RC-14-450 �• Miami Shores Village RF,(--FTN D
Building Department �� ' �, :
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
BUILDING Master Permit No. -ig '`lam
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [—]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: y7 dS c..j ®�
City: Miami Shores County: Miami Dade Zia: :3314?
Folio/Parcel#: 11121 .% C0 3 0 Z O� Is the Building Historically Designated:Yes NO Q
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): J�%i r tw tq-'UC i Aa Phone#: —W(o jQ1 105-4
Address: 00 5W k 05 5-r
City: t"L..".&V%". S1•orso State: QCs Zip: 3.31(o?
Tenant/Lessee Name: lu I Phone#:
Email: 4
CONTRACTOR:Company Name: '6'1 i P%Lei 0 MOR4El6A! -T—h(C, Phone#:
Address: !2 3 JS AJ W 13(n( ?L
City: MX 4 r+.,` State: FL Zip: 331 T Z.
Qualifier Name: Tto re 1 a nJ Phone#:
State Certification or Registration#: GSC OJ Ick4 Z Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: tA City: State: Zip:
Value of Work for this Permit:$ 14000 Square/Linear Footage of Work: !�®O
Type of Work: ❑ Addition g Alteration ❑ New D Repair/Replace ❑ Demolition
Description of Work: N4,-j Pgr lnj. T2.,.or�4�
Specify color of color thru tile:
Submittal Fee$ '00 Permit Fee$ Z �' CCF$ Q- (,O CO/CC$ 0
Scanning Fee$ 01• OD Radon Fee$ DBPR$ Notary$
Technology Fee$0' �3 K) Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 19 2-
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
Inspection will not be approved and a reinspection fee will be charged.
Signature AA4 Aejz2 Signature
OWNER or AGENT NTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
8 day of i�� 120 s by day of t� 20 ti by
,S r�2w %"a who is personaall �.�i7i Di 0 MO ce 100,who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
' '= A
Seal Seal: '`� P'
=•: my COMMISSION#EE11416a �•• °= MY COMMISSION#961`14162
'. •°� EXPIRES July 20,2019 �" EXPIRES July 20.2015
(401)388 0153 FlorldaNOWYSM12!t m (4011388 0153 FloriDaAlofaiy3eroico.G�
N��Fa&#U+r�ii�l�YNi�kw.1.�]..g�F#+k+k�+xi�}+k�S�l�h�k�►�10#+kweka4�l�l+►�l�k+t�Y akak�l+t4re�k�k+F�Y�k90#�t+k�k�k+k�eaF4d�i�#�F�le.y�M+A�k�i+t�F�l�+k�k&�Ie4Fw�k�t+t�kN��Y�k�Yar�k�N+kM�M el+L�i
APPROVED BY ( J -cc1'o Plans Examiner Zoning
Structural Review Clerk
(Revisedo2/24/2014)
RICK SCOTT,GOVERNOR _ KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
Y e.
CFC057942
The PLUMBING CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 488 FS.
Expiration date: AUG 31,2016
MOREJON,ELPIDIO 0•
ELPIDIO MOREJON INC
933 NW 134TH PLACE ry
MIAMI FL 33182"
0. 16j .�
ISSUED: 07103/2014 DISPLAY AS REQUIRED BY LAW SEQ s L1407030000971
STATE OF FLORIDA
DEPARTMENT OF.BUSINESS AND
PROFE$S'50 REGULATION
CFC057942 ISSUEM 0710312014
CERTIFIED PL AM CONTRACTOR
MOREJON,ELP1610-
ELPIDIO MbREJCI+I 11+x,
IS CERTIFIED underthe provisions of Ch.488 FS.
Exphatbn date:AUG 31.2015 L1407030000971
Local Business Tax Receipt
Miami—Dade County, State of Florida
THIS IS NOT A ALL-00NOT PAY �ILBTI
676418$
BUE ME""AMIR LOCA"ON RECEIPT NO. EXPIRES
ELPIDIO MOREION INC RMIEWA. SEPTEMBER 30, 2014
933 NW 134 PL 7097583
Must be displayed at piece of business
MIAMI,FL 33182 Pursuant to County Cade
Chapter$A-Art.8&10
OWNER BEC.TYPE OF 13USINEGS PAYMENT
ELPIDIO MOREJON INC 196 PLUMBING CONTRACTOR BY TTA ELECTOR
75.00 07/08/2013
Worker(s) 1 CFCD57942 0221-13-000392
This Local Business Tax Recelpt only confirms paiment at Om Local Business Tau.The Receipt is not a Rcema,
pera t.or a mftcffdu of Ike holder's queRRdtiam to da bodoess.Holder met comply with any goverrevastal
or nownruntental rapletory laws sial regairemsant which apply to the buslam ,.
The RECEIPT NO.above amt be displayed as all commercial vales-Ilami-Dade Coda Seo t&-M
For More iatarmathm.vhf
CERTIFICATE OF LIABILITY INSURANCEDATE '�°14""'
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 ATTEND,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: Sthe card icate holder is an ADDITIONAL INSURED,the poticy(tes)must be endorsed. If SU13ROGATION W WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certStcate does not confer rights to the
certgicate holder In tieu of such endorsement(s).
PRODUCER =ACT MARTA ALONSO
Florida Bankers insurance (305)266-6493 FAX
jAIc,No): (305)262-0679
7278 SW 8 Street SS. Hoddabarikerainsurance.eom
Miami,FL 33144 INSURERS)AFFORDING COVERAGE NAIL e
Phone (305)266-6493 Fax (305)262-0679 INSURER A: FEDERATED NATIONAL INSURANCE CO.
INSURED INSURERS:
ELPIDIO MOREJON INC INSURER C:
933 NW 134 PI INSURER 0:
MIAMI,FL 33182- (305)553-7019 04URER 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.
LTTRR TYPE OF INSURANCE ADDL RWVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
® COMMERCIAL GENERAL LIABILITYM SOEe occurrence) $ 100,x.00
A [] ❑ CLAIMS MADE Q OCCUR GL-0504011390-0 11AW013 11/092014 NED EXP(Any one person) $ 5,000.00
❑ PERSONAL&ADV INJURY $ 1,000,000.00
❑
GENERAL AGGREGATE $ 1,000,000.00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-comptop AGG $ 1,000,000.00
®POLICY ❑ ❑ LOC $
AUTOMOBILE LIABRJ7Y I.NEDTNGLE LIMIT
d.
❑ ANY AuTo BODILY INJURY(Per person)ALL OWNED $
❑ AUTO ❑ ALRO�ILED BODILY INJJRY�(Per accident) $
❑ HIRED AUTOS E] N S Pp-P-9 YYAE $
$
❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $
E] EXCESS LIAS ❑CLAIMS-MADE AGGREGATE $
El DED El RETENTION s $
WORKERS COMPENSATION 0 YTIMT TTµ
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIErOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
CFFICERfMEMBER EXCLUDED? N I A
(Ma Adwy in NH) E.L.DISEASE-EA EMPLOYEE$
If yes.describe urde
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,P more apace Is required)
CERTIFIED PLUMBING CONTRACTOR
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MtW SHORES VILLAGE
BUILDING DEPARTME-Iff AUTHOR>ZED REPRESSUTATNE
10050 NW 2 Ave -
Mlemi Shores,FL 33138 117186,bmp
®1988.2010 ACORD CORPORATION. AD rights reserved
ACORD 25(201(/05)OF The ACORD name and logo are registered marks of ACORD
JEFF ATWATER
CHEF 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 certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 2/22/2013 EXPIRATION DATE: 2122/2015
PERSON: MOREJON ELPIDIO
FEIN: 274044596
BUSINESS NAME AND ADDRESS:
ELPIDIO MOREJON INC
933 NW 134 PLACE
MIAMI FL 33182
SCOPES OF BUSINESS OR TRADE:
PLUMBING NOC AND
DRIVERS
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from tut chapter by fikrg a certificate of election under this section my
not recover berme or compensation under this chapter.Pursuant to CtapW 440.05(12),F.S.,Certificates of election to be exempt..,apply only whin the scope
of the bush or bade listed on the notice of ern 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 sttbJect to revocation if,at any time atter the filing of the notice or the Issuance of the cer ificate,the person named on the rhotioxj or
certificate no forger meets the retpdrements of this section for Issu;ence of a oxime.The department shell revoke a certificate at any time for lure of the
person named on the certificate to meet to requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609