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PL-16-1711 (2) f 4 Miami Shores Village 10050 N.E.2nd Avenue NW WOW, Miami Shores,FL 33138-0000 AdOlti p AFF Phone: (305)795-2204 F. ,le "11 Expiration: 01/1812017 Project Address Parcel Number Applicant 165 NW 92 Street 1131010331000 Miami Shores, FL 33150- Block: Lot: WE BUY MIAMI LLC Owner Information Address Phone Cell WE BUY MIAMI LLC 18800 NE 29 Avenue (432)349-4620 AVENTURA FL 33180- Contractor(s) Phone Cell Phone Valuation: $ 500.00 BERGERON PLUMBING INC (561)445-2115 _.._ _..rx._. __._._ ._. ....._.. _ Total Sq Feet: 200 Type of Work:TO BRING EXISTING PLUMBING UP TO CO Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning:1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# PL-6-16-60267 $2.25 06/20/2016 Credit Card $50.00 $109.10 DCA Fee $2.25 Education Surcharge $0.20 07/22/2016 Credit Card $ 109.10 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $159.10 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 co ction and ni ore,I authorize the above-named contractor to do the work stated. July 22,2016 horize SI ature: ner / Applicant / Contractor / Agent Date Building Depa ent Copy July 22,2016 1 t 3 7RECRIVFID Miami shores Village JUN 2 0 2016 Bim: 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 1,10 FBC 20M BUILDING Master Permit No. Re° 4 /6' 104S a PERMIT APPLICATION Sub Permit No. �� I ❑BUILDING ❑ELECTRIC ❑ ROOFING M REVISION ❑ EXTENSION ❑RENEWAL LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑SHOP CONTRACTOR DRAWINGS JOB ADDRESS: • City Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):- W6 ® 1J % N eN o L C O- Phone#: Address: 1860 A/C 21 A Vr AVAJI City: AVow1 'A State: �� a Zip:__33180 Tenant/Lessee Name: Phone#:�9�Z" Email: [ ]� CONTRACTOR:Company Name: P- r Phone#: Addres : T" �dl City: — State: (��✓ Zip: /a3( I _� Qualifier Name: t 105 P_rer/ Phone#: C. State Certification or Registration#: 1 1 tQ Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work forthisPermit:$ Square/Linear Footage of Work: Type of:Work: .:1::_l .addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition DescriptionofWork:' 'ZR to I(y CNK-k's ld.LC3 0-<liN-' -M e"_S IIW- N ' Specify'cOorroof color thru tile: Subrnitfal Fee.$T�' Permit Fee$ ✓ CCF$ U CO/CC$ Scanning Fee$ Radon Fee$ -> • `L' DBPR$ ? - .� Notary$ �j� Technology Fee$ �- ® Training/Education Fee$ ® • Double Fee$ 7' Structural Reviews$�_ Bond$ TOTAL FEE NOW DUE$ 1/ O9. 1 (Revised02/24/2014) � 4 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 therecorded notice of commencement must be pasted 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. Signatur Signature �Ror AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of �i9 n4p- 20�by f! `T day of , -tie 20 by 11�1✓i�) �•� ll►i)ocir who is personally known to Q-A i who is personally known to me or who has produced _ 2. 2J Z02 as me or who has pro uced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: fit_ Sign i� 4 Pri o�,,,, 9,,, v Print: �. r s[� ��lC,t�� �� .►.� •� Se 'r: '.�'' bii Notary rc.State of Florida tri .• Seal: •; dr My Comm.Expires May 13,2018 •��� Commission N FF 105510 APPROVED By �` Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 BERGERON, DAVID MICHAEL BERGERON PLUMBING INC 5562 ASPEN RIDGE CIRCLE DELRAY BEACH FL 33484 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to CFC1427568 ISSUED: 06/01/2014 serve you better. For information about our services,please log onto wwwr.myfloridalleense.com. There you can find more information CERTIFIED PLUMBING CONTRACTOR about our divisions and the regulations that impact you,subscribe BERGERON,DAVID MICHAEL to department newsletters and!earn more about the Department's BERGERON PLUMBING INC initiatives. Our mission at the Department is:License Efficiently,Regulate Fairly. We constant) strive to serve you better so that you can serve your Customers. lank you for doing business In Florida, IS CERTIFIED Under the provisions of Ch.488 FS. and congratulations on your new license! Expimftndate:AUG31.2016 u406MO=472 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC14275M The PLUMBING CONTRACTOR Named below IS CERTIFIED W Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 BERGERON, DAVID MICHAEL a BERGERON PLUMBING INC r 5562 ASPEN RIDGE CIRCLE DELRAY BEACH FL 33484 ISSUED: 05101/2014 DISPLAY AS REQUIRED BY LAW SEQ# L140601DD02472 Adffllbhk 'ANNE M. G AN N O N P.O.Box 3353,West Patin Beach,FL 33402'3353 —LOCAT®ATN cottsTtntnoM Tax COLLWNa wym4betmwomTeL(561)355-22B4 5562 ASPEN RIDGE CIRCLE serving Patna Brack cow" DELRAY BEACH,FL 33484 Serving you. VMOf01 a s ma►T"M as rPPM saa s za MPu mm onvm�vv& c see wss3o¢rs-om+rns tRzeo This document Is va d arty when nod by the Tax Cotes O ftL STATE OF FLORIDA PALM BEACH COUNTY ` -83-800 201=016 LOCAL BUSINESS TAX RECEIPT BERGERON PLUMBING INC LBTR Number. 200819386 BERGERON PLUMBING INC EXPIRES: SEPTEMBER 30,2016 5582 ASPEN RIDGE 33 .fids s "l of e�9bi8 in or DELRAY BEACH.IR.33484.2582 probsolon AAor ocopoon t its aril LI T be a s d yed at to PIDW of buftwa end in such a ma mw as to be oto to the view of the P A to,. r JEFF ATWATER STATE OF FLORIDA CLEF FINANCIAL OFFICER 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: 312912016 EXPIRATION DATE: 3/29/2018 PERSON: BERGERON DAVID M FEIN: 261941399 BUSINESS NAME AND ADDRESS: BERGERON PLUMBING INC 5562 ASPEN RIDGE CIR DELRAY BEACH FL 33484 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pursuant to Chapter 440.05(14),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 benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be 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 shalt be subject to revocation H,at any time after the filing of the notice or the Issuance of the certificate, the person named on ttre notice or certmcate no longer meets the requirements of this section for issuance of a certificate.The department Shap revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 -- BERGPLU-01 LDEZIC CERTIFICATE F LIABILITY INSURANCE DA TlYYYY) 6//14/201412016 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 policy(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 endorsement(s). PRODUCER CONTACT NAME: Plastridge Insurance Agency PHONE (561 276.5221 FAX 561 276-5244 820 NE 6th Avenue oE.11:1 ) AIc No Delray Beach,FL 33483 ,,,DESS:dairaydocs@plastridge.com INSURER(S)AFFORDING COVERAGE MAIC It INSURER A.Old Dominion Insurance 40231 INSURED INSURER B:Progressive Express Ins.Co. 10193 Bergeron Plumbing Inc. INSURER C: 5562 Aspen Ridge Circle INSURER D: Delray Beach,FL 33484 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. WSR ADOL SUBR POLICY EFF POLIO EXP LTR TYPE OF INSURANCE JNSD WVD POLICY NUMBER MIOD MMMO LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE ®OCCUR MPG94396 01122/2016 01122J2017 DAMAGE TO RENTE15-- PREMISES Ea occurrence $ 500.000 MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑PRO- Q JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER. $ AUTOMOBILE LIABILITY EOMBBIIN65 NGLE LIMIT $ 300,000 BI AUTO 021116181.3 0410112016 04/01/2017 BODILY INJURY(Per person) $ ALL OWNED �( SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTYDAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILI Y YIN STATUE ER ANY PROPRIETORIPARTNER.EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1I describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORO 101,Additional Remarks Schedule.may be attached if more space Is required) Plumbing(Residential) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 201 Westward Drive,2nd Floor Miami Springs,FL 33166 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1. 1.93 Lel s Miami shores Village mills g p Buildin Department .�„ '� 10050 N.E.2nd Avenue �ORtDp' 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: I. 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: �� State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of— U V—P, ,20—" By. bli Vj b S e u f who is personally known to me or has produced 2> 9 6, as identification. i Notary: " atA9e,"., NANC:.SCatFD Notary Pub SEAL: My Comm.E8 Commiss 5562 Aspen Circle Ridge Delray Beach,Fl.33484 561-445-2115 Date: 7/5/2016 State of Florida County of Miami-Dade County !I � Before me this day personally appeared who,being duly sworn,disposes and says: That he or she will be the only person located on this project located in: G a st�-O(LQ-S Sworn to or affirmed)and subscribed before me this day of 2016,by (�► Personally know: OR introduced Identification: ���1111111111l11/�// g.0 D EV,y�/�i� Type of Identification Produced: maty FF>lUM Op 4"IP Ilf 1111 Print,Type or Stamp of Notary