Fee Simple Titleholder): Phone#: C( U 5 Address: 11 S�1 � " (00 City: State: Zip: n)3 6' Tenant/Lessee Name: t�` Phone#: Email: �� ctQS`1n 15 C byP^atr� < C-Q, I", CONTRACTOR:Company Name: �' /3, LV�r' te �0f �.t Phone#: 3 a d-- 7 �- -(3 D Id Address: (0 (V 8 fit% City:1Vr1r*rt4' M eA`Lt ( State: r- 11- Zip: 77 t (. - — Qualifier Name:�,�/� I'►�' /3 O!-1- 1) C"r;} Phone#: State Certification or Registration#: y " I 2- -7 U -7 O Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Square/Linear Footage of Work: Type of Work: ❑ Addition f=i Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: e 4en d�,.��'� ¢. �'I /� �� Q� sin k i C e �• $v Specify color of color thru tile: Submittal Fee$ Permit Fee$ f , f-y CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ CO (Revised02/24/2014) s 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 exceedffig$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property' is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the'Job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be a ved and a reinspection fee will be charged. Signature Signature `L OWNER or AGENT CONTRACTOR The foregoing instrume t was acknowledged before me this The foregoing instrument was acknowledged before me this !_day of � 20 )3 .by day of k/� �f .20J by who is personally known to who is personally known to me or who has produced as me or who has produced _ as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sig Si n • s Print: rint S of Florida Seal: yy Notary Pubes Stave of Pia ary Pubik State 4^ M Fenno anna M F@I 2753 ,� Joanna FF pg2i53 Commission < MYCy�yr@sOtNy2018EX'00501M21201a JrEj� * ******************************* * ******************************* APPROVED BY .1,`$ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND • PROFESSIONAL REGULATION CFC 1427090 ISSUED: 07/13/2014 CERTIFIED PLUMBING CONTRACTOR ROADWAY,JAKE AUSTIN JB WATERWORKS CORP IS CERTIFIED under the provisions of Ch.489 FS. Expiration date:AUG 31,2016 L1407130001219 01500 Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY 5859278 LBT BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES 1B WATERWORKS CORP RENEWAL SEPTEMBER 30, 2016 668 NE 161 ST 6110688 Must be displayed at place of business MIAMI FL 33162 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS JB WATERWORKS CORP 196 PLUMBING CONTRACTOR PAYMENT RECEIVED CFC1427090 BY TAX COLLECTOR Worker(s) 1 $75.00 08/02/2015 CREDITCARD-15-039365 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 holders qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sac Ila-278. For more information,visit www.miamidade novAucollector 12/02/2015 14:38 305-740-0516 Ren6 E.Samayoa Page 1/1 e CERTIFICATE OF LIABILITY INSURANCE DATE(2/02D/YYYY) 12/02/15 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 certilicate 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 otsuch endorsement(s). PRODUCER CONTACT NAME: Ren6 E.Samayoa Acceptance Insurance Services PHONE Exti: (305)740-0515 A/c No): (305)740-0518 6887 S.W.40th St. AgDDREss: rens@acceptance)nsservices.com Miami,FL 33155 INSURER(S)AFFORDING COVERAGE NAIL#r Phone (305)740-0515 Fax (305)740-0518 INSURER A: Endurance American Specialty Ins Co 10641 INSURED INSURER B: J.B.Waterworks Corp.dba J.B.Design&Build INSURER C: Progressive 11760 668 NE 161 ST INSURER D: MIAMI,FL 33162 (305)919-7939 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. IN ADDLSUBR POLICY EFF POLICY EXP LTRSRI TYPE OF INSURANCE INSR WVD POLICY NUMBER MWD MMID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 ® COMMERCIAL GENERAL LIABILITY DAMA E TO RENTED 100,000.00 PREMISES Ee occurrence $ A ❑ [—] CLAIMS-MADE 12/152014 12/152015 CBC20000191800 MED EXP(Any one person) $ 5,000.00 N N ❑ PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 POLICY ❑ jpoCi ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident ❑ ANY AUTO BODILY INJURY(Per person) $ 10,000.00 B ❑ ALL OWNED SCHEDULED 02278921-1 AUTOS AUTOS N N 06282015 06282016 BODILY INJURY(Per accident) $ 20,000.00 El HIRED AUTOS NON-OWNED RppEE�R �q�, ❑ � Per ecciderd GE $ 10,000.00 ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ DED El RETENTION$ $ WORKERS COMPENSATION WC STA OTH AND EMPLOYERS'LIABILITY Y/N ❑TORY LIMITS ❑ER ANY PROPRIETOR/PARTNER/EXECUIIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑N 1 A (� If yes dl(Mandat;gibe unIn do E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,V more space is required) Certified Building and Plumbing Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ZONING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave AUTHORIZED REPRESENTATME MIAMI SHORES,FL,33138 305-756-8972 ACORD 25(2010105)OF 0 1988-2010ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks Of ACORD ' 10-30-2014 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 10/28/2014 EXPIRATION DATE: 10/27/2016 PERSON: BOADWAY JAKE A FEIN: 204641735 BUSINESS NAME AND ADDRESS: J.B. WATERWORKS CORP DBA J.B. DESIGN & BUILD CORP 668 NE 161 ST NORTH MIAMI FL 33162 SCOPES OF BUSINESS OR TRADE: 1- LICENSED PLUMBING CONTRACTOR 2- LICENSED BUILDING CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 0504), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.0502), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.0613), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing 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 certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the •.__ _ .e go tn,s section. QUESTIONS? (3501 4?3-?"aGtS DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 it PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14}, F.S., an officer of a corporation who CONSTRUCTION INDUSTRY 0 elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW °`°b-•"¢ D chapter. EFFECTIVE: 10/28/2014 EXPIRATION DATE: 10/27/2018 Pursuant to Chapter 440.05112►, F.S., Certificates of election to be PERSON: JAKE A ROADWAY H exempt... apply only within the scope of the business or trade listed on FEIN: 204641735 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.0503), F.S., Notices of election to be exempt J.B. WATERWORKS CORP and certificates of election to be exempt shall be subject to revocation DBA J.B. DESIGN & BUILD CORP ! if, at any time after the filing of the notice or the issuance of the 666 NE 161 ST certificate, the person named on the notice or certificate no longer meets NORTH MIAMI, FL 33162 the requirements of this section for Issuance of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this 1- LICENSED PLUMBING CONTRACTOR 2- LICENSED BUILDING CONTRACTOR section. QUESTIONS? (850) 413-1609 CUT HERE Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 f i CERTIFIED PLUMBING CONTRACTORS 668 NE 161 ST NORTH MIAMI,FL 33162 LICIT`CFC-1427090 12/4/15 STATE OF FLORIDA COUNTY OF DADE � � � MR - Before me this day. ing duly swom,deposes and says: Yi '}4, n JxN1t That he or she will be tie onlyan worfihl� tilted at 1155 NE 100 ST, MIAMI SHORES, FL 33135. Sworn to(or affirmed)and subscribed,;before me this 4 deaf M— er 2015 by Personallfa x iq 0 MW QR Produced 14fitlflcatlon _- =fi r yper gntification Produced '*'ice A Type or Stamp Name of Notary R Notary Public State of Florida Joanna M FelicianoMy Commission FF 082753 Expiresol/tan 18 ,y1roR'� Miami '+shores Village Building Department R1DA 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. f: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 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. ILI Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this. day of ,20 1_5 1 9 By_, /y�D!7 7 O S// 4, who is personally known to me or has produced as identification. No r ovq� WWI P+�c St815 of flo�da a4 ,Dana M Feiidano s My Commission FF 082753 SEAL: aw E)OMSov12no18