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PL-16-1353 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-259102 Permit Number: PL-5-16-1353 Scheduled Inspection Date: July 18,2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: BACON, KEITH M Work Classification: Addition/Alteration Job Address:1632 NE 105 Street A-2 Miami Shores, FL Phone Number (305)332-6164 Parcel Number 1122300530020 Project: <NONE> Contractor: TERRA GROUP INTERNATIONAL INC Phone: (786)385-9502 Building Department Comments REPLACE ONE BATHTUB, TWO TOILETS,THREE infractio Passed Comments SINKS, RECONNECT KITCHEN SINK AND DISHWASHER. INSPECTOR COMMENTS False Inspector Comments Passed v, Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. July 15,2016 For Inspections please call: (305)762-4949 Page 12 of 44 46 A-% Miami Shores Village ` P7�7t ��fJm� i�f@+n 5; tid 10050 N.E.2nd Avenue NE dool"', Miami Shores,FL 3313&0000 ` yyry� $ Phone: (305)795-2204 \ 3 3� 4 �I311 "� i _ � y � �� Expiration: 12/07/2016] Project Address Parcel Number Applicant 1632 NE 105 Street Number: A-2 1122300530020 KEITH M BACON Miami Shores, FL Block: Lot: Owner Information Address Phone Cell KEITH M BACON 1632 NE 105 Street (305)332-6164 MIAMI SHORES FL 33138- 1632 NE 105 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 1,500.00 TERRA GROUP INTERNATIONAL INC (786)385-9502 Total Sq Feet: 0 Type of Work:REPLACE ONE BATHTUB,TWO TOILETS,T 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 $1.20 Invoice# PL-5-16-59825 DBPR Fee $2.25 DCA Fee $2.25 06/10/2016 Credit Card $315.70 $0.00 Education Surcharge $0.40 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.60 Work without Permit Fee $150.00 Total: $315.70 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 ins ' conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this pe it I su a responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELEFIRICPL,PL JMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFF VIT: ce fy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an o i g. re,I authorize the above-named contractor to do the work stated. June 10,2016 Authorized Signatu :Owner / Applicant / Contractor / Agent Date Building Department Copy June 10,2016 1 IID Miami Shores Village Y 18 2010 Building Department By- 10050 050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)752-4949 j r"- FBC 20 I BUILDING master Permit Imo. 16-z-'51 PERMIT APPLICATION Sub Permit No. T'�J �-1353 ❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL EPLUMBING ❑MECHANICAL OPUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 163Z ME=. 105- Vt t-S f2T Miami Shores n Miami D / is the Building Hilar .Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): KC-i T 4 5 AGO H Phone#: k - )33z,- 6/641 Address: 16ZO M5 /06 5�-MG-C--r City. z4l,4,01 State: f:L Zip: 13/39 Tenant/Umee Name: Phone#: Email: !(j5)T k f3Ar,?01_DA0L.,CZ>A4 CONTRACTOR:Company Name: 'r4EPL" aQQ 0? lWOJA"O"L INC.- Phone#. Address: v i`f i COP-A C_. wA Y 61 City A!) l State: FL Qualifier Name: phe#;lr) �e �O Z State Certification or Registration#: Certificate of Competency#:f P6'i Z.6g ls,-c DESIGNER-Architect/Engineer J> �gI PI C-:1-hS Phone#.T3 9)_xW47 ePgl Address: C8 2Z 1-46 ZWP ll✓t: City:AAM,: I4DP45K, State: T�_ Zip: 3 Value of Work for Ols Permit;$ If 52?0,vt7 Square/Unear Footage of Wer Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Desawon of work: _Pz-PL w OMr- ad rT Tt�, `rwo TO R LC-- . TY,P ifS. t Specify color of color thm tile: Submittal Fee$ IT Permit Fee$ �.�� CCF$ CO/CC$ ScanMng Fee$ . �� Radon Fee$ a`� DBPR$ Notary$ TedWAftn Fee$� TraJ /Ed t Fee$ q 6 Double Fee$ (3 M Structural Revs$ Bond$ TOTAL FEE NOW DUE$ L (RevbecNW24/=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 taws 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 AFRDAVIT: 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. ffWARNING 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$25W, the applicant must promise in goad faith that a copy of the notice of commencement and construction lien law brochure wiB be delivered to the person whose property is subject hment Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first ins which curs seven (7) days after the building permit is issued. in the absence of such posted notice, the inspection will n tf approved nd a refnspection fee wNl be charged. Signature-6 Sign O R or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing Instrume t was acknowledged before me this _NJM_day of (`(A .20 W . ,by j� day of 20 ,by who is personally known to ® l� "(of 47AW-' .who is_personally known to me or who has produced �d rle- t as me or who has produced as Identification and who did take an oath. Identification and who did take an oath. NOTARY PUBLIC: NOTARY Sign: Sign: Print l ��V��-' Print: / U /✓�! Seal: r oue tdotary Public State of Florida Seal' Sindia AivaraZ i .•��",,., AAIGUEk A.M{AETE My Commission FF 1567:50 "ae'•. Expires 0910312018 =� °�;E �NotaaroymPuublt State of FlwWaa ssssssssssssss*ss* s sass*asswsss****s*as* �ieY��€is *': 03 ii sssss**s**s J. CbrMn-jo aI EE Bonded Through National notary Assn. APPROVED BY l®'��' Plans Examiner Zoning Structural Review Clerk (RevWedW24M4) son a v.l" Miami shores Village Building Department lOR 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION 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 BADE 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 form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 18V50 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ■os��sst��a��s��s��e��aa��t��s�o��t��r BUSINESS NAME: 7ER-II,A, CU,"v-P llr�P-NA-PoYdt /tqU BUSINESS ADDRESS:3111 eo QAL WA CITY STATE FL ZIP 3 I BUSINESS PHONE: ( j FAX NUMBER L--j CELL PHONE Fj!�K 366-` 150 L QUALIFIER'S NAME: RAIVgL,� &2a�LL?-- QUALIFIER'S LIC NUMBER:60cay/Z/-e3 r— '—`_",.. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION t.f CONSTRUCTION INDUSTRY LICENSING BOARD (850)487-1395 '° '``` 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 GONZALEZ,FRANCISCO JAVIER TERRA GROUP INTERNATIONAL INC 1310 S GREENWAY DR MIAMI FL 33134-4767 Congratulallorts! With this License you become one of the nearly one million Floridians licensed by the Departmetit of Easiness and Protassional Regulation. Our professionals and businesses range :. STATE OF FLORIDA from architects to yacht brokers,from boxers to barque 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 CFC1426856 ISSUED: 09/0712014 serve you better. For information about our services.please log onto myl com. There you can find more information CERTIFIED PLUMBING CONTRACTOR about our divisions and the regutabons that Impact you,subscribe GONZALEZ,FRANCISCO JAVIER to department rffasletters and learn more about the tent`s TERRA GROUP INTERNATIONAL INC initiatives_ Our mission at the Department is:License Efflc iercety, Regulate Fairly. VW Constantly strive to serve you meter so that you can serve your customers. Thank your for doing business in Florida, IS CERTIFIED under the provisions of Ch.489 FS and congratulations on your new license! �c:WW aW-- AUG31 CIE ue: rcae' DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTNIENT OF BUSK4ESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1426M The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 ® k. 8 GONZALEZ,FRANCISCO JAVIER TERRA GROUP INTERNATIONAL INC 1310 S GREENWAY DR MIAMI FL 33134-4767 .. t IssUED: t WMA14 DISPLAY AS REC L RW BY LAIN M# 04OWM002982 Local BusimuTax s 2418424 G 3191 CORAL VW 46 ANWRIM45 owwm- 2. fi 2 - r� �3 i k �} i nj1 6Nt•'\)J CERTIFICATE OF LIABIUTY INSURANCE .THIS CMU94CATE IS ISS AS A ATTER OF U*WmTION ONLY ARID CONFERS NO RiGM UPON THE C�T�fCATE HOLDER. T1gS CERTtF1CAT E IsoEs NOT AFFt "TMELY OR NEGATi1/ELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORD® BY THE POLICIES 7 MLOW. THIS CERT'Rr-ATE OF WSURANCE DOES NOT CONST MITE A CONTRACT BerWM THE ISSUWG 9SUREWL AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: ceciRicate holder Is as ADDITIQNAL W$URE%the boli ISS)must to endorsed.ff SUBROGAT M Is WAIVED subject to the torts and conditions Of the policy,certain pogo may require an endorsement.A statement on this c er8Picate does not confer rights to the CSTMcats holder In lieu of such end s). PRODUCER T Cannizzaro P.O. Insurance Agency PHaLaE F P.O.Bax 295 386)775-1781 (386)775-3M inst MInc 8 g Uy aCB.rcC0In assedaga aFFaRL tG cov�aGE C L+atclf INSURED A FL 32706 • ACCIDEW INSURANCE COMPANY INC 11573 INSURERS: Tens GIOUP International Inc C: 3191 Coral Way tea: Sufte 60 Coral Ga61es E: FL 33145 LLibMRER F: COVERAGES CERTIFICATE NUi1MEER: REVISION NUMSER: THIS tS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTU n+WANDING ANY RECIURREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT EC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED T TO WHICH THIS HEREIN IS SUBJECT WITH RESPEC ALL THE TERMS, ExCLUTONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPEOPURBtrRANtAIM POLLCYRNIZ POLICY !� X IJbIEtr3 CONIERCIALGaIERALLIABILITY ( FACHOCCURLMNcE S 1.000,000.00 aAmsmm FX lR j Es ,: p S '00.000.00 A CPP 0004M03 08/11=15 08/11/2016 r�oow{nnyoae ) S S.000.W PI AL&ADV INJURY S 1.000,000.00 s>armicyEGATEUIdrFAPPttE,RPBft c3s+>atal.Ac GATE S 2.000.000.00 Q o Loc PRaDuctS-CM4PJOPAW s 2AOO.000.00 S ANY Ar1T0 ALL CrAffaD d ns SWILYMMY{PerPOMM) S AUTOS I MON-OWNED BODILY 94JLIRY{Pa & HIREUAJJ7OS AUTOS PR�OAQW GE $ UIMRE L A L,IAS S OCCUR MICESS L.IAS CLARMAMDE EACH OCCURRENCE g ANRE KTE S OEa REfEN'fIONS IJABIUTY unaR�Rs cotaPeusaTwar S anrr PROPRLEr YIN ST (Bdyand,dabory U NH)OCCLIDID? NIA E L EACH ACCIDENT' $ OP71ON OFOPERATION$below �-MEAM-EAEMPLOYEE S EJ-O1sEA8E-POUcYLMgT S >ESCR@►fta%OFOPERATIONS iLOCA7(011 'VMCLERJACORDISi.Ad tRmaark%Schedifta gbe If is Electrical and plumbing contractors :ERTTFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED pOLIClES BE CANCELLED BEFORE THE Miami Shares VtEXPRA� THE POLICY FRONS.ON DATE THEREOF, NOTICE NRI.! DELIVEFIED IN Mage Building Department ACCOI 10050 PIE 2nd Avenue AUTH010M REPIUMEWTATM Miami Shores FL 33138 ::ORD 25(2094/01) The AGORD cram®and ®9988-='4 ACORD CORPORATION.All rights reserved. b90 We fired marks of ACORD JEFF ATWATER CMEF 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 listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 7/16/2014 EXPIRATION DATE: 7/15/2016 PERSON: GONZALEZ FRANCISCO J FEIN: 650173759 BUSINESS NAME AND ADDRESS: TERRA GROUP INTERNATION 1310 S.GREENWAY DR CORAL GABLES FL 33134 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL LICENSED PLUMBING LICENSED ELECTRICAL CONTRACTOR CONTRACTOR CONTRACTOR Pursuant to Chapter 440.05(14).F.S..an officer of a corpora*m who elects exemption fiom tlds dopier by Ming a vie of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S..Ceriffitcates of elect=to be exen ..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 cerUflcates of election to be exempt shall be subject to revocation if,at any time after the flog of fire notice or the issuance of the certrTtmte.On perm named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revolts a certificate at any time for failure of the person named on the certifical a to meet the requirements of tits section. DFS-F2 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-11309 Terra Group International,Inc. Miami FL 33145 Tel: 786-306-7853 License: CGC05888,CMC1249566,CFC1426856,EC0001218 Miami,05/12/2016 State of County of �- Before me this day personally appeared � � who, being duly sworn,deposes and says: That he will be the only person working on the project located at: 1632 NE 105 Street Miami Shores, FL 33138 Sworn to (or rmed) and subscribed before me this 7 day of 20 bytim �l�o C -- Personally Know OR Produced Identification Type of Identification Produced . . MIGUEL A.MIRETE tPRr Pvbti�i �: Notary Public State of Flea My Comm.Expires Oct 1.2018 Commission#t EE 839533 ....... Bonded Through National Notary Asan. Print,Type or Stamp Name of Notary Miami ShoresVillage owe Building Department tQR11 10050 W.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 Notice to owner —workers' Compensation Insurance Exem tion 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 I0 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 ACKNO E THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: p PwInwer State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of By)�, who is personally known to me or has produced FL'QCk U C(,V, !X as identification. Notary: SEAL: a°5pP Pu*moo Notary Public State of Florida Sindia Alvarez a My Commission FF 156750 A o� Ex ices 09103/2018