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PL-16-239 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-251814 Permit Number: PL-1-16-239 Scheduled Inspection Date:June 01,2016 Permit Type: Plumbing- Residential Inspector: Hernandez,Rafael Inspection Type: Final Owner: RAYBURN,RALPH Work Classification: Gas Job Address:250 GRAND CONCOURSE I-VOW"Ml Miami Shores, FL Phone Number Parcel Number 1132060136220 Project: <NONE> Contractor: EPJ GAS SERVICE CORP Phone:(786)299-6311 Building Department Comments RUN GAS PIPING TO RANGE AND FUTURE TANKLESS Infracdo Passed Comments W/H AND INSTALL 120 GAL LP TANK INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid May 31,2016 For Inspections please call: (305)762-4949 Page 3 of 45 COMMERCIAL S RESM&MAL OAS PPM t SW NW 11th Sbw Pw&ft RM F1 33024 � y�rroocmn ?-338. 311 ADDRESS PERMIT ER THIS SYSTEM HAS BEEN MANOMETER TESTED FOR 15 mmurES. START / INCHES W.0 FINISH_, INCHES W.0 A �� INSTALLER This installation will meet all Florida SWMw 527.06 LP Division rule 4H-1.01, The South Florida Bldg.code NFPA 54,NFPA 58 and regula- tions of The Stare Fire MarshalL Job as:.�: ... ... 00� ..... QUALIFIER LPG Z66)1? Q e 6 ,�'/Pryubffc Skb of Fiftla m`...� 3W0413 Miami Shores Village ¢ , , v's 10050 N.E.2nd Avenue Miami Shores,FL 33138-0000 Phone: (305)795-2204 Project Address Parcel Number Applicant 250 GRAND CONCOURSE 1132060136220 RALPH RAYBURN Miami Shores, FL Block: Lot: Owner Information Address Phone Cell RALPH RAYBURN 250 GRAND CONCOURSE MIAMI SHORES FL 33138-2853 Contractor(s) Phone Cell Phone Valuation: $ 1,900.00 EPJ GAS SERVICE CORP (786)299-6311 Total Sq Feet: 0 Type of Work:RUN GAS PIPING TO RANGE AND FUTURE Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Retum: Press Test Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# PL-1-16-58485 DBPR Fee $2.25 02/03/2016 Credit Card $ 121.70 $50.00 DCA Fee $2.25 Education Surcharge $0.40 01/28/2016 Credit Card $50.00 $0.00 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $171.70 In consideration of the i uance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and i s ict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I a ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRI A PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVI certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zon rmore,I authorize the above-named contractor to do the work stated. February 03,2016 Autho Signature:Owner / Applicant / Contractor / Agent ate BUildin epartment Copy February 0 ,2016 1 Miami Shores Village F� Building Department JAN tS 201 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY: INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 2014 BUILDING Master Permit No. L. I(a _ 2-3cl PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF []CANCELLATION ❑ SHOP / CONTRACTOR DRAWINGS JOB ADDRESS: 2r 6- 62ei¢J�� ca lx s��T1j1j,4&i City: Miami Shores County: Miami Dade ZiD: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: , 1 Flood Zone: BFEE: FFFE: ®G OWNER:Name(Fee Simple Titleholder): jP gflyw r,e/�iC/ Phone#: 3- b 49 d d Address: -12Z (7611 foU/zJ& City:,41& ( .S'/�/1�S State: �L64 Zip: 3-3 Tenant/Lessee Name: Phone#: Email m $ Ak ® e. CONTRACTOR:Company Name: /SPS C�Ag J't,�/PC. Gcytl—� Phone#: 7,g zz !- 4311 Address: 0 31 U Q fy vJ 7 L ri City: fes//�A ri State: 1 Zip: 33182, Qualifier Name:_ ��1 c,A chin �r:Sv� G, "d G'l�lA Phone#: 7g(" State Certification or Registration#: L.6 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 1,100 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration [ONew ElRepair/Replaace 1 ❑ Demolition Description of Work: GASP; 4.2 AS P�; f t NCS T�3 f,.0� 1�•--C �v( i/?� �A1�1�1C�S w 44 A c", Ir�s_-�1:�,1I ' 7-6 COAL L.f Tl,rvk _ Specify color of color thru tile: Submittal Fee$ • ( ) Permit Fee$ CCF$_L. ��_ CO/CC$ ` Scanning Fee$ Radon Fee$ DBPR$ Notary$ E.Ql Technology Fee$ •G® Training/Education Fee$ Double Fee$ q Structural Reviews$ Bond$ 07 TOTAL FEE NOW DUE$ t I ° (Revised02/24/2014) • 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person' whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site; for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature • Signature ER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing(n r ment was acknowledged before me this 2-7 day of �11./dA 20 16 ,by day of 20 r- .by �, //who is personally known to �bU�d 1 ,who is personally known to j me or who has produced�a� ��s 4r^ as me or who has produced y-�-J"aj�� ( )Q'U-N Somas identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: SIgn. Sign: Print: 4 Print: I NIN D P�-b � Seal: ,:+'- WCOMNSSIONW9410) Seal: P � EXPIRES:February 17,202D Notary Public State or Florid® BMW Thm No"Pv*uildem is Sindia Aivarea 4 My Commission FF 188750 �,�oe$ Expires 09/03/2019 APPROVED BY 4;) Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) j r " Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number. 26019 Business Mailing Address Licensed Location Address EPJ GAS SERVICE CORP. EPJ GAS SERVICE CORP. 13101 NW TTH LN 13101 NW 7TH LN MIAMI,FL 33182-2364 MIAMI,FL 33182-2364 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. AD LP Gas licenses must-be-renewed - annr . Afty 1{ ase d-tc c pir lb. b �ase_of Jure to-rennm DfQr restoration of a cense is egtialFto lfie�otlht�l (hiss#hisrtd•rr bed beo►� eer► e mdY�';' > ; operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THS BUSINESS LOCATION: This license may be transferred to any person,firm of corporation for the remainder of the current license year upon writteniuest to the department by the original license holder. Uoense transfers must be approved by the departm`Te AIGensing requ au of reIP SGas Inks met by the transferee and a transfer fee of$60 will apply, To apply for a transfer,contact the Inspections at($60)921-1600. Pursuant to Chapter 627,Florida Statutes,LP Gas licensees must present proof of licensure to any consumer, owner,or end user upop request when engaged in the business of servicing,testing,repairing,maintaining or Installing LP Gas systems and/or equipment For future conespondence,,pipase make any,ne ad coradions or changes to your business mailing address and/or your licensed loc i tbn address an&1*Utn.fhe UPPER PORTION Wth'dotrecfiionsito e c. q Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here Staft of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number. 26018. Bureau of Liquefied Petroleum Gas Inspection Explradon tee: August 31,2018 (850) 921-1600 Oafs of Issue: September 1,2016 GO POST LICENSE Tallahassee, Florida Type and cl�' Fee: oeo3$21440 CONSPICUOUSLY Liquefied'P'etroleum Gas License Ll' GAS INSTALLER GOOD,FOR ONE LOCATION ONLY ANY CHANGE OF OVOIERSHtP OR SALE OF THIS BLESS RENDERS THIS LICENSE INVALID e This Hamm is issued under authority of Section 627.02,Florida Statutes,to: EPJ GAS SERVICE CORP. q 13101 NW 7TH LN ADAM)H, PU,rLNAM-- MIAMI, FL 33182-23,4 COMMISSIONER OFF AGRICULTURE Izea Local B iness fax Rece�nt Miami-Dade County(, State of Rori -THIS IS NOTA:SRI - DO NOT PAY 7157811 sua34mmft g^wm o".noN EPJ'f�AS SERVICE Ct1RPMMAL siPTB , '18 3101 NW 7`W 7434788 must he d—playreei�t' a of'Cu�nesa MAAAI R 33182 Puraaaht to CW.MV Code Chapter 8A Art 8& OWNER SBC.TYM OF BUSINESS PA1rBIlEMT R ? EPJ GAS SERVICE CORP 205 LPG INSTALLER Tnx , 26019 $100.00 08/06/2015 tREDITC4RD-15-040058 This Local BasiaessTax Receipt only aoatka>s pay auent aids Lead Business Tax.Mm Iteoelptis not a ltaeree, perreit,or a cerllflaatlon ofthe hotter`fficattaas to tales Homer an comply arfllr am il"verinner l rogatory regntram�xrhiahap�Ipta the bow Tire RECEIPT 111111 above must he on ail commercial dales-Mhun him ems$ea ea-m Forams bdormatlon,vfait f 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 ce0es that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 9!20/2015 EXPIRATION DATE: 911942017 PERSON: PENICHET EDUARDO FEIN: 262850037 BUSINESS NAME AND ADDRESS: EPJ GAS SERVISE CORP 13101 NW71-N MIAMI FL 33182 SCOPES OF BUSINESS OR TRADE: GAS MAIN OR CONNECTION?CONST Pursuant to Chapter 440.06(14),F.S.,an officer of a corporation who elects exemption from this chapter by tiling a camcxate of election under this set on may not recover benefits or compensation under tits chapter.Pursuant to Chapter 440.05(12).F.S.,Certificates of election to be exempL..apply only within the scope of ftrs business or trade fisted 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 9,at any time after the f ing of the notice or the Issuance of the certificate, the person named on the notice or certlifiCate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a DFS-F2 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 CERTIFICATE OF INSURANCE ISSUE DATE 1/26/2016 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 CONRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUDER,AND THE CERTIFICATE HOLDER. IMPORTANT:IF THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED,THE POLICY(IES)MUST BE ENDORSED.IF SUBROGATION IS WANED,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 INSURER(S)AFFORDING COVERAGE Claudia'sInsurance,Inc 18901INSURER A: Scottsdale Insurance Company 18901 SW 106 Ave P Y Ste 132 A Miami,FL 33157 INSURER B: N/A INSURED INSURER C: N/A EPJ Gas Service Corporation 11201 SW 55th Street Box 236 INSURER D: N/A Miramar,FL 33025 INSURER E: NIA COVERAGES 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 POLICY POLICY POLICY LIMITS LTR INSURANCE NUMBER EFFECTIVE DATE EXPIRATION DATE General Aggregate $5,000,000 Products-Com/Op Agg. $5,000,000 A General Liability CPS2274432 10/92015 10/9/2016 Personal&Adv.Injury $2,000,000 Each Occurrence $2,000,000 Damage Prem Rented To You $100,000 Med Expense(Any one person) $5,000 Combined Single Limit B Personal Liability Medical Payments To Others C Excess Liability Each Occurrence Aggregate D Building E Property Contents Loss Of Use THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW.PERSONS INSURED BY SURPLUS LINES CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA GUARANTY ACT TO THE EXTENT OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER. SURPLUS LINES INSURERS'POLICY RATES AND FORMS ARE NOT APPROVED BY ANY FLORIDA REGULATORY AGENCY. Description of Operations/Specialty Items Appliances&Accessories installation,servicing or repair commercial,Appliances&Accessories installation,servicing or repair household Certificate Holder Should any of the above described policies be cancelled before the expiration date MIAMI SHORES VILLAGE BUILDING DEPARTMENT thereof,notice will be delivered In accordance with the policy provisions. 10050 NE 2ND AVE Authorized Signature MIAMI SHORES,FL 33138 4;4 . . ... . . . ... .. .. . . . .. .. . . . . . . . . . . . . . ... . . . . ... EPJ GAS SERVICE CORP 13101nw7ln : : ' : . : : •: :. Miami 03182 .0 •� 0 ... . . ... . 786 229 6311 . •.• • • . • •• . DATE: State Of County Of �. �►�- Before me this day personally appeared,Q, ��" e � o,being duly sworn,deposes and says: That he or she Will be the only person Working on the project locate at: 2 GA±SL2 D C.o N Gv U g SE-, Sworn to (or affirmed) and subscribed before me this 3 day of F 20 t(by rRE4,,4 (G-r rL-T Personally Know OR produced Identification Type of identification produce \��1�111111111////! xS SIlV��%� ' ' 0314612016 lit '•. Commission# ;� %,��cs,�9. EEi13059 \�Q`� �o • . ••. • • . ... Miami-Shores Village �� •o: • QWtQepartment �tORlll� :•• '•' •:4Ot& N.E.2nd Avenue Miami Shores, Florida 33138 •, , , .. ,,. .,Tel: (305) 795.2204 •• :.: : : : :• '• Fax: (305) 756.8972 ••. •. . • • • • ••• •• Notice to Owner — Workers' Compensation Insurance Exempt on 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. a,Signature: Owner State of Florida County of e 4"w40-P J The foregoing was acknowledge before me this_L day of /`'� ,20 By_A �p A 1?A4 i�/ao� who is personally known to me or has produced s on. 4, LU�IIDEIYIWE � . #�:, gYCOYbY�SSIQJ+1#FF9M Notary: EXPIRES:Fefx W 17,2020 - SEAL: .ip;' Bid Tin Pb�ry PvISc I! -