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PL-16-471 A RL - 2 g�g Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shone,FL Phone: (305)785-2204 Fax: (305)7568972 Inspection Number INSP-259212 Permit Number: PL-2-16471 Scheduled Inspection Date: May 23,2016 Permit Type: Plumbing - Residential Inspector. Hernandez,Rafael Inspection Type: Final Owner. SOUZA,HENRIQUE Work Classification:Addition/Alteration Job Address:479 NE 102 Street Miami Shores,FL Phone Number (646)320.4171 Parcel Number 1132060170840 Project: <NONE> Contractor M&C CONTRACTORS Phone:(305)763-8166 Build ' ing Department Comments REMODEL 2 BATHROOMS&KITCHEN hdrecdo Passed Comm—eft INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP 253340. ANCELLED BY RITA Failed El Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-Inspection fee Is paid Miami Shores Village 10050 N.E.2nd Avenue NE a4 °' ' 61,11"R 1' Miami Shores,FL 33138-0000 Phone: (305)795-2204 , ww Expiration:v081240201 ' Project Address Parcel Number Applicant 479 NE 102 Street 1132060170840 Miami Shores, FL Block: Lot: HENRIQUE SOUZA Owner Information Address Phone Cell HENRIQUE SOUZA 479 NE 102 Street (646)320-4171 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,600.00 M&C CONTRACTORS (305)763-8166 Total Sq Feet: 0 Type of Work:REMODEL 2 BATHROOMS&KITCHEN Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Retum: Final Classification:Residential Scanning:1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type :50.00 id Amt Due CCF $1.80 DBPR Fee $338 Invoice# PL-2-16.58758 DCA Fee $3.38 02/22/2016 Check#:3024 $189.56Education Surcharge $0.80 02/26/2016 Check#:1171 $0.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $2.40 Total: $239.56 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 inforrnati ccuraije and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the abo amed n to do the work stated. February 26,2016 Authorized Signature:Owner / Applicant / C&dtmctor / Agent Date Building Department Copy February 26,2016 1 ,"P Miami Shores Village ItF B 2 2 2016 i Building Department - 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No. kC— to`24 PERMIT APPLICATION Sub Permit No. F-]BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL %PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF [:] CANCELLATION ❑ SHOP !,��2 CONTRACTOR DRAWINGS T JOB ADDRESS: g N6 I®c)- S"f - City: MiamiShores /� County: Miami Dade Zip: 3�L 3 �_ Folio/Parcel#: l r "J�0p � Q 17 - Q t3 `k) is the Building Historically Designated:Yes NO \ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): LIU Phone#: Address: -7 9 Af 6 IM 100 A 31 City: l �f Oj�S State: Zip: 3Ir' Tenant/Lessee Name: Phone#: Email: - ON CONTRACTOR:Company Name: C WI Y 1 � r] Phone#:�� 'T - • . WbbG Address: UOU Arnxof aMf-'rw M. A.BoY 111 City: St e• P- Zip: /� �_ Qualifier Name: m��V—) i� ' Phone#:�d .392 y y7-3 State Certification or Registration#: Mtfb Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: /Zip: Value of Work for this Permit:$ 2.4660 Square/Linear Footage of Work: i "1(�U Type of Work: ❑ Addition ❑ Alteration ❑ Newj Repair/Re lace f, �❑ Demolition Description of Work: Rewdd 2 r�'f Qi nt,S k.t �C k1 Specify color-of co/vrithru tile: Submittal Fee$ Permit Fee$ ; S­ CCF$ 1 tO CO/CC$ Scanning Fee$ .cz�! Radon Fee$ & DBPR$ 38 - Notary$ Technology Fee$ `) Training/Education Fee$ D6uble Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ C . (Revised02/24/2014) Bonding Company's Name(if applicable) iQ 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. 1 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—+ Signa OWNER or AGENT CONTRACTOR Theforego g instrument was acknowledged before me this The foregoing instrument was acknowledged before me this l� y of 20_lJ(g by day of i b\Je4- I� .20 [ S ,by �Q �1 who is pers nown to ersonally 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. r NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: V QUIDA JA print: l a l ra Q YPX� Print: ISSION#FF43855 �piRFS:A�� Seal: Seal: MY COMMISM 0 FF 912MI * * EXP--E8:Augud2,2D19 APPROVED BY L ' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RS .... Miami Shores Village Building Department �OAtI 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to Owner — Workers' Compensation Insurance Exemption 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 SIGHTING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Uwn r State of Florida County of Miami-Dade The foregoing was acknowledg efore me this day of By Vfhd iA is personally known a or has produced tas identification. QUIDA JACOBS Notary MY COMMISSION 11 FF43MS EXPIRES:August 14,2017 SEAL: Y Contract-orsM & C %0Ai0w Godfrey ft"#304 MI=d Beach,FL,33,140 Phone(305)763-8166 License:CFC-1426809 February 2,2016 State of FL County of Miami-Dade Before me this day personally appeared German Previsdomini who,being duly sworn,deposes and says: That he will be the only person working on the project located at 479 NE 102nd St.,Miami Shores,FL 33138. Sworn and subscribed before me this 2nd day of February,2016 by German Previsdomini. Produced a FL Drivers License ^�n+�wNnnnn QUIDA JACOBS MY COMMISSION 8 FF43855 EXPIRES:August 14,2017 Quida Jacobs co� CERTIFICATE OF LIABILITY INSURANCE DATE 05/16/16 PRODUCER Florida Bankers Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 7278 SIN 8 Sheet ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Mme,FL 33144 ALTER WE COVERAGE AFFORDED BY THE POLICI ES BELOW. Phone(305)266.6483 Fax(305)282-OR9 INSURERS AFFORDING COVERAGE NAIC# INSURED MANAGEMENT&CONSULTING INC INSURERA: ESSEX INSURANCE COMPANY D/B/A M&C CONTRACTORS INSURER B. 960 ARTHUR GODFREY RD.STE.304 misuRER c: INSURER o: MIAMI BEACH,FL.33140 INSURER I- COVERAGES INSURER F.- THE :THE POLICIES OF INSURANCE LISTED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Det ADMTYPE INSURANCE POLICY POLICY NUMBER EFFECTIVE MMATM LIMITS GENERAL LIABILITY EACH OCCURRENCE 1,000,000.00 ®COMMERCIAL GENERAL LIABILITY GE TO RENTED 3C06W 04/20/16 04/20/17 PREMISES ocaaerm 1,00,000.00 ❑❑ a.aMs MADE 0 OCCUR MED EXP(Any one person) 5,000.00 A ❑ ❑ PERSONAL S ADV INJURY 1,000,000.00 ❑ GENERAL.AGGREGATE 2,000,000.00 GEN'.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 2,000,000.00 ® POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ia ) ❑ AL OWNEDAUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per person ❑ HIRED AUTOS BODILY INJURY ❑ NON OWNED AUTOS (Per eoddent) ❑ PROPERTY DAMAGE (Per GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN E►ACC ❑ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ y A ❑ gw EMPLOYERS'LIABILITY ANY PROPRIETOR I PARTNER I EXECUTIVE E.L.EACH ACCIDENT OFFICER I MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DEBCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS LIC#CFC1426809 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL MIAMI SHORES VILLAGE BLDG DEPT 30 DAYS WRITTEN NOTICE TO THE cERTLFICATE HOLDER NAMED TO AVEHE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO 00LIGATION OR LIABILITY 10050 NE grid OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. MIAMI SHORES, E 33138 AUTHORIZED REPRESENTATIVE MARTA ALONSO ACORD 25(2001/06)OF 0 ACORD CORPORATION 1988 � � . � ' �- �Li� � � � I IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endomement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or after the coverage afforded by the policies listed therm. ACORD 25(20MM)QF