PL-14-2695 Inspection Worksheet j
Miami Shores Village i2c (S _A oZ I/
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)7564972
Inspection Number: INSP-224979 PermitNumber. PL-12-14-2695
Scheduled Inspection Date:April 19,2016 Permit Type: Plumbing - Residential
Inspector: Hernandez,Rafael Inspection Type: Final
Owner. ROY,WILLIAM Work Classification: Addition/Alteration
Job Address:1280 NE 101 Street
Miami Shores,FL Phone Number
Parcel Number 1132050210010
Project: <NONE>
Contractor: PULLES PLUMBING COMPANY Phone: (786)251-1234
Building Department Comments
REMOVE EXISTING BATHTUB 2ND FLOOR BATHROOM 1O ° PassedComments
INSTALL NEW BATH TUB BY OWNER CUT THROUGH INSPECTOR COMMENTS False
CEILING KITCHEN AREA CASTIRON PIPE FROM TUB
INSTALL PVC PIPE
Inspector Comments
Passed 1Z
Failed
Correction
Needed A
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
e� o�*
f, Miami Shores Village -
Building Department 112014
V I 10050 N.E.2nd Avenue, Miami Shores,Florida 33138
12Tel:(305)795-2204 Fax:(305)756-8972
INSPECTIONL
LINE PHONE NUMBER:(305)762-4949
FBC 20`0
BUILDING Master Permit No.P L. JLt --20,�;7
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION r-]RENEWAL
PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ Q / CONTRACTOR DRAWINGS
JOB ADDRESS: l �d / 1-071-
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): " />—, Phone#cV' 7�3�
Address:/' I Z go t � ) .0i �� �P-47 /
City: A 'E'
_ P� State: P Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: �✓��� ��� `� Phone#:,�
Address:
City: p State: m F Zip:.A,
Qualifier Name: �j ��� Phone#: 296
State Certification or Registration#: C�� <X5�6 OC 1-3 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 ar Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: v&"vw, znp/S i3 70. 10 2 �-� �.e�
it/�"�e � � v h �u�/�� �e.,J,� eel
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ _ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ l
TOTAL FEE NOW DUE$
(Revised02/24/2014)
s
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 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 Signature
OWN CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
/Z/QI day ofD&n--,ryl C .20 by ��day of ,� /O� ,20 by
who is personally known to ��f/� �), ,who is II nown to
/� l •P!1
me or who has produced� L/LJ�S��J me or who has prod �� as
0
identification and who did take an oath. identification and who did take an oath. �O�'lp''
.y
NOTARY PUBLIC: NOTARY PUBLIC:
a .Y
Sign:
P ' Florida Print*
Joanna M Feliciano Seal. Zo4pP1 mtyy4 N�ra,•.r=t r „a c'nrida W
Seal: a My Commission FF 082753
of ®`TQ Expires 01112/2018 u7 nnv •,,•,-. c,;j2753
�
4�4I°Ef`+tl ;°F Rev:
e'tA1a"Ea�
APPROVED BY a/�G Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami shores Y
qq�
Building Department
lOR1DA 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.In these circumstances,Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,youmaybe
personally liable for the worker compensation injuries of M person allowed to work under this permit. Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Contractor
Print Name: v`'�� L �� Print Name: z—
fl m
Signature: �� �; Signature:
State of Florida) 9 State of Florida) N
County of Miami-Dade) N iv b County of Miami-Dade) to
Sworn t and subscribed before me this 10 Q,0 Sworn to and subscribed before me this T
N
day o e 20 L• o CDco day ofd-�mp
t7: ,2019, N 0
In 0
°'
' of T al t0 W O.
By N ° By S S • °'
C1
W O,
(SEAL) m (SEAL)
T entification produced T dentification produced
i
1
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
`$ PROFESSIONAL REGULATION
CFC056693 ISSUED: 07/06/2014
CERTIFIED PWAWNC CONTRACTOR
PULLES, CARL, S HU8ERT0
PULLES PLUiVl 13 G COMPAW
IS CERTIFIED under the provisions of Ch.489 FS.
Expiration date:AUG 31,2016 L140706OW0419
Local Business Tax Receipt
Miami-Dade County, State of Florida
TH;8 I:�N•:3T i1 FILL Dv N01 PAY
3252384 LBT
BUSINESS NAME/LOCATION RECEIPT NO
PULLES PLUMBING COMPANY RENEWAL SEPTEMBER EXPIRES
S 2015
8641 SW 133 PL 3388139
MIAMI,FL 33183 Must be drsplaved at Male otbusines.,
Pursuant to County C o4 e
Chapt?r SA—Mtt 9&10
OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED
PULLES MARIA 196 PLUMBING BY TAX COLLECTOR
CONTRACTOR 75.00 09112`2014
Worker(s) 2 CFC056693 0242-14.002767
This local Besiuess Tax Recut only confirm payment of the Local Business Tax.The Receipt 6 nota license,
permit,or a eetfificadon of the holder's quali6eations,to do business.Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
Giiillllk The RECEIPT N0,above must be displayed on all commercial vobicles-Miami-Dade Code Sec as-276.
MIAMIAMI For more information,visit www miamidade.gov/lexcollector
f
From: 7865395989 Mon Apr 18 19:42:49 2016 I (�QZ / I�1 of 1
AcoR1�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
`..� 04/18/2016
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 endomement(s).
PRODUCER UUNTAUT NAME: Xamet Barreras
FAX Temax Insurance PaCCNNo Ext: (786)539'5989 No): (305)356 1235
7990 SW 117 ave#113 E-MAIL @
ADDRESS: xamet@temaxinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC 8
Miami FL 33183 INSURER A: UNITED STATES LIABILITY INSURANCE COMPAl' 25895
INSURED INSURER B: PROGRESSIVE EXPRESS INSURANCE COMPAN 10193
Pulles Plumbing INSURER C:
8541 SW 133 PI INSURER D:
INSURER E:
Miami FL 33183 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.
INSR AWL�u ON TR TYPE OF INSURANCE
POLICY NUMBER PM DDtr YYY) EXP LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE FRIOCCUR EU
PREMISES Es occurrence $ 100,000
MED EXP(Any oneperson) $ 5,000
A CL1746061 04/10/2016 04/10/2017 PERSONAL a ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE Is 2,000,000
X POLICY E PECTRO- ❑
JLOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED 7MnEn_17FI_ $
Ea sodden
ANY AUTO BODILY INJURY(Per person) $
ALLOWNEDSCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
S
AUTONON-OWNED PROPERTY DAMAGE
HIRED AUTOPer accident $
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB HCLAIMS-MADE AGGREGATE $
DED I I RETENTION $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? F N/A E.L.EACH ACCIDENT $
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
ffye s describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY OMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddRional Remarks Schedule,may be attached If more space is required)
Plumbing Contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2 Ave
AUTHORIZED REPRESENTATIVE
Miami Shores FL 33138 :'
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
' 'Q-#;RES VILLAGE
�.PPROVED BY DATE
�i 5=
ZON;NG
4 Ij eAr
r
STRUCTURAL
_ �(fttLt
_ r ELECTRICAL
� lbs '� d
PLUMBING nuc,.� Z� I.00 � ` �P'b`t leggy
Fol
f
MECHANICAL
I�i/� �/�•tiara
KDG.
SUBJECT TO CCNiPLiA.Vi E �r"o'a A
. .. � STATE AND COUNTY RULES AND REGJi_AIIO.:S c
• . .•. . • .. ti — ' a�
...... CgZBo 72 /®l s^r�
•
SCALE: / APPROVED BY. DRAWN BYe -
•...• •..• ••..•• DATE' JZ REVISED
..... . ......
• • • • •• x��, �� ��� DRAWING NUMBER
• • • •
• • 4