PL-16-380 9-6 6 - 3
Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone.(305)795-2204 Fax:(305)7564972
Inspection Number: INSP-252655 Permit Number. PL-2-16-380
Scheduled Inspection Date: May 19,2016 Permit Type: Plumbing-Residential
Inspector: Hernandez,Rafael
Inspection Type: Final
Owner. MAULE,SUZANNE Work Classification: Addition/Alteration
Job Address:1700 NE 105 Street 506
Miami Shores,FL Phone Number
Parcel Number 1122300500820
Project <NONE>
Contractor. DALE PLUMBING Phone:(786)6634804
Building Department Comments
CHANGE 2 SINKS BATHTUB AND SHOWER DIV. Infractio mrd
INSPECTOR COMMENTS False
Inspector comments
Passed
Failed
Correction
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
reinspection foe is paid
q
Miami Shores Village
10050 N.E.2nd Avenue NE
Miami Shores,FL 33138-0000
Phone: (305)795-2204
OW
Expiration:
F
E
Expiration: ® 171216
Project Address Parcel Number Applicant
1700 NE 105 Street Number: 506 1122300500820
Miami Shores, FL Block: Lot: SUZANNE MAULE
Owner Information Address Phone Cell
SUZANNE MAULE 1700 NE 105 ST UNIT 506
MIAMI SHORES FL 33138-2142
Contractor(s) Phone Cell Phone Valuation: $ 1,000.00
DALE PLUMBING (786)663-1804 Total Sq Feet: 1200
Type of Work:CHANGE 2 SINKS BATHTUB AND SHOWER D Available Inspections:
Type of Piping:
Inspection Type:
Additional Info:
Top Out
Bond Retum: Final
Classification:Residential Scanning:1 Review Plumbing
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 Invoice# PL-2-16.58651
DBPR Fee $2.00 02/10/2016 Credit Card $50.00 $58.60
DCA Fee $2.00
Education Surcharge $0.20 03/21/2016 Credit Card $58.60 $0.00
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,P ING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFI I I rt' at a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction ing. he .I authorize the above-named contractor to do the work stated.
March 21,2016
Autho ed S gnature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
March 21,2016 1
Miami Shores Village
Building Department MAR IA ,10
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 $Y:
INSPECTION LINE PHONE NUMBER:(305)762-4949 %1 ,
FBC 20 Md"'l
BUILDING (waster Permit No. �t to -3 1.
PERMIT APPLICATION Sub Permit No. ��� �
BUILDING ❑ ELECTRIC ❑ ROOFING REVISION EXTENSION Ej RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
r CONTRACTOR DRAWINGS
JOB ADDRESS: Y o s s" o t`7
City: Miami Shores County: Miami Dade zip: / L 71W
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction rTypee:� p Flood Zone: BFE: FFE:
/OWNER:Name(Fee Simple Titleholder):�U ZQnn e 1"]• 1"IGI1ot� 1®E70_FR4S*hone#: _70y 45;_7q7 K ® /G
1► Address: ''10 0 ` ?
City:��, A'U., S�art__S State: �-► Zip: 33 ( .J e
Tenant/Lessee Name: Phone#:
Email: ckA.-,Q 4A P_ , A M A;
CONTRACTOR:Company Name:
zR�'"`15!1 Y� Phone#: ��i S� �O �!
Address: "-4— N W
city: ti i A m a Staten ,C' (b-A zip: 3
Qualifier Name: r10' �� �1, Phone#: ?86 66 R l8,04-
State Certification or Registration M Certificate of Competency#: C`Fc -' 4-'21-
DESIGNER:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ f coy Sip Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: P
Specify color of color thky tile:
Submittal Fee$ Permit Fee$ 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)
l
Bonding Company's Name(ifapplicable)
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.
-T '
Signature :�4 Signature
OWNER or AGENT L-m' s4eOCONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 1 4VCO& ,20 / .by t O day of c ,20 t 4 ,by
,G>61rjq/Lp 4'44KLf— ,who is 1personally known to LI M,4 t^— 6c,�a..� / ►ho is personally known to
me or who has produced J���t1-�1� Lc�i� `� as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY P
Sign: Sign: 6k
Print: W Print: aV%A.A-
KUUM W.
CONNECTICUT Seal: NOTARY PUBLI OF CONNE TSeal: �.�"'" LAM FAFILEY
ID#
*y CSA 645
t.3.8.VJ/bV�
wJY $
APPROVED BY 3' Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
y
soon am
Miami shores Village
- �� Building Department
ICjpR ► 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.
f1. 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.
V
Signature:
Owner
State of Florida fi
County of Miami-Dade
The foregoing was acknowledge before me this 11,k.day of4nag4 _,20_16 .
BYCL01-1 e� ( V\a-L who is personally known to me or has produced
t /f as identification.
Notary: c�G 4r 1-111
SEAL: EUSSEL W. BLIgESS
NOTARY PUBLIC OF CONNECTICUT
ID 0164538
GWrM8
Miami Shores Village
Building Department FEB 1 11116
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 201`1
BUILDING Master Permit No. R G 6 — c3-7c1
PERMIT APPLICATION Sub Permit No. X110- '5&0
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION Ej RENEWAL
X
PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGEOF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
.7—
JOB ADDRESS: / 'o a ���� d `S ��` o 7-
. //✓
City: Miami Shores County: Miami Dade
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):C5-1- 2--4 r-e- /4f l^�o9 u /Q- Phone#?, el?
Address: /70 0 /�� /D . ���� 7T�� 7` ��d.L
City: � � �. . a n e--!c State: / c� r+ r �s.. Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: y ��`'�� ��C Phone#:
Address: /� - N�
City: /--"/.Q 12"/' "If 10� State: ''t_L c, l Q 1 Zip:
Qualifier Name: �� P Phone#:
State Certification or Registration#: 4 2 � o�7 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 4 Y Q Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ����"" 0 New 0 Repair/Replace ❑ Demolition
Description of Work: l' � w5 {� TV7 .. Gi e L!/t°✓
Specify color
roof^color thru tile: /
Submittal Fee$ w Permit Fee$ /00 CCF$ CO/CC$
Scanning Fee$ Radon Fee$ 2,,6 U DBPR$7 P ®' Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ j;f-1 '
(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 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 '�7VA .qA9A0—&gnature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The(foregoing instrument was acknowledged before me this
U day of 20 L ,by iY day f2 ,20) ,by
hoq personally known to k 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 P NOTARY P BLIC:
Sign: Vt Sign• rr8�-
Print CJ's Print:
Seal: * °•M•" * M1IOIiFF11 Seal: * * tEXPIRerog,MamheutY
EXPIRES:kW 19,2019 '0�
� Boa>adnNaw "Safi
************************************************************************************************************
APPROVED BY _ Plans Examiner Zoning
Structural Review Clerk
(ReAsed02/24/2014)
Dale Plumbing
154 N.W 97Street
Miami Shores.Fl.33130
02/09/2016
State of Florida
County of Dade
Before me this day personally appeared Linton Dawkins who
\being duly sworn,deposes and says,that he will be the only person
working on the project located at 1700 N.E.105 St. Miami Shores
R M S TA L. P ►XT L S 1 N .2 &,%-r-XI P.0 0 M -4. be o�Cdt£ti
f--
Swo sobs 'bed before me this-•-day of�2016
1
2 — Z(n -2- (945,
Personally known
6666
Print name-Laura Farley ••• '••••' •••• •
6666..
6666..
g� 6666
6666..
6666 . 6666.
69.09. •06• 6666.
►�" LAURA FARLEY •• •• •• •••• •
* My CMISSO#FF 1M
* EXPIRES;Merl 18,2019 •••••
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69 0 •6..
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Miami shores Village
L � Building Department
�ORIDA 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tet: (305)795.2204
Fax: (305)756.8972
Notice to Owner— Workers' Com ensation Insurance Exemption
oem'
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 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
••••
Signature.
Owner .•. •••• •••` •
State of Florida •••�•• • •• •••• •
County of Miami-Dade .••••. �..... ••••
The foregoing was acknowledge before me this t day of4_k. , 20L�P_. • • • •
By�cJ�i(6 cti�c J who is personally known to me or has produc$d % •••• •
identification. •••• •
Notary (� * Aw
* WCOL8l11SS=#FF18W
EXPIRES:Mad 16,2019
SEAL: ''�OMPBond lhru"W"Spkes