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PL-16-2630 ; •� Miami Shores Village pelpltf Type pluf'1b) Rei*o tlal 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 Stats A�FRO wsp �° Phone: (305)795-2204 �ceRr � p� Ex iration: /0 17 _ Project Address Parcel Number Applicant 933 NE 99 Street 1132060340250 Miami Shores, FL Block: Lot: DARYL GALLO=. Owner Information Address Phone Cell DARYL GALLO 933 NE 99 ST (305)756-6217 (305)491-2876 MIAMI SHORES FL 33138-2568 Contractor(s) Phone Cell Phone Valuation: $ 2,695.00 BRADFORD PLUMBING LLC (305)871-3094 .. Total Sq Feet: 0 Type of Work:PLUMBING FOR KITCHEN REMODELING 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 $1.80 DBPR Fee Invoice# PL-9-16-61448 $2.25 10/05/2016 Credit Card $ 167.30 $0.00 DCA Fee $2.25 Education Surcharge $0.60 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $2.40 Total: $167.30 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 AFFID VIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction aqd filing. F th�more,I authorize the above-named contractor to do the work stated. �` October 05,2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy October 05,2016 1 t Miami Shores Village "EP [Jy 212 0 1 6 Building Department BY r J` 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 N BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL *UIVIBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [--] CANCELLATION ❑ SHOP /� CONTRACTOR DRAWINGS JOB ADDRESS: 3 / /= S 7' A , 5,A-0 City: Miami Shores County: Miami Dade Zia: 173/ Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: e.5 Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Phone#: Address: 9 -33 lyi-; City: /2N• 5, State:_ �� Zip: 7 -7 , Tenant/Lessee Name: Phone#: Email: oo rk�'��a Ex\� , �e(IS e�►J�h ��` L � F CONTRACTOR:Company Name: �12,0V�� �fv rb��-j ��f- Phone#: 3 10 Address: 'fro `� l City: �p 0 �. / State: Zip: 3 91 Qualifier Name:� �� '� ��� �1�"� Phone#: OF-f-' ® � !r/� State Certification or Registration#: 7 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$_ � Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 124C-1h0v 1-f, Specify color of color thru tile: �h Submittal Fee$ 0 Permit Fee$. d CCF$ J CO/CC$ 10 '' Scanning Fee$ �' Radon Fee$ 2 ' 2S DBPR$ 2-S;2-S; ll Notary$ l) Technology Fee$ a- 1-f 0 Training/Education Fee$ 60 Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 1 G-3 ° 0 (Revised02/24/2014) c 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 ishereby mlde 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 the recorded notice of commencement must be posted at the job site for the first inspection which occurs s ) days after the building permit is issued. In the absence of such posted notice, the inspection will not be app oved and a ein tion fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this _�day of 5QF19 M&-V t� 20 1 � by � day of "QEM M_p� ,20 (� by N�A21CGAS %ho is personally known to ("� y �VFi is rsonally known to me or who has produced B- .h&lkL Ulu SE as me or who has produced "& �'(p��/7G, 5-87.71'/ identification and who did take an oath. identification and`who did t •' =C-V,,d State of Florida NOTARY LIC: NOTARY PUB I rez ion FF 156750 / 018 Sign: Sign: Print: S`�I�tE� - 1��"C� Print: I A�—Ml �C� Seal: a s� e Notary Public State of Florida Sindia Alvarez +a o� My Commission FF 156750 'xt Expires 0910312018 APPROVED BY �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) QTY. MATERIAL PRICE AMOUNT BRADFORD PLUMBING, LLC. INVOICE No. -� y � "We're Certified Plumbers" P.O. Box 660835 JOB PHONE DATE ORDER M _ �hL �,,, S ,� Miami Sprigns, FL 33266-0835 JOB NAME LOCATION Phone: (305) 871-3094/ Fax: (305) 876-9254 St. # CFC 041673 yam,, DISC VER „MEQ /� P ,../J ��, __ Member: PCA I X55 (9 c7� Plumbing Contractor Association www.Bradfordplumbing.com r �( /� J TO D/` C.�f' PHONE f 1 �� >r f r- 0, .'�SfA� 11 ORDER TAKEN BY ItHMS f r r—v/ 7/LeP//- e-t- ,-, , ter, rt G 1. c r7 �t ' - �? G,�.�" L✓z (��!fir✓ ..�- (7 LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR / 7 3 L Permit Fee Service Call $50.00 Rental Sewer Machine $20.00 WORK ORDER BY DATE COMPLETED TAX SIGNATURE(I Haraby acknowledges the sagsfa¢ory CC16,tign of the above d—ibad wotic) THANK YOU! �J S (MAYBE CONTINUED ON OTHER SIDE) �`//� � PAY THIS AMOUNT -`�) "E STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION i4 CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 WX1 1940 NORTH MONROE STREET ° TALLAHASSEE FL 32399-0783 BRADFORD, DAVID RUSSELL BRADFORD PLUMBING LLC 3980 NW 64TH AVENUE VIRGINIA GARDENS FL 33166 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 rangeyQDEPARTMENT STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque OF BUSINESS AND restaurants, and they keep Florida's economy strong. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order CFC041673 ISSUED: 06/14/2016 to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more CERTIFIED PLUMBING CONTRACTOR information about our divisions and the regulations that impact BRADFORD, DAVID RUSSELL you, subscribe to department newsletters and learn more about BRADFORD PLUMBING LLC the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! Expiration date : AUG 31,2018 L1606140001056 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION tf CONSTRUCTION INDUSTRY LICENSING BOARD .. CFC041673 � The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018jar � . � R• .M BRADFORD, DAVID RUSSELL �,_ �� `. , -� r BRADFORD PLUMBING LLC ` .,. `ti �• ` 3980 NW 64TH AVENUE ,:." '""+ +ems : _. a. 110% 1!`� -r, VIRGINIA GARDENS FL 33166 ISSUED: 06/14/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1606140001056 Local Business Tax Receipt Miami—Dade County, State offlorida THIS IS NOT ABILL—DO NOT PAY ' 4368288 BT BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES BRADFORD PLUMBING RENEWAL SEPTEMBER 30, 2017 3980 NW 64 AVE**" 4559358 Must be displayed at place of business VIRGINIA GARDENS FL 33166 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED BRADFORD DAVID 205 LPG INSTALLER BY TAX COLLECTOR LPGO14078 $60.00 07/16/2016 CREDITCARD-16=041339 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holder's qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276. For more information,visit www.miamidade.govRaxcollector Sep 2216,02:05p ALL SECURITY INSURANCE 305-885-5956 p.2 CERTIFICATE OF LIABILITY INSURANCE DATE(UM/DWYYYM 09122!15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder lean ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement Astalement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NME: BARBARAAYASH All Securily Insurance -MOVE (305)887-9544 FAC (3057885-5956 No: 373 N.Royal Poinciana Blvd. allsecins@aol.com Miami,FL 33166 INSURE AFFORDING COVERAGE NAIC0 Phone (305)887-9544 Fax (305)885-5956 INSURERA: COVINGTON SPECIALTY INSURANCE CO INSURED INSURER B: PROGRESSIVE INSURANCE Bradford Plumbing LLC INSURER C: 3980 NlN 64th Ave INSURER D: Miami Springs,FL 33166 (305)885-64r 14 INSURER E: COVERAGE$ INSURER F: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT'.FICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, NNgg EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILrR TYPE OF INSURANCE ADD UB POLICY NUMBER POLICY EFF POLICY EXP GEVERALLIABILITr MM/DD MMVDDiYYYY LIMITS EACH OCCURRENCE $ 2,000,OOO.DO COMMERCIAL GENERAL LIABLnY pAMAU S RENTED Hca $ 100,000.00 A ❑ ❑ CLAMS MADE ❑V OCCUR VBA373262-00 MED EXP(Anyone rson $ 5,000.00 ❑ 04102/2016 04/02f2017 PERSONAL&ADV INJURY $ 2,000,000.00 I GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LWT APPLIES PER: El POLICY [:] PRO- PRODUCTS-COMP/OPAGGI S 2,000,000.00 ❑ LOC j AUTOA101gLE LIABILITY i $ COMBINED SINGLE IJMT ❑ ANYAUTO Eaacciden g 100,DOO.OD ALL OWNED ❑ AE BODILY INJURY(Per person) $ B © AUTOS C 02331543-2 ULED BODILY INJURY WON-04VNED 07/26!2016 `07126/2017 NryJ (Per accident $ ❑ HIRED AUTOS ❑ ALROS PR ant ANAGE $ ❑ ❑ ❑ UM13RELLALIAB ❑OCCUR ' $ ❑ EXCESS LIAR ❑CLAp13 MADE EACH OCCURRENCE $ rV2VORWKERS RETENTION$ AGGREGATE $ COMPENSATIONOYERS'UA131UTYYIN W C STATU- DTH. RIETORIPARTNERIE:(ECVTWE EBEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENTy in NH)ribe under E.L.DisEASE-EAEMPLOYEI $ ION OF OPERATIONS bele-, E.L.DISEASE-POLICY LIMIT I S i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addltlorml Remarks SchedWo,H more apace Is required) ADDITIONAL INSURED: TEXEIRA CONTRACTING,INC. 901 DOUGLASS AVE STE#200 ALTAMONTE SPRINGS,FLA.32714 CERTIFICATE HOLDER CANCELLATION Miami Shares Vfflage Bldg De SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Pt THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 11105D NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. r Miami Shores,Fla.33138 AUTIiOR2ED REPRESENTATIVE ACORD 26(2010/05)QF ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo aye registered marks of ACORD BRADFORD PLUMBING LLC Date: G9 12-21M(0 I State of �:L,Ot?(T�)A County ofM I A 04 (' D- --Before me this day personally appeared�U[_9 MOSS` LL ')31RVho being duly sworn, deposes and says: That he or she will be the only person working on the project located at: '133 NE C9 ST PJ tam l Sworn to (or affirmed) and subscribed before me this day of 20 by Personally know =Pubfic State of Floridaez OR Produced Identification on FF 1567501201 S _ Type of Identification Produced �'L MX(L L"o-ENSE, P ' ype Stamp Name of Notary ♦SOUSES G� o Z s� Miami shores Village evil Building Department 10050 N.E.2nd Avenue �IORIDp' 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 cover9n from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU AC WLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. / Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this 23 day of d ,20J!� . ByMy&� who is personally known to me or has produced as identification. Notary: SEAL: 00 Plp% Notery Public Stet®cit Fl®r'ia Sindia Alvarez a Mv Commission FF 156750 pf0.d Expires 09103120116 CHIEF FINANCIAL OF 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: 3/30/2016 EXPIRATION DATE: 3/30/2018 PERSON: BRADFORD DAVID R FEIN: 81167175D BUSINESS NAME AND ADDRESS: BRADFORD PLUMBING LLC 3980 NW 64 AVE VIRGINIA GARDENS FL 33166 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Puraumd to Chapter 490.05(14).F.S.,an oflker of a wporatba wiro sleets ezetrtptlsn fmm ihk vmpter pq tBtrg a ceM6mfe or elecRat uMer @gym aeetbn map m2 retaver oenefda or oompertsaBon toonieer itda enal9er.Pweusnt to Chapter 440.05(72).F.3..Cefiliwtes of eteNon to be m�empL._epp1Y ony vu9ldn the scope of Ota Dus"utesa m trade Bated on the m0ce of etegion to bee�empt PursueN to Cfiepfer440.05(13),F.3..Noikes of eteObn to be exempt atttl ceroBcatea of elecOmt m M exemf6 sha0 m aua)eUto revoratton i�et arty 0me afterthe 03tg ot0ee aolke or Oce 6amnce of Ore cerBtirate, Ore person nertted on 0te mVke or no brtgermeeffi Ore requkemenis of Ods se�ttat for issuance of a certBicate.The depatintetd rites revoke a DFS-F2-OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850),113.1509 https://apps8.fldfs.com/crreportviewer/reportV iewer.aspx?data=kdvpginc9D7Q3 gH6TER6... 10/5/2016