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PL-16-3117 S 737?s Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756.8972 Inspection Number: INSP-272631 Permit Number: PL-11-16-3117 Scheduled Inspection Date: December 08,2016 Permit Type: Plumbing - Residential Inspector. Hernandez, Rafael Inspection Type: Final Owner: MARIANA JULIA LIVORE,FABIANO Work Classification: Addition/Alteration Oil %1C10w w -1 m Job Address:9935 NE 13 Avenue Miami Shores,FL 33138-2634 Phone Number Parcel Number 1132050090470 Project: <NONE> Contractor: BROTHERS BACKFLOW SPECIALISTS, INC Phone: (954)382-2099 Building Department Comments INSTALLATION OF 420 LBS PROPANE TANK Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-271172. need drop test Failed Correction Needed Re-inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid 12/07/16 11:11 HP LASERJET FAX p.02 6800 Bird Road#439 Miami, FL 331SS 954-382-2099 CFC1426564/LPG29029/LPG27025 DROP TEST This tag is to state that this installation has been inspected and approved to be to code and in conjunction with F.B.C. & N.F.P.A. —58 - -- � . Min. W.C. Job Address• i :'t\i b `� '� / r ' Z 4 7�4 Technician'° -11 Date: Pedro M Sail ana f' ` #•; 'a. STATE OF FLORIDA ) COUNTY OF MIAMI DADE Before me, a Notary Public authorized in the State and County set forth above, personally appeared Pedro.Santana known to me and known by me to be the person(s), who, executed the foregoing Drop Test, 1N WITNESS WHEREOF, I have hereunto set my han� 'nd affixed my official seal, in the State and County aforesaid, this 1-k.. day of i,3 v , 20�\ i 1 (Notary Stamp) A0117 P&ro 5x � CQMMISSI N#FF=1315 NOTARY PUBLIC 'y EXPIRES: Mach 29, 2019 STATE OF FLORIDA www.AARONNOTARY.COM ' . MM g � YI Miami Shores Village 7y � v � �IiF , 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 „ Phone: (305)795-2204 g 8 l r� . tss� 1 4201 " Expiration: 05/2'U 1? Project Address Parcel Number Applicant 9935 NE 13 Avenue 1132050090470 Miami Shores, FL 33138-2634 Block: Lot: FABIANO SILVEIRAAGUILAR M Owner Information Address Phone Cell FABIANO SILVEIRA AGUILAR MARIANA 9935 NE 13 Avenue --- MIAMI SHORES FL 33138-2634 9935 NE 13 Avenue MIAMI SHORES FL 33138-2634 Contractor(s) Phone Cell Phone Valuation: $ 1,495.00 BROTHERS BACKFLOW SPECIALIST: (954)382-2099 Total Sq Feet: 0 Type of Work:INSTALLATION OF 420 LBS PROPANE TAN Available Inspections: Type of Piping: Inspection Type: Additional Info:INSTALLATION OF 420 LBS PROPANE TAN Top Out Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee Invoice# PL-17-16-62064 $2.25 11/22/2016 Credit Card $ 116.70 $50.00 DCA Fee $2.25 Education Surcharge $0.40 11/15/2016 Credit Card $50.00 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $166.70 In consideration of the i n o me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in t ct o formity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I e responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECT P MBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFF AV I ify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction i . F t rmore,I authorize the above-named contractor to do the work stated. __ November 22,2016 ho re:Owner / Applicant ontractor Agent Date Building Department Copy November 22,2016 1 Miami Shores Village � Building Department artmen NOV 15 2010,• t 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 201q BUILDING Master Permit No. P/ JCO -31 , PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP (� 1 �• CONTRACTOR DRAWINGS JOB ADDRESS: cJ �lv� � 3T d4 City: Miami Shores County: Miami Dade Zip: 33139 Folio/Parcel#: 0 -3Q0-5- oos `1}c7 Is the Building Historically Designated:Yes NO Occupancy Type: Q Load: Construction Type: Flood Zone: VE BFE: FFE: OWNER: Name(Fee Simple Titleholder): 188'Afj® J . 4 Lnk Phone#: Address: 11335 ri F_ t3 T` A I/6 2 City: h (AM( S4099 State: FL Zip: 3 13 Tenant/Lessee Name: Phone#: Email: F g91AA)0_ CONTRACTOR:,Company Name: b y S (A u ` S e L.Phone#: 5 3 J ZZ a Address: 'OAm � City: \ 1M 1 State: C �' Zip: /J S } ss Qualifier Name: Q e (�Nc A S (N1n\ U a Phone#: A 5 i 56110 °) �l State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$_ i 1 5 , Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace 1 \ ❑ Demolition Description of Work: 1 I (�� 0 V\ L_ o b \P Y 01 ashy Specify color of color thru tile: /2 Submittal Fee$ �V• Permit Fee$ CCF$ GO CO/CC$ Scanning Fee$ - Radon Fee$ DBPR Notary$ Technology Fee$ 00 Training/Education Fee$ 0• CIO Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 1 I (Revised02/24/2014) . . . 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. SignatureSignature OWNER or AGENT CONT ACTOR The ii foregoing instrument was acknowledged before me this 1he regoing instrument was acknowledged before me this 1� da �- �/ r h Y of ,/J 20 ��P , by n day of 1�1�0 y• ,20 �'� , by 1C.. ma -r 1Cy ,who is personally known to T Q Y � 611X k A'lot ,wh ' ersonally known me or who has produced as me or who has prn1did d as identification and who did take an oath. identification and take an oath. NOTARY PUBLIC: NOTARY PUBLIC: u < Sign: Sign: Print: ClY"(wQr) tom' lir' l LSl U Print: COMMISSIt)IV;ffF0201.3:: pIRES� �— 201EX i. S Seal: Seal: ��rr��., �'o;�pF `� WWW.AARONNOTARY.G^ CARMEN ESTHER JUSINO ,R ., 'yyWW MY COMMISSION#FF046931 PAS Gc: *********** *�warx***> 111� *1 * *1>k ** * *************** * *****»******* *x ****** ******* *** ****** (40�398-0153 FloridallotaryService.com APPROVED BY 11��6®j�,s Plans Examiner Zoning if Structural Review Clerk (Revised02/24/2014) .. .. . . • .. .. . . . . . . . . . . . w- • LP p _ �--„� r•-._:: � ' ... ... ... . ... . �(L/ry 00 0 402-Li • .00 • ... . . . . .. . . . . . . .. . . . . . . 11 •• ••• .•. �'ge. etre f Cot a�C�GGC2 2� 15tb ect i+E 7�. Optjw4N G peep Of Miami Shores Village 4.205 soy APPROVED BY DATE LpC-t f�c.n E ZONING DEPT �y BLDG DEPT Sfe2Yt jt:F*f,:le,#® SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS ow f � � AL � LOCA'T'ION MAP ... ,• c� SCDI0:1'P OF SURVEY.. fill sc"t a •• 1 .. . 3 a 25' L • • • • � • • • •• Ld OA Z+ - -. A 69.97 .. ... . — A4 PeYeRw*v + 93A9' TPA 931i -- •• • • • 4i• • s -- ` • • • • • • p 7 $ a g 3 • •l ; s •s•s• •• 27°OfkMO+ a o !lock-4^ /+ S00°tID'00"E 93.49 o3.a9• 93.47 93.17 95.49' _ 127.17Found Found 1/7vcnpipeJ. „... f} - �. 1 _ SWAYNE BAY 16DDiCid. ; •' $ 1600 NO-ki LEGAL DESCRII'TiON: - a- ,. FOLD.1142050090470 I.ASRE X)RDEDIN LAT SOC t4 9TPAGE8 ACCOR�IGTOWIWCOFPLATOFF�OF. - - - Cow��y/• -16. ASRECCKmED BV FIAT 800K43,AT PAGE 80,OF THE Pt$)C AECORDS.OF - � 22.30' MK%#)AMCOJMY.Fi0RIDAT6:7U Geoge . PROPERTY ADDRESS: CEi2TlFIED TO c fJ:Ete..5 3s j 2 9938N.E 131h AVENUE,MIAMI SHORES.FL43MA 33138 FAB ANO SL\4M AGUILAR - ` . -34.35' a PLOCD2ONE NE' COMMUNOYt.120652 PANEL-M MARANA JLA.LA UVOTE `* " RATE OFFK1Fk O9.11.2009 SUFFM:L ELEVA1101*11AFEEr t4 - 1-STORY-BUILDING GENERAL NOTES: Ty, ReddeTwe No.9935 6ZT� 1)LEGAL DESCRIPTION PROVIDED BY OTHER& - - O00 Lmv F �ev."6:SFJ" .� c 02 2)9LAMINATION OF THE ABWACr OF THE W WILL HAVE TO BE MADE TO DETERMINE ABBREVIATIONS AND LEGEND: RECORDED INSIRUPAEM$.IF ANY.AFFECT IIS PROPERTY. A/C -DEVOTES AnCOD1RON11%;UNII g _ 3)THE LANDS SHOWN HEREON WERE NOTABSTRACTEDFOR EASEMENT OR OTHER CONC. AEVoTESCOVC m z '+ 35.70' z RECORDED ENCUMBRANCES NOT SHOIVN ONTHE PLAT. N9 -DEOIRETESAEASO 4)UNDERGROUAPORTION OF FOOTNG.FOuNDATK)NS OR OTHERIMPROYEIIEMS 4'D .DENOTES RECORDWERE NOT .7,a --L4• EQ 5)ONLY VISIBLE ON ABOVE GROUND ENC E. �NTS LOCATED -13MIESCALCCUTAAIFD C4 P. Z - 'i. .Z. a A. '- ,o d 6)WALL ARE THE FAODER1W -OMTESRIgR-CF•WAY Q EW WALL q AENDISSCENTUam I.T) V TBB AMC Ld 7)FENCE OwNHNoT oERE•IanffD. _ - - 8)BEARINGS TO UNE NOTED AS BA EASDAW R6. .DENOTES PLAT 9001 49..D' )&W - 9)8OUNDARYSURVEYMEA.PUADRAWNGAND/ORGR4PWCR NRATKNNOF PG. -DENOTESPAGE �T lO.OP THE SURVEY%YM PERFORMED IN THE FIELD.COULD BE DRAWN AT A SHOWN SCALE ® -DENOTESWATERKIER -. AND/OR NOT TO SCALE -DENOTEStbtf 10)NOIDENRgCAMJN FOUND ON PROPERTY CORNEFIS UNLESS NOTEo . •DENOTES WOOD POWER PENC 11)NOT VALID UNLESS SEALED MH THE� 1�SIGNNGS3lSVEVORSE DSEAL. -DENDTFsaMAN111NCFsxE 12)09hffNstONSSHOWN ARE AMEASIJf�UNlESSOttffR.YLSE SHOv4v. -DENOIESPONFENCE- .. 13)ELEVATIONS IF SHOWN ARE BASED UPON N.G.V.D.1929UNLESS OTHERWISE NOTED. --OH— .DENOTESOVERHEADWIRES e UNLESS �+ 16)THISBOU DARN SURVEY RAS BEEN PREPARE SPARE M�N0IED. � .DENOTES FOUND PONPM(NO D.) 16)THIS BOUNDARY SSAAIEI'FHA$�EI'1TM>FPARE FCM1Tiff EXCLUSIVE LSE OF THE OMIES .DENOTES FOUND NAIL AND MC t)=t F NAME HEREON,THE CERTIFICATIONS 00-NOT DMM TO ANY UNNAMED PARTIES 16)BENCHMAII(:8-/AO...,..,..ELEVAIION:&a FEET , LOCATIDEI:N.E.99th AVENUE&BISCAYNE BOULEVARD - FounC 1/7 Found 1/7.. W"A /' CERTIFICATION• Nold - S00°O(!'00"E 93.49 4800 r - ! Nod -- — ---- 541 -TRUE ANV(N:141ER EPRESOMADON OF ASBQNDARY j. - r.-_,... _...... -.. .-....-::. SURVEY'MATR1)E tx)RRECT'�PRESENWEKINDAUMT CHNICPARFD ALLBFARNCi3AND b5TANCESSNCMNFfEEEONAW T9VT)ETMY DHLK7rON.TTl6COAR'1.(ESIa3ilittff 6'ffi.IDMI/M TECF)NI[AL - _ - .. STAPI3AIID5.ASSTKRthTBT'1TSE5[ATE OF FLOMDAf�OF RECO�AADAffA91PE W+A£ ORMTINSENCTW. - - PNAL$[7RVEYtAtSAND/4APPER N'oF.aP1PRN-ITABT.flw®A *�,Lam. _ na8�118O7,Vwaer :. 'BiSCAYNE BAY ^�"�xatBr Elevaddw2aa AD7IONFSTR4TTVEMY)DE TvRSUANTTOSJ:C71IXV4.7-0iT.=W0ASTATT M W ESP�A LAND Su1�T�C.Y��TG INC. r_ - � - PR©Ff,IONAL StQWYO2 APS MAPPER E- tA565SW. S'lNFT,9AfE 3111.49AAR.R0l46A33157 SIGNED FmTmF'LSMPFICf�(30920R--A 2 FA>t O=164-M MCL LEWC40SA PSM.FP,STEL-STASSOFttORIDA g'�� c _ 18 Na4e69 - c" 7.0 - NOTVAUDWITIOX ANAUTrffT=ELECMOMCSIGNA WANDAkuFffAlifCATED 130UI�iF.?AR1',7LTI�T/E'Y fLGC?Pd`HC SfVN ANDA7R WIS MAP R NOT VAId6TKTNDN IWSPS TM AND S.2Q6O; 7!¢CSlIGRYAL RA6EDSFAL OF.AUCENff WRVEYORAf Y1AAPPEA. 04gnTY DCfe: F{piq -_, Drcwnty- -bb NO. - 04/071201$ L)a (2075 04107/2015 FILL 8•i)507 _ -I ' 5N 0 GQ Miami Shores lVillage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 CONTRACTORS' REGISTRATION Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. -COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER farm and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ■a�e��e��s��serro■omru®asnae��a■ ■■��a��a�s�oe�os�aa■■asr2 8 a®0 00 6a 00 0 ea' BUSINESS NAME: Y A (,k Q 0 o f BUSINESS ADDRESS: \Ib l a I� CITY M 1 A m STATEL ZIP 33 S S BUSINESS PHONE: ) 3 0 0) 0\ FAX NUMBER °t 5 1 2 t o, CELL PHONE( ti 1 UALIFIER'S NAME: ! e a Y y 4I YIN Ati )q. QUALIFIER'S LIC NUMBER: Q 015 ACOORL® CERTIFICATE OF LIABILITY INSURANCE r- DATE(MM/DDIYYY`) 11/7/2016 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 pollcy(les)must have ADDITIONAL INSURED provisions or 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 SUNZ Insurance Solutions, LLC. ID: (Ally) NAME: Melissa Ash Go OAK Inc. PHONE 90739 2722 FAX No): 904-262-2760 9016 Philips Highway MAIL Jacksonville, FL 32256 ADDRESS: mash@matrixonesource.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: SUNZ Insurance COITIDagy 34782 Ally HR, Inc. INSURER B: 9016 Philips Hwy INSURERC: Jacksonville FL 32256 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 32746213 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. INILTR RR TYPE OF INSURANCE im ADDL U D POLICY NUMBER POLICY EFF YYYI MM /IDCD EXP YYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any One person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILnYCOMBINEDSINGLELIMIT $ Ea accident ANY AUTO OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED DAMAGE TY AUTOS ONLY AUTOS ONLY P PROPERTY er Y $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WCPE00000323 02 1/1/2016 1/1/2017PER OTH- AND EMPLOYERS'LIABILITY Y 1 N ✓ STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? El N/AE.L.EACH ACCIDENT $ 1,000,000 E Mandatory in NH) (t yam,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more apace Is required) Coverage provided for all leased employees but not subcontractors of:Brothers Backflow Specialists,Inc. Effective date:2/29/2016 CERTIFICATE HOLDER CANCELLATION 9414 Miami Shores Village Bldg Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2nd Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Glen J Distefano ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 32746213 1 Master Certificate I Holly Parrish 111/7/2016 4:27:03 PM (EDT) I Page 1 of 1 r , Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number. 29029 Business Mailing Address Licensed Location Address BROTHERS BACKFLOW SPECIALISTS,INC. BROTHERS BACKFLOW SPECIALISTS,INC. 6800 BIRD RD STE 439 419 NW 8 ST MIAMI,FL 33155-3757 MIAMI,FL 33155 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LP Gas licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person,firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the departmen. All licensing requirements must be met by the transferee and a transfer fee of$50 will apply. To apply for a transfer,contact the Bureau of LP Gas Inspections at(850) 921-1600. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of,licensure to any consumer, owner,or end user upon request when engaged in the business of servicing,testing, repairing,maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here State of Florida `'�''`.4 Department of Agriculture and Consumer Services Division of Consumer Services License Number: 29029 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31,2017 (850) 921-1600 Date of Issue: November 8,2016 POST LICENSE Tallahassee, Florida License Fee: 0800.00 Type and Class: 0803 CONSPICUOUSLY Liquefied Petroleum Gas License LP GAS INSTALLER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license is Issued under authority of Section 527.02,Florida Statutes,to: BROTHERS BACKFLOW SPECIALISTS, INC. 419 NW 8 ST ADAM H.PUTN M MIAMI, FL 33155 COMMISSIONER OF AGRICULTURE Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apalachee Parkway Tallahassee, Florida 32399-6500 Master Qualifier Mailing Address Licensed Location Address PEDRO SANTANA BROTHERS BACKFLOW SPECIALISTS, INC. 6800 BIRD RD STE 439 BROTHERS BACKFLOW SPECIALISTS, INC. MIAMI, FL 33155.3757 3855 SW 79TH AVE APT 2 MIAMI, FL 33155-6737 Certificate Number 27025 License Number 29029 " This Master Qualifier Certificate is issued pursuant to Chapter 527, Florida Statutes. This certificate is valid only for the person and licensed holder listed. Any changes to the Master Qualifier status (such as transfer or termination of employment) must be reported to the Bureau of Compliance at(850) 921-1600 immediately. The Master Qualifier Certificate is valid only through the date noted on the Certificate. A notice of renewal will be sent to you in advance of your expiration date. A Master Qualifier Certificate may be renewed if certification of a minimum of 16 (sixteen) hours continuing education is provided along with the renewal form. If train;ng cannot be documented, an examination must be taken. If there are any errors on the certificate, please submit all changes in writing to: Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apalachee Parkway Tallahassee, Florida 32399-6500 ------------------------------------------------------ Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services Bureau of Compliance Certaflcate No: 27025 Exam Date. June 28,2010 (850) 921-1600 issue Date: June 28,2016 Tallahassee, Florida Expiration Date: June 27,2019 Exam: 0803 MASTER QUALIFIER CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes,to: Valid For PEDRO SANTANA License Number: 29029 BROTHERS BACKFLOW SPECIALISTS,INC. 3855 SW 79TH AVE APT 2 �A.RICU�LTURE MIAMI,FL 33155-6737 A PUTN ¢COMMISSIONER OF 2016 / 2017 MONROE COUNTY BUSINESS TAX RECEIPT EXPIRES SEPTEMBER 30, 2017 Business Name: BROTHERS BACKFLOW SPECIALIST RECEIPT#30140-113359 Owner Name: ASHLEY PIZARRO, PEDRO SANTANA Business Location: MO CTY Mailing Address: QUALIFIER KEY WEST, FL 33040 6800 BIRD ROAD#439 Business Phone: 305-267-3992 MIAMI, FL 33155 Business Type: CONTRACTOR(GAS) Employees 3 STATE LICENSE: DEPT OF AG 29029127025 Tax Amount Transfer Fee Sub-Total Penalty Prior Years Collection Cost Total Paid 20.00 0,00 20.00 3.00 0.00 0.00 23.00 Paid 000-16-00002522 11/07/2016 23.00 THIS BECOMES A TAX RECEIPT Danise D. Henriquez,CFC,Tax Collector THIS IS ONLY A TAX. WHEN VALIDATED PO Box 1129, Key West, FL 33041 YOU MUST MEET ALL COUNTY AND/OR MUNICIPALITY PLANNING AND ZONING REQUIREMENTS. MONROE COUNTY BUSYNESS TAX RECEIPT P.O. Box 1129, Key West, FL 33041-1129 EXPIRES SEPTEMBER 30, 2017 Business Name: BROTHERS BACKFLOW SPECIALIST RECEIPT# 30140-113359 MO CTY Owner Name: ASHLEY PIZARRO, PEORO SANTANA Business Location: KEY WEST, FL 33040 Mailing Address:QUALIFIER Business Phone: 305-267-3992 6800 BIRD ROAD #439 Business Type: CONTRACTOR(GAS) MIAMI, FL 33155 Employees 3 STATE LICENSE: DEPT OF AG 29 Tax Amount Transfer Fee Sub-Total Penalty Prior Years Collection Cost Total Paid 20.00 0.00 20.00 3.00 0.00 0.00 23,00 Paid 000-16-00002522 11/0712016 23.00 ��®® CERTIFICATE OF LIABILITY INSURANCE 11/7%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 endorsement(s). PRODUCER CONTACT Plymouth Insurance Agency PHONE F AICNo Ext: 727-682-4040 ac No:727-682-0239 2739 US Hwy 19 North Holiday, FL 34691 ADDRESS:Certs@plymouthinsuranceagency.com INSURER(5) AFFORDING COVERAGE NAICS INSURER A:Arch Specialty Ins. 21199 INSURED Brothers Backflow Specialists, Inc. INSURER B:Mt. Hawley Insurance Co 37974 6800 SW 40th Street, #439 INSURER C: Miami, FL 33155 INSURER D: 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. LLTTRR CT-07- POLICY EXP__ TYPE OF INSURANCE pgD WVIL D POLICY NUMBER MM/DD MMIDDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, 00,000 CLAIMS-MADE CI OCCUR PREMISES Ea occurrence $ 100,000 A X INSTALL/REPAIR LP GAS AGL003321-03 8/17/2016 8/17/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY F JET L—I LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY AUTOS Per accident $ UMBRELLA LIAB x OCCUR $ ]( EXCESS LIAB EMX0322031 8/17/2016 8/17/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ PROD/COMPL OPS $ 1,000,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A $ IMamlatory in NFp E.L.DISEASE-EA EMPLOYEE $ If yee describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) LICENSE #Is: CFC1426564 / 29029 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD25(2014/01) The ACORD name and logo are registered marks of ACORD