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PL-16-628 0 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-254328 Permit Number: PL-3-16-628 Scheduled Inspection Date: May 24,2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: LEVY, RAPHAEL Work Classification: Addition/Alteration Job Address:10276 NE 12 Avenue Miami Shores, FL 33138- Phone Number 3051758-9065 Parcel Number 1132050190020 Project: <NONE> Contractor: MAR B PLUMBING CORP Phone: (305)324-0909 Building Department Comments ROUGH AND SET 1 WATER CLOSET AND 1 LAVATORY Infractio Passed comments SET 1 KITCHEN SINK 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 23,2016 For Inspections please call: (305)762-4949 Page 24 of 42 12 7 CERTIFICATE OF LIABILITY INSURANCE 4/DATE I DNYM 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 holder is an ADDITIONAL INSURED,the pol)cy(les)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 endorsemen s. PRODUCER CNMONEAcT Nuria Fletes Coastal Insurance Group PHONE .305-887-5999 FAX 305-887-7809 150 Westward Drive E-MAIL ,nfletes COastalin ro Miami Springs FL 33166-1660 nfletes@coastalinsgroup.com up.com INSURERS)AFFORDING COVERAGE MAIC# INSURERA:Brid efield Employers Ins. Cc 31267 INSURED MARBP-1 INSURERB:Kni ht Specialty Insurance 15366 Mar B Plumbing Corp INSURERC:EVANSTON INSURANCE CO. Silvio Martinez 131 NW South River Drive INSURERD: Miami FL 33128 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1274969087 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 ADDL SUOR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MMMD LIMITS B X COMMERCIAL GENERAL LIABILITY Y Y KSVENA160052200 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE ❑X OCCUR DAMA T —RENTED PREMISES Ea occurrence $50,000 MED EXP(Any one person) $Excluded PERSONAL BADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑PES LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ AUTOMOBILE UA131LITY COMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL ED SCU rHEDULED BODILY INJURY(Per accident) $ OS NON-0WNED PR PER DAMAGE HIREDAUTOS AUTOS Par. de'a $ C UMBRELLA LIAR X OCCUR Y MKLV20LE107321 411/2016 4/1/2017 EACH OCCURRENCE $3,000,000 EXCESS LtAS CLAIMS-MADE AGGREGATE $3,000,000 DED I I RETENTION$ $ A WORKERS COMPENSATION y 83023337 4/1/2016 4/1/2017PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE F— N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Scttedule,may be attached H more space is required) Description of operation: State Plumbing License CFC05779 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building De arlTn@nt SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 9 9 p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD � F 00 Miami Shores Village , �� ' !r 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 Phone: (305)795-2204 Expiration: 09/12/2 Project Address Parcel Number Applicant 10276 NE 12 Avenue 1132050190020 Miami Shores, FL 33138- Block: Lot: RAPHAEL LEVY Owner Information Address Phone Cell RAPHAEL LEVY 10276 NE 12 Avenue 305/758-9065 3051812-3637 MIAMI SHORES FL 33138 Contractor(s) Phone Cell Phone Valuation: $ 5,413.00 MAR B PLUMBING CORP (305)324-0909 Total Sq Feet: 00 Type of Work:ROUGH AND SET 1 WATER CLOSET AND 1 Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Retum: Final Classification:Residential Scanning:1 Review Plumbing Underground Fees Due Amount "Date Pay Type Amt Paid Amt Due CCF $3.60 Invoice# PL-3-16-58960 DBPR Fee $3.38 03/16/2016 Check#:4157 $ 194.36 $50.00 DCA Fee $3.38 Education Surcharge $1,20 03/09/2016 Check#:1320 $50.00 $0.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $4.80 Total: $244.36 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and th all o ill done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to o t rk t March 16,2016 Authorized Signature:Owner / Applicant / Contractor Agent Date Building Department Copy March 16,2016 1 e • Miami Shores Village aA#A;R Building Department10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20N BUILDING Master Permit No.YC- It— Z(-)07- PERMIT 7PERMIT APPLICATION Sub Permit NO.P t. 1 —+ 6 2$ ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL 5/PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1 b a-16 NE 1Q 0e4 6 City: Miami Shores County: Miami Dade Z(o• Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Phone#: Address:_ 10�;k7l Co ME; 12L ME, City: 4`c\kState: t Zip: 'b3\ 0 Tenant/Lessee Name: Phone#: Email: Ar ncLrC �_ � Cgzrv® CONTRACTOR:Company \\Name: `, Plumbing C6 Phoneda��3�3— Address: 3 1V W • A G p: 2 City: p State: Zi Qualifier Name:���V�D Cl./L7� Phone# State Certification or Registration#:� � 05-17A Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ rJ, 4 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace ❑ Demolition Description of Work: Qv r av)cj Spe 'fy ® ieithr Submittal Fee$ !_2 Permit Fee$ � CCF'$ ._3, G6 _._ CO/CC$, Scanning Fee$ `�/y�c�� Radon Fee$ 3 L� . DBPR$ 3 ` 30 Notary$ /�c®` Technology Fee$ 't'. J Training/Education Fee$ _0 Double Fee$ 10 Structural Reviews$ Bond$ gg 5a' TOTAL FEE NOW DUE$ (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 v exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien la broc re will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of corn nce t must be po ted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the nce of suc posted notice, the inspection will not be approved and a reinspection fee will be charged a v Signature Signature OWNER or AGENT r' CONTRACTOR Thgfror9going instrument was ack owledged before me this The foregoing instrument was acknowledged before me this �� day of I`Ir Lill�o� ,20 J by day of Much c fi ! .20 by ,who is ersonally kno to 0 e2 who is personally known to ------------- me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sian: Print: �OIV� 1V � Print: OSCAR 811 Seal: • ,�►� • ALEJANDRA WRANDA Seal: my I+fI PuEx•State N ..anal$ •: MY COMMISSION sit FF=798 COMM..E><OIrK AAS d.Z@1A •,;�_i comtrtbtie�a FF o�8 EXPIRES OdDlw 19.2019 .2110 wool APPROVED BY 3 `�� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax:(306}7x6:8972 - CONTRACTORS' GIS TION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT C.7COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE" (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor AffilaviQ IF CONTRACTOR HAS A:MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF:CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY Of-LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE" E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) '"YOUR INSURANCECOMFA[1fY MUST ISSUE A CERTIFICATE AS FOLLOWi Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ssrssss4'�'rw:ftitt;Af. :Mb :+rWa 0 x 0 N.J98assa w aarraEm®asMo®s 'Alibksaso'�orasses museum as �saer�ss�sas SUSINES$M * i . BUSINESS°ADDRESS:31 N w �MATkLow-LE-L BUSINESS PHONE: 3 L"1()C)�FAX NUMBER�� 2.-`�CA 19 3.3129 r CELL PHONE 4��QUALIFIER'S NAME: � 1QUALIFIER'S LIC NUMBER: �J 015 l � � :.STA"L"E FL DA . 0EPARTMENT OF BuSiNessPROFESSIONAL Ca► T CONSTRUCTION INDUSTRY LICENSING BOARD (850)4871395 194014ORTH MONROE STREET TALLAHASSEE FL 32399-0783 MTIME MSLV4 CC►RP 131 NW SOUTH RIVED DRIVE' MIAMI FL 33128 s Conlitulatiorl itis�tsi�" you ate of th�r7teay-.� y _.. one mlillon Fr iar Iicethe 0 .4parbrient of ess and Pralbabnai Reoulation. Our b and businesses range STATS OF FLORIDA yad t yrs,from bogs to ue DEPAR"C�NT ;�3USII ESS AND end Flo>iita's ec nbmy stratg; lei PROFESS, 4AI.REGULATION S Every day vve.work to the"y:vve do business In order to CFC;q '772 ., fl7J1 fil201 s vet YOU bar. For Information abo$our service,.please log onto .ntyR or ilcense can. There yi u can find more infom�tionwwwCERTIFIED Pt4i ISIN i about our dhrisions and,=learn that impact you,subsct CERTIFIED SIS fo d n rslet rs'and learn- e about the Departments MAR 13 PLUMbD : Our mission at the Depattment is:Umnse Efftlently,Regulate Faidyr .... sh hive to serve you better so that you can your hk you for doing business in Flt*idd. 1S CERTIFIED under the Provisions Of Ch.489 FS. mrd congratulations aiyour now iftenset :AUG a1,201® DETACH HERE RFK SCOTT,GOVERNOR KEN LAWSONN,SECRETARY STA'L'E.OF FLORIDA - '0.' WENTO USIN W lid:PROFESSIONgrp��. ` A J IO 'I'be PLUM CC NTRACTC?R .. - a_ Netled a 3w IS CERTIFIED Undo ' , wise aefChelpter 9 FS. dab: A€G_31,2016 a I3 aka v_ MIAMI" , \ f OWTO --' x , Of 4Wo t y y `1��� '`R� � aot �`sred at pate crf 4ut�toss` . WAWA- �� Rurwe'At to C tiY Cade Chapter 8A-Art.0*40 OWNSIV Sec.TV06 OF t3 . .: PAYMENT RWEMP MR t�8lNG CORP 196 PL MING #a�RRI ft BY TAX CODS r {5 ,10 CFCU5a7 .:$45.00 07/1:7/ 015 ,CREDITCARD--t 5-036887 tb l easiae T ceilx u L s 19uslawa Telt.The Is nota Remo, the hem8Y gowat�smontel greosateete! ataryie& roiios►osniitrlwp mtl��", Wrte hatotiot,gist CERTIFICATE OF LIABILITY INSURANCE 3/DATE 6M/DDM/YY) 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 holder Is an ADDITIONAL INSURED,the policypes) 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 Nuria Fletes Coastal Insurance Group PHONE 305-887-5999 FAX 305-887-7809 Mia Westward Drive ADDRESS,nfletes@coastalins rou com Miami Springs FL 33166-1660 E-'�"I9 P INSURER AFFORDING COVERAGE NAIC# INSURERA:ASSOCIation Insurance Cc 11240 INSURED MARBP-1 INSURER B:Brid efield Employers Ins.Co 31267 Mar B Plumbing Corp INSURER c:Scottsdale Insurance Company 15580 Silvio Martinez 131 NW South River Drive INSURER D: Miami FL 33128 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1463566079 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 TYPE OF INSURANCEADOLSUOR POLICY EFF POLICY EXP LTR I POLICY NUMBER p LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y GLP014494602 4/1/2015 4/1/2016 EACH OCCURRENCE $1,000,000 CLAIMS-MADE FX REM OCCUR DE T RE PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY D JECT F LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE UABILnY 1 $ Ea accident ANY AUTO BODILY INJURY(Per person) $ AAULL,I,SrED SCHEDULED BODILY INJURY(Per accident) $ V0 NON-OWNED PROPERTY1 DAMA E HIRED AUTOS AUTOS Per acciden $ C UMBREL.LALIASX OCCUR Y XBS0049928 4/1/2015 4/1/2016 EACH OCCURRENCE $3,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $3,000,000 DED RETENTION $ B WORKERS COMPENSATION Y 83023337 4/1/2015 4/1/2016 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yesdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached M more space Is required) Description of operation: State Plumbing License CFC05779 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami FL 33138 AUTHORED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD