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PL-15-2593 ILI Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-250448 Permit Number: PL-10-15-2593 Scheduled Inspection Date: March 03,2016 Permit Type: Plumbing- Residential Inspector: Hernandez,Rafael Inspection Type: Final Owner: MUSTAD,KRISTEN Work Classification: Gas Job Address:1260 NE 94 Street Miami Shores,FL 33138- Phone Number (305)6614633 Parcel Number 1132050100180 Project <NONE> Contractor. EH WHITSON PLUMBING Phone:954929-3599 Building Department Comments RUN GAS LINES TO POOL HEATER, RANGE&BBQ Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-245583. pending drop test Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-Inspection fee is paid March 02,2016 For Inspections please call: (305)762-4949 Page 9 of 44 i E.H. WHMON PL Il G 421S21A HOLLYWOOD:FL 3 20 (954)929-35 STATE LICENSEFC 425789 DROP TEST CERTEM ATION OWNERS INMRMAT10N: r1AME: K� S4f• U ADDRESS:—11 b &) 6 s MY:, STATE TYPE OF INSTALLATION: NEW UT GRADE DESCRIPTI NOF WORK: SYSTEM PRESSURE FROM h(ETER: 2- S T tF YBRID SYSTE K BRANCH PRESSURE: WATER COLUMN: l C7 TEST DURATION: DATE OF TEST: U Lsf. F a lY b g t CO CT R{QUAL )SIGNATURE DATE 3 Z' 1 PRDrr-NAME �$ � •' State of florwa {• °° Ctntnty of� . sworn to and stibscribed befin me this 2—day o 4c20. V"Wly known{)produced identi CWOR— of identification 744 I'M ? +25 `x* .ck bf'7 pelY77 # +1� �YI� IN Miami Shores Villages i � �bing R te( n 10050 N.E.2nd Avenue NE - �01a +kafiir� .... b Miami Shores,FL 33138-0000 �3 ` 06 ei Phone: (305)795-2204 6GOR1q� Ex piration: 04/16/201 „ { sura ate' 1t11 'll2di ,5 Project Address Parcel Number Applicant 1260 NE 94 Street 1132050100180 Miami Shores, FL 33138- Block: Lot: KRISTEN MUSTAD Owner Information Address Phone Cell KRISTEN MUSTAD 1260 NE 94 Street (305)661-6633 MIAMI SHORES FL 33138- 1260 NE 94 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,400.00 EH WHITSON PLUMBING 954-929-3599 _. :... r.. ..._ ..... ._. _..,._..__. _......_.._ ..._ _ _... Total Sq Feet: 0 Type of Work:RUN GAS LINES TO POOL HEATER,RANGE Available Inspections: Type of Piping: Inspection Type: Additional Info: Final Bond Return: Press Test Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1,80 DBPR Fee Invoke# PL-10-15-57406 $2.25 10/19/2015 Credit Card $ 168.30 $0.00 DCA Fee $2.25 Education Surcharge $0.60 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $168.30 . In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the abov a e tractor to do the work stated. October 19, 2015 Authorized Signature:Owner / Applicant Contactor / Agent ate i Building Department Copy October 19,2015 1 Miami Shores Village OCT 14 15 Building Department ,i 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 ==_i Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201 BUILDING Master Permit No. Rc ILI` 2:7-02 PERMIT APPLICATION Sub Permit No. ?L 157- 2523 ❑BUILDING F-] ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL LUMBING ❑ MECHANICAL [:]PUBLICWORKS E] CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: //�V C 90 City: Miami Shores Coun Miami Dade Zip:Of u ' Folio/Parcel#: / _3.261f-7 6/for Is the Building Historically Designated:Yes NO ,OeWancy Type: Load: Construction Type: Flood Zone::/_BFE: FFE: OWNER.Name(Fee Simple Titlehfed}-� Phone#� Address: City: C State: Zip: -31,3d Tenant/Lessee Name: Phone#: Email: e CONTRACTOR:Company Name: Phone#: _ 9?-3 Address: / t!- City: ! x G� State: Zip• ✓ _ Qualifier Name: 6 Phon � State Certification or Registration#: l �O 1 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: ON, 4City: State: Zip: Value of Work for this Permit:$ ' Square/Linear Footage of Work: Type of Work: ❑ Addition Alteratisn ❑ New / ElRepair/Replace El Demolition Description of Work: Z 1 'y— Specify color of color thru tile: Submittal Fee$ Permit Fee$ <r 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) s 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 pe n whose property is subject to attachment. Also,a certified copy of the recorded notice of commenceme ust be poled at the ' site for the first inspection which occurs seven (7) days after the building permit is issginthence f suc osted tice, he inspection will not be approved and a reinspection fee will be charged. Signature Signa re OWNER or AGENT CT The foregoing instrumer ras acknowledged before this The ore g instrume t was acknowle/gedefore m this day of 20 by day of 20 by who is personally own to .who is sonally kno to me or who has produced 1 as me or who has produced D:aa4�HHlal�e,�s identification and who did take an oath. �\�0011111111111/////i identification and who did take an oath. ,�� ........A 41 w,� `a�egv��gAFFR4,V i>i�� `�;GpM b�8SS5o�%.9pip NOTARY PUBLIC: <��•°•M,SSIO�y •.6cflNOTARY PUBLIC:or 5 p��0 �oyfA •� M ° ®o.® N #FF 053983 Sign: tiJJCn- . .- I I -- n: tc Ude;;:•• Print: r =°�q•••mo, BondedlbNrint: Seal: � i/'B'IC,ST N1 �ao�\\Seal: 071 7 p n �r Z /B®R/'098061001110®� iPlllllll APPROVED BY C <90`> `ry fJ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT.OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD i _ CFC1425M The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expingon date: AUG 31,2016 LIPKA,JOHN S E. WHITSON PLUBBINe 421 SOUTH21STAVE HOLLYV ..- . -n-iW t 0 ' a MUM 08N012014 DISPLAY AS REQUIRED BY LAW SE-Q# L140810WWO1 A� CERTIFICATE OF LIABILITY INSURANCE110/9/2015 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 holler is an ADDITIONAL INSURED,the policyoes)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 of such endorsement(s). PRODUCER CONTACT NAME: Suzie B. Keyes Coverage Insurance PRONE 5900 Hiatus Road - - Ne Tamarac FL 33321 ADOREES& suzieb@ke escovera e.com cUSTOME R ID t.12193 INSURER(S)AFFORDING COVERAGE NAI:# INSURED INSURERA:Allied PropertV & Casualty Ins Co 42579 E. H. Whitson Plumbing Al & John Enterprises Inc d/b/a INSURER a:Philadelphia Insurance Company 423 S. 21st Avenue INSURER C:Commerce and Industry Ins. Co 19410 Hollywood FL 33020 BSURERD:Zenith Insurance Co. 24 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1163583999 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 MOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lLTR TYPE Or INSURANCE INSR G POLICY NUMBER PoLry EFF POLICY SXP MUMO LIMITS A GENERALLNBILNTY Y Y ACP GLPO 5944902956 3/7/2015 3/7/2016 EACH OCCURRENCE $1,000,000 X COMMERCUaL GENERAL LIABILITY PREMISES Ea o=nence $100,000 CLAIMSMADE O OCCUR MED EXP(Any one person) $Excluded PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 OEN'L AGGRECaATE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO-JECT X LOC $ B AUTOMOBILE uABOJTY Y Y PHPK1299029 3/7/2015 3/7/2016 COMBINED SINGLE LIMIT $1,000,000 (Ea accldem) X ANY AUTO BODILY INJURY(Per parson) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Perao*WM) $ X NON-OWNED AUTOS $ $1,000 C X UMBRELLA LIAB X OCCUR Y BE012111309 3/7/2015 3/7/2016 EACH OCCURRENCE $1,000,000 EXCESS LMS CLAIMS-MADE AGGREGATE $1,000,000 HXDEDUCTIBLE $ RETENTIC N $0 $ D WORKERS COMPENSATION Y Z127057801 4/12/2015 4/12/2016 X I WCSTATU- OTH- AND EMPLOYERS LL624J Y YIN ANY PROPRIETORIPARTNER/EXECUENE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yea,dewilbe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 701,Addfflc"RenwAo SchodLde,I more spree lsmgldred) Certificate holder is included as an additional insured when required by written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICE BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVMED IN ACCORDANCE VATH THE POLICY PROVISIONS CITY OF MIAMI SHORES 1050 NE 2 AVENUE MIAMI SHORES FL 33138 AUTHORRED REPRESENTTAATTNE, �" f O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 41"1 N, . . . _ . _ ._ � u BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954831-4000 VAUD OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA:E H WHITSON PLUMBING R�elpt 'PLU22ABIA7GjLWN SPRNKL/CONTRA.CR Business Name: Business Type:(PLUMBING CONTRACTOR) Owner Name:JOHN S LIPKA Business Opened:o I/0 7/2 0 0 5 Business Location:421 S 21 AVE State/County/Csrt1Reg:cFc1425789 HOLLYWOOD Exemption Code: Business Phone:954-929-3599 Room seats Employees Machines Prof "k"Vals 11 For vel wishm s only Humber of tYt hirtss: Vendt q Type: Tax Atnotrrd Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 54.00 0.00 0.00 0.00 1 0.00 1 0.00 54.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning I IT WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: JOHN S LIPKA Receipt 1t01C-14-00002623 421 S 21 AVENUE Paid 08/17/2015 54.00 HOLLYWOOD, FL 33020 2015 - 2016 r �. �'; ..........v ,w...Y.`V�iAa1� V��Y � LVC��L, V��M��r�r'V1 ■-�� ALT•'{_._ (�'�""+�...�Yit ..,a.. .... 115 S. Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VAUD OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA:E H WHITSON PLUMBING Receipt#*182-1266 Business Name: Business Type'PLUMBING/LWN SPRNKL/CONTRACTOR (PLUMBING CONTRACTOR) Owner Name:JOHN S LIPKA Business Opened:01/0 7/2 00 5 Business Location:421 S 21 AVE Staate1C0UntY/CertfRe$:CFC1425789 HOLLYWOOD Exemption Code: Business Phone: 954-929-3599 Rooms Seats Employees meemnes Profe mlonals 11 signature For Valu 8testn m only NurrAw of 1Maetdrtes: Vert(! T Taut Amount Transfer Fee I NSF Fee Penalty I Prior Years Collection Cost Total Paid 54.00 0.001 0.001 0.001 0.001 0.00 54.00 Receipt 0010-14-00002523 Paid 08/17/2015 54.00 E.H. Whitson Plumbingr 4421 South 21st Avenue HORYWOOd, FL 3302 FC1 257 - p Y*' " oawnwmame: PL f S" 2-5-'7-3 OCT 14 2015�j phwe Esdmaftd At• < % r DNO#ftn of Work: e Ile ----_ iso \\0091IIIISAFF1hp0 • • • • 0:0 • • _� c • • • • • • • • • • '.�a O53983 S • •• •• • • • •• •• • •'��s�oB�%fd10111111N\�\�\ E.H. Whitson Plumbing 421 South 21st Avenue Hollywood,, FL 33020 CFC1425789 CUqWMer ee zip: s - a Phone A" W4)rk to COMPIY With N.F.PJL Code ft*naftd Job : tea Dexdptibn of Work: a I)ate� ,pisaPp�Oved ��'� � 00 see Pipeofto ISO 06 Oe . . . . + •• • • • • • • • • Q. arS i +•• • ••• • • • _� G Q •ii ° ® cn . . • .. • • o t® F 9 �� i i i i•="_..—'�----•-- ... �>�9h°p ra eondedth�m�e�; 2 • • • • • + • • • • <� A°°4 Lblicb