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PL-15-2879 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (306)756-8972 Inspection Number. INSP-259572 Permit Number: PL-11-15-2879 Scheduled Inspection Date: May 25,2016 Permit Type: Plumbing-Residential Inspector: Hernandez,Rafael Inspection Type: Final Owner I Work Classification: Addition/Alteration Job Address:280 NE 91 Street Miami Shores,FL 33138- Phone Number Parcel Number 1132060190410 Project <NONE> Contractor: G WHITAKER INC Phone:(954)658-9119 Building Department Comments INSTALL LAUNDRY AND KITCHEN PLUMBING INSTALL Whim oComments INSPECTOR COMMENTS False NEW BATH PIPES AND FIXTURES 05/18/2016 STOP WORK ORDER NEED TO SEE QUALIFIER ON JOB. Inspector comments Passed CREATED AS REINSPECTION FOR INSP 259145. CREATED AS REINSPECTION FOR INSP 259059.CREATED AS REINSPECTION FOR I NSP-247802. not ready Failed STOP WORK NEED TO SEE QUALIFIER ON THE JOB. Correction 5/24/16 called to cancel, reschedule for tomo Needed Re-Inspection D Fee No Additional Inspections can be scheduled until re-Inspection fee is paid 05/16/2016 09:00 18510�IFICATE 4827042, C� ODD-DORROH INS. PAGE 01/01 �� E �� P ID:Fl 14.�,.�-�� CE OF LIABILITY INSURANCE °0511 as�1#2016 THIS CERTIFICATE IS ISSU®A� A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOU) .THIS CERTIFICATE DOES NOT AFFI TNELY OR NEGATIVELY AMEND, EXPEND OR ALTER THE COVERAGE AFFORDED BY THE UCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN TME ISSUING INSURER(S� A ORMED REPRESENTATIVE OR PRODUC AND THE CERTIFICATE HOLDER. IMPORTANT: If the OWNICate hO�der Is an ADDITIONAL INSURED.the 00110 (lee)must be endorsed. If SUBROGATION IS WAIVED,- btecr to the berms and conditions of the icy,certain policies Wray require an endorsement A state relent on this cortiflcate does not confer rig to the cer i icide holder in lieu of such anba g PRODLICER Todd-DOrroh insurance,IIS. 4368 Clinton St. Marianna,FL 32"S Franolne Todd GWHIT-7 IN APfOROM OOVBRAGIS 4NAICS R IN8tfR14O 4 R INC WRIT INSImma ENDURANCE AMERICAN SPECIALTY N.E.20TH ST D104 BOLA RATON,Fl.n 132 amwa INSURER C; IMSURM - IMSURM D I Et COVERAGES CATS NUMB : REVISIONNUMBER: THIS 13 TO CERTIFY THAT THE POLI HIS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLI PERIOD INDICATED. NOTWITHSTANDING REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO CH THIS CEffnFIGATIM MAY Be ISSUED OR Y YF-RTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL TH TERM. EXCLUSIONS AND CONDITIONS OF S CH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TYP80PUIsuRANce (Vow I — CNfrRAL L7AiSuiY Linens EACH OCCURRENCE a -9,000,001 A X COMMERCIAL GENERM.LLABRITY CBC20t1012'10=1 W171=6 03/17/2017 _ $ 100,00L CLAIMS-MADE EK fx'.GUR wrttnP pv,y ah, rw d s O,ODC PERSONAL&ADV INJURY 4 160001000 GENERAL AGGREGATE a 2A0voa BEMlPAX*MWAlaLQgIiAPPLIES Ppb POLICY P f7 LOC PRODUCTS-COMProaAt3(i $ 2.000,000 - PWTOMOVIL.E UAEUJTY to ANYAUTO SINCALELKITpe ALL OWNED AUTOS BODILY INJURY(Per Pers) S COt MOULED AUTOO BOLDLY INJURY(Per BOW") S HIIO AUTOS PROPERTY DAMAGE S (PER ACCIDENT) NON-OVVNEDAIJTQS ... -.,, . S YAABRE].LALWB OCCUR WCESS LIAR LACN OCCURRENCE S CLNM8 E AWWiftr4AIh S bEDUCTRU R&EPMONS $ wore;ene��UVBA'rtoN i AND SArPLOYERS'IlAaIUry OTH- ANYPROPRIETORIPARTN@q E Y N (FR In WGEQt CSE NIA E.L EACHACCOENT $ N I 8.L=EME-CA OAP s . EL DISEASE-POLICY LIMIT $ DIB(�RIppPTppIO��N��OP OPMTIOMS I kOQAA7lONS I VVl NAM VAM ACCRA 101,A40NOW Raab 9CFrodtdv,K1Asaa sp�e it roQ��p1 LJ%W$TAT OF PLOORiDA �4 FCO Oa8054 DESCRIPTION OF OPERATIONS. NSTALLING 2 TOILETS AND 2 SINKS AND SHOWER CE rMle HOLDER LQANNa�LA1TOR CIT'YMS1 SHOULD ANY OF Tm ABOVE DBSCR WD poL=s BE WCELLEO FORE City of Miami shores THE GXPIRATWN DATE TFIERLo£or, NOTICC WILL BE DELrm tw IN FAX 305-71511-M72 ACCORDANCE WITH THE PoucY PROVISION& 10M NI;2ND AVE MIAMI SHORES,FL 33 38 A R NTQ Fra . r ACORD 28(XMW) 019'MM ACORD CORPORATION. All rightsrag Prved. Tire ACORD nam and logo are registered raft of ACORD ` Miami Shores Village 7Y: Y 12 2015 Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 -- Tel:(305)795-2204 Fan:(305)7S6-8972 INSPECTION UNE PHONE NUMBER:(30S)762.4949 FBC 20 BUILDING masw Permit ft. PERMIT APPLICATION Sub Permit No./ BUILDING ELECTRIC M ROOFING ❑ REVISION EXTENSION RENEWAL ®PLUMBING []MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION M SHOP CONTRACTOR DRAWINGS r 10B ADDRESS: City: Miami Shores G 11Countw Miami Dade ZiD: gat-Rx _ Folio/Parcei#:�I 321016 01 7 — d 7 141 Is the Building Historically Designated:Yes N0 _ z Occupancy Type: Load: Construction Type:a4FloodtZ]on�e: BFE: F'FEI: r OWNER:Name(Fee Simple Titleholder): 774041A i, )V4 vUl Who.e#: Address: 9�� City: 1GA44-4 YG s State: Zip: 3 �3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: ;4Al, Phone#: Address: Oty: Stater Zip: Qualifier Name: Phone#: State Certification or Registration#: 47 Certificate of Competency#: DESIGNER:Arthitect/Engineer. G A/ GOV Phone#: 2- Add Address: City: State: Zip: Vahie of Work for this Permit:$ So o' SquatrelLinew Footage of Work: Type of WorL- ❑ Addition 14 Alteration ❑ New 02 rlace ❑ Demolition 7on of Work: �,N.P aAwGL �/}��•d / At MU10 'M3 P1 lam, 91 E® iQ°�Qta .t1Rltt4, M A S Specify color of color thm t/le. 'ankh"W0�* Submittal Fee..$ .=-,C2C ) Permit Fee$ u- r CCF$ CO/CC$ Scanning Fee$ Radon Fee$_..s DBPR$ Notary S Technology Fee$ Training/Educadon Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ G iRew,eMZ/24/2014i 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$25w,the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the buildJessue . In the absence of such osted notice, the inspection will not be approved and a reinspection fee will be charged r' Signature_;�_/�OWNERorAGENT ONTRA ORThe foregoing instrument was acknowledged before me this nstrurn )t was acknowledged before me this day of (�cA)Q r►.,b.s✓ ,20 lS ,by �+ of /u�t�I�PbI�b ,20_/.5 ,by M,►`r lnw$ , .�O+--u�t ho is personally known to 6rffdu h ' sker ,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: �I f Sign Sign: Print: rdft IM d i , Print: ON 11110 lime My Cam ilk�19.1019 �, . Seal: 1* Jam. Seal: r;t►""` ;, FRANCES L MORRIS •`ki MY COMMISSION*FFQ088;5 •',"+;�;� ! EXPIRES April 16.2017 aryServlao.com APPROVED BY /� /3''f Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) �V Yµ "C IRA cuss �lV�Z8-2�Z-32.205.0 04M'•MM*t?i 11ptOf ^OM6M�T �� ..•. SAY fOil•lQtp bIIi fbprf„„by IiM STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CPCO22546 ISSUED: 07/01/2014 CtRTIFIED PLUMBING CONTRACTOR WHITAKER,GRADY L G WHITAKER INC IS CERTIFIED under the provisions of Ch.489 FS. Expl4tion date:AUG 31,2016 L1407010001271 ANNE N1. G A N N Q N P.O.Box 3353,West Palm Beach,FL 33402-3353 -LOCATED AT" .. CONSTITUTIONAL TAX COLLECTOR www-pbctax.com Tel:(561)355-2264 County ticrzd„g tPalint3intlr 400 NE 20TH ST APT 104D SOCA RATON, FL 33431-8159 Serving you. TYPE OF BUSINESS OWNER C°PTIFiCATION# RECEIPT#!DATE PAID AMT PAID I BILL 23-6069 PLUMBING CONTRACTOR WHITAKER GRADY -CQ22546 815.844340-0-151-1, $27.50 1 64014:918 This document is valid only when receipted by the Tax Collector's Office STATE OF FLORIDA PALM BEACH COUNTY 2015/2016 LOCAL BUSINESS TAX RECEIPT `✓ B2-356 G WHITAKER INC %r� LBTR Number: 201006054 G WHITAKER INC EXPIRES: SEPTEMBER 30, 2016 400 NE 20TH ST APT D104 BOCA RATON. FL 33431-8117 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. OP ID:FT A R�� CERTIFICATE OF LIABILITY INSURANCE 11111 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 tmrtlficate holder is an ADDITIONAL INSURED,the pol(cy((es)must be endorsed. N 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 endorse 9". PRODUCER CONTACT NAM Todd-Dorroh Insurance,Inc. PHONE 4388 Clinton St No): Marianna FL 32446 Francine,Todd ADDRESS: =rD0.GWHff-1 INSU AFFORDING COVERAGE NAIC# INSURED 0.WHITAKERINCINSURER A:LLOYDS OF LONDON 400 N.E.20TH ST APT D104 BOCA RATON,FL 33432 INSURERS: INSURER C INSURER D 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. INSR REOL 51JUR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER Lam GENERAL LIABILITY EACH OCCURRENCE $ 1,000, A X COMMERCIAL GENERAL LIABILITY SCLOOM10 03/1212015 03/12/2016 PREMISES Me o«xsrerwre $ 1 OOr CLAIMS-MADE 'r OCCUR MED EXP(Arty one peraon) $ 101 PERSONAL&ADV INJURY $ 1 r0�r GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000, POLICY PRO LOC $ AUTOMOBILE LWBILITY COMBINED SINGLE LIMIT $ (Ea aoddern) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Peraeddent) $ SCHEDULEDAUTOS PROPERTY $ HIRED AUTOS (PACID NON-OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU OTH- AND EMPLOYERS'LIABILITY YIN STAT T T ER ANY PROPRIETORIPARTNERIEXECUTIVE N i A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ p€SCRIPT 0 PERATIONS I LOCATION I VEHICLES(Attach ACORD 101,Additlonal Rmrrarks Schedule,[fame space Is roquked) CERTIFICATE HOLDER CANCELLATION VILLAGM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF MIAMI SHORES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE Francine Todd m 1988-2008 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Aug 04 15 07: 49p 366-441-7575 p. 1 JEFF ATWATER •�"�wa ` 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 certifies that the individual listed below has elected to be exempt from Florida Workers- Compensation law , EFFECTIVE DATE: 11/1/2015 EXPIRATION DATE: 10/31/2017 PERSON: WHITAKER GRADY FEIN: 270477023 L BUSINESS NAME AND ADDRESS. G. WHITAKER INC. 400 N. E. 20TH STREET,APT. 10 BOCA RATON FL 33431 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pursuant toc Chapter 440.05com 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 f t beneft business compensation under this chapter.Pursuant to Chapter 440.05(12},F.S.,Certificates of election to f e exempt...apply only within the scope of the business or trade listed 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 she be subject to revocation if,at arty 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 0 awns men Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to Owner-Workers' Comppnsation Insurance Exernetion K "4 -,;i U-11 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 constriction 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: &W 'Ovmher V *My/tt11k-ftft of Floes CoMMINN!FF 187948 State of Florida My Ctl M&MW AIW 18.2019 =Wftw0NNWNfty Ann, County of Miami-Dade The foregoing was acknowledge before me this 1 day of��5aiz.,A L ,20_� By t who is personally known personally knowntcxy� hcxd Vientification. SEAL: G. Whitaker Plumbing 400 ne 20th st 104d Boca Raton, FI 33431 10/31/2015 State of Florida County of a\,\ elm Before me this day appeared f C'8 who, being duly sworn,deposes and says; That he or she will be the only person working on the project located at 280 ne 91st st, Miami Shores, FI 331��2015,by Sworn to rmed) subscrib efor a ,day of Personally known or produced identification Type of Identification e - � iV�S �.�C)1(o " cQq -Ja- 0NMI Pift Notary FF rm 9AI1 »•gets