PL-15-3175 (2) Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-249968 Permit Number: PL-12-15-3175
Scheduled Inspection Date: February 11,2016 Permit Type: Plumbing- Residential
Inspector: Hernandez,Rafael Inspection Type: Final
Owner: KING,ROGER&JUDITH Work Classification: Addition/Alteration
Job Address:137 NE 105 Street
Miami Shores, FL 33138- Phone Number (306)__-.__
Parcel Number 1121360050120
Project: <NONE>
Contractor. EDWARD ROJAS PLUMBING CORP Phone: (305)944-6788
Building Department Comments
RECONNECT WASHING MACHINE&CONNECTIONS Infractio Passed Comments
FOR NEW IN LINE WATER HEATER. INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
February 10,2016 For Inspections please call: (305)762-4949 Page 13 of 38
Miami Shores Village �, ,,. z •
10050 N.E.2nd Avenue NE
w
ti
,
Miami ShoresFL 33138-0000
Phone: (305)795-2204
Expiration: 07105/2016
Project Address Parcel Number Applicant
137 NE 105 Street 1121360050120
Miami Shores, FL 33138- Block: Lot: ROGER S JUDITH KING
Owner Information Address Phone Cell
ROGER&JUDITH KING 137 NE 105 Street (306)---
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,600.00
EDWARD ROJAS PLUMBING CORP (305)944-6788
Total Sq Feet: 0
Type of Work:RECONNECT WASHING MACHINE 8 CONNECT 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 Amt Paid Amt Due
CCF $1.20
DBPR Fee $2 25 IflVOIC@# PL-12-16-58152
DCA Fee $2.25 01/07/2016 Credit Card $110.70 $50.00
Education Surcharge $0.40 12/23/2015 Credit Card $50.00 $0.00
Permit Fee $150.00
Scanning Fee $3.00
Technology Fee $1.60
Total: $160.70
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWN S AF IT: I rtify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
const ctio nd zo ' uthermore,I authorize the above-named contractor to do the work stated.
January 07,2016
A Ignature:Owner / Applicant / Contractor / Agent Date
Building epartment Copy
January 07,2016 1
4 A C2 � 2��
' Miami Shores Village
Building Department
` 10050 N.E.2r:d Avenue,MIAMI Shores Florida 39138
Tek(WS)795-2204 Fac(305)756-8972
AIECT1 LAKE
MW MMOft(Ep$)M4190
FBC 2014 5— -
BUILDING mnwftm*fft
PERMIT APPLICATION Sib r No.R-.
[BUILDING ❑ELECTRIC 0 ROOFING 0 REVISION ❑EXTENSION (RENEWAL
PWMBING MECHANICAL [:]PUBL C WORKS 0 CHANGE OF ❑CANCELLATION 0 SHOP
As CONTRACTOR DRAWINGS
137 V.lF . /j)c
3 i
Folft D Is die Aulft NbUdony :Yes NO.
OccupwxY Type:__Load: .Construction Type:____y___._.�,Hood Zone, SFE: FIFE:
OWNER:Name(Fee Simple Tl ,n k J, ..-u 1j re
mdress: 1-31 52 "' I O 111 S
CIw stere• '�''�-'- rp: 3
TewnVLessee Name: Phone#:
Email:
NTRACTOR:Comps ►� S .(
Address:
at,—3
Qualiiier Name:
q Ph�es:
State CerdffcWo or Regation#. L r.dJ - .J? Comficate Of Competency#:
DE MER:ArchitecUTroneer
Address: �
e t W+wl:for ap Sryte *4ftm ftotw of We&.
Type of Wodc ❑ Addition [� Alteration ❑New ❑RepaiyReplace ❑Demolldm
of Waris__R+ " r.�.
SPOCO codarofadorthru Me.
SubwM0I Fee$ Fexndt Fee$ P
..cx CCF$ co/cc g
Fee$ 22 Ft-do::Fee$-- DWRR NowyS
Tit Fees_ S Tralidnaffola aenFee$(`)_ Dwft Fee$_ (�
morel Reviews$$....� _._._ Bond$ __
cdo2nenmal TOTAL FEENOW oL1E$_x k().
. t
Bonding Company's Name(if applicable)
Bonding Company's Address
c1ty mate ZIP
M*rWp Lender's Name(Napplitable)
Mortgage Lender's Address
city State Zip
Application Is hereby made to obtain a permit to do the work and Installations as Indicate& i car ft that no work or installation has
commwmed Prior to the issuance of a permit and that all work will be performed to most the standards of all laws regulating
construction in this jurisdiction. I understand drat 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."
Nottoe to Appkant: As a condidan to the is:huanoe of a b&dkft permk with an esdrnated value ehamedNg$2M,the applkant must
promise in good faith that a can of the notice of commencement and o7tutrucdan ben taw brochure will be delhwed to the person
whGsve properly Is subject to alt rt Afro,a ceabW copy of the recorded notloe of mast be pasted atthe job site
for the Aust inspeWw which occas seven 17)days after the buSAV permR is&sued, M of such posted notice, the
Inspection wiN he approved and a reinspection fee whYbe charged.
++ +re Signature
� R
The forevis acknowledged before me Is The foregoing ku&ument was admowledged before me this
day of by �day of AJ 00 by
I nown o is personally kn to
me or who has produced as me or who has produced as
ldendff don and who did take an oath. bion and who did take an oath.
NOTARY PUBLIC WART PNBM
Sign. Sign.
Print: s = Print
Seal: .;�;. �� Seal:
S
ss�sa+wraMssaM��s•a�s ++as�s�Mse+r�+aws�rsa�s�*sssss���stra �� �sa�sar�s�as�y
APPROVED BY Z' Plans Examiner
Zoning
Structural Review Clerk
(�a/zotai
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3,.
To:
Miami Shores Building Department
10050 NE 2"d Avenue
Miami shores FL 33138
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that Roger King and Judith King,
jointly and severally (hereinafter referred to as "Principal") has made, constituted and
appointed, and by these presents does make, constitute and appoint Leonard Feldman
of Star Construction Company, Inc. (hereinafter referred to as "Agent"), true and lawful
attorney for Principal and in the name, place and stead of Principal.
This Power is given to enable the Agent to legally represent the Principals and to
take all actions necessary and to execute any and all documents, applications and
permits in connection with the issuance of Electrical, Mechanical and Plumbing Permits
under Master Permit No. RC-9-15-2395 regarding the property at 137 NE 105 ' Street,
Miami Shores FL 33138
The Principal exonerates the Agent from liability for all non-negligent acts of the
Agent. All acts done by Agent pursuant to the powers conferred herein, shall have the
same effect and inure to the benefit of and bind the Principal.
GIVING AND GRANTING unto said Agent full power and authority to do and
perform all and every act whatsoever requisite and necessary to be done, as fully to all
intents and purposes as the Principal might do, hereby ratifying and confirming all that
said Agent shall lawfully do or cause to be done by virtue of these presents until this
power is revoked or terminated by the Principal.
IN WITNESS WHEREOF, the hand and seal of the legal representative of the Principal
has hereunto been affixed this day of December 2015.
IRMNNG
STATE OF FLORIDA
COUNTY OF MIAMI DADE
The forgoing Power or Attorney swo to and su before me this
day of December byAo49' wh d did not n oath.
Notary Pub c
STATE OF LORIDA �,tiq
My Comm' ion Expires:
r&
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE OF-'FLORIDA _
DEPARTMENT OF BUSMESS-ANQ F311OFES$!C>!NAL REGULATION
CONSTRUCT) ..IN USTR t :IOENSING BOARD
TO-49434"
lfie: 'L:UA aJNG �RAZTIOR
j N a 4bobw t E RT aEfl F
d lirSdd proansforts s Cfiiapi 489 FS.
E.VifaWn.'.dets, Al 1,:2016 "
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of ,,,. �. re F ��''•r -.�, ,A7�fr*s � ��'', "e 4. "a' R
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ISSUED: 0810512014 DISPLAY AS REQUIRED BY LAW SEQ# L1408050001639
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y
loyal u-s nem Tax Recelp,t
Miami-Dade County, S#�#e of:Florcd�l
14 S,&NOT A 1 ILL-DO NOT PAY
LB
5176658 ::..
susmtEss NAME/LOCAT1oN" IiECEIP7 No EXPIRES
EDWARDRoms PLumisiNG
COMP RENEWI I FTEM$ER; Q, 2Q9fi
2371250'
880 NE 111-ST'*"'; Must be d[spisYed at place of ttu&ir►ess .:.'
BISCAYNE PARK,FL 331$1 Pursuant to County Code
Chapter 8A-Art.9&10
OWNER SEC.TYPE OF]RUSINE"
EDWARD ROJAS PLUMBING CORP 198 PAYMENT RECEIVED
PLUMBING BY TAX COLLECTOR.-
CONTRACTOR 45.00 08/31/2015
rller{sj 1 CFC049431 0235-15-005999
This Local Owbess Tax RooWp o*code=Peymeaf01the Local Business Tax.The Receipt is nos license,
permit era ca"caft atm Kohler s 411101111callonoto dobasisess.Holme am cow*whis gerygowmaoslal
reguletary laws taml `whisk eppitr is the bow.. ;,
7M RECEIPT 1Y0.abowa m1Et IR�Iht►eA a all ficial vehM a- cobs"60-M
® Foreorme ,visit :
CERTIFICATE OF LIABILITY INSURANCE
k,,� I 12!04118
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
MPORTANT: tf tm cwbVCate hakW(s an ADD CONAL iNSURED,the policy)mit be endorssd. if SUBROGATM IS WAiYED,subjectto
the team and conditions of the policy,cortsin pollctee may require an ertdorseaenL A 9bleamt on this owe does not cwdbr right to the
certttcate holder in Hsu of such ohdareenteh .
PRODUCER Luca Estrella
Accurate (308)226-6727 , (306)226.4M
8300 West Flagler Suite 114
Miami,FL 33144 INSURINWAFFORDINGICOVSRAGE N=#
Phone 05 Fax (308)2268767 A: Arch S y h=90=CWMarW
INSURED S.
Edward Rojas Plumbing Corp c:
860 NE 111 St D•
Biscayne Park,FL 33161- IRE'
I RF
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:_
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQU11REtvENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESECT 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.LiFTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
i E] TYPEOFiNSURANCE POLICYNMMM Lam
GENERAL LIABILITY EACH O NCE S 1,000,000.00
DAMAGE TO RENTED
® COMMERCIAL GENERAL LIABtLrrY $ 100,000.070
❑ CLAW411ADE ® «� AGLOO28426-00 EXP 0W 5,000-W$ 8, -W
A ElY 08=1201616 PEIVIONNAL&ADVINJURr S 100,000.00
❑ GENERAL AGGREGATE S 1,000 000.00
GEWLAGME9ATELIWiTAPPLIES PER; PRODUCTS-COMPIOPAGG S 1,000,000.00
Rpm= ❑ ❑ Loc
AhrroMaeI.E LaM mr LW.=?NGLE LIMIT
❑ ANY AUTO BOD9.Y INAW ft p=on) $
❑ �OWNED ❑ S ED SOm.Y KAIRY(Per awkient 8
F1 H�AUTOS ❑ AUTOS UWASE
S
❑ UNRREIJ A L1AS ❑OCCUR EACH OSE S
❑ EXCESS LIAS CLAIMS ANTE $
DED El RerewtoNs S
WORKERS tX URI NSATIO N Y&S1 A H
AND91111PLOYERS LIABILITY Yin
OFF�I EXCL NIA E.L.EACH ACCIDENT $
(11300daIMinNH) EL.DISEASE-EA EMPLOYEI $
DESCRFWN aF OPERATIONS tdow EL DISEASE-POi ICY UMiC $
DESCRIPTION OF OPERATXM 1 LOCATIONS t VEECLEB(Atte=b ACORD 101,Addidomi Rauft S=h=dute,E moreepe=e is requhed)
Plumbing Contractor.
State Certified:License#CFC-049431
Dept.of Professional Regulation
State of Florida
CERTIFICATE HOLDER CANCELLATION
SHDULD ANY OF THE ABOVECiES BE CANCELLED BEFORE
Amami Shores Village THE EXPIRATION DATEELIVERED IN
Building Department ACCORDANCE WITH THE
10050 NE 2nd Ave AUTHORS tRM"tM NTA7NE
Miami Shores,FL 33138
Luna Estrella
®1988.2010!CO RATION. All rights reserved.
ACORD 25(2010106)OF The ACORD name and logo are registered marks of ACORD
Report Viewer Page 1 of 1
_...l; .... _...�/1 ......... 11ao% z
JEFFATINATER `�,"�•+�•
CHW 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 Usted below has elected to be exempt from Florida Workers'Compensation taw.
EFFECTIVE DATE: 7/12/2015 EXPIRATION DATE: 7/11/2017
PERSON: ROJAS EDWARDO
FEIN: 453073611
BUSINESS NAME AND ADDRESS:
EDWARD ROJAS PLUMBING CORP
680 NE 111 ST
BISCAYNE PARK FL 33161
SCOPES OF BUSINESS OR TRADE:
PLU BERING NOC AND
DRIPanuaM�Wmptef4ea d3(14).F.B.,as efRmtotaemyOoaamfaAo dela aten> 1aeaf2b sAaptm yyr8fgaeelaaeate erakdos aadmaiy ma n
w�lathearnpa�Ueatnbrosa C tietea onon Metro eefdP edf atebeOM LPq Fp. Of b °xt aP
ab a tAe 1e ° semeewbjearorevomuonnl4ffiaarua�mror erare�«r6;I,reacemue n,
teaparmada Ma ragnbemenb 0,=Sac=FW IMAM ofaeafffeato.Tae depmtaed.deataalea
L
OF&R2 DWG2S2 CERTIFICATE OF ELECTION TO BE EXEMPT ReV18ED OB•13 QUESTIONS?(B60413.7808
file:///C:/Users/RUTHL/A`ppData/LocaYremp/5PNQSAi C.htm 6/30/2015%
EDWARD ROJAS PLUMBING
880 N.E. 111TH. STREET
BISCAYNE PARK,FL. 33161
TEL: 7860443-9846
12/15/2015
State of Florida
Dade County, Florida
Before me this day personally appeared Edward Rojas,who being sworn,deposes and
says:
That he will be the only person working on the project located at:
137 N. E. 105T. ST.
Miami Shores,F1.33138
Sworn to(or affirmed)and subscribed before me this 15�`Day of December,2015 by:
ersonally kno
OR Produced Identification
Type of Identification Produced
y�4
Print tary
Bull Miami Shores Village
ye Building Department
LD 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305)756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
x
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 SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade t /
The foregoing was acknowledge before me this_LJ day of G• ,20 J .
By_ T20oPw%A44_.,e,, is personally known'to a or has produced
as identification.
�9
Notary:
SEAL: ' 4.
1l 83
�s