PL-12-2226Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 184939
Permit Number: PL -11 -12 -2226
Scheduled Inspection Date: January 31, 2013
Inspector: Hernandez, Rafael
Owner: GLINN, MacDAM & DENISE
Job Address: 1201 NE 102 Street
Miami Shores, FL 33138-
Project: <NONE>
Permit Type: Plumbing - Residential
Inspection Type: Plumbing
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132050250160
Contractor: PSG PLUMBING SERVICES, INC Phone: (305)796 -7304
Building Department Comments
REPLACE FIXTURES AND NEW THIRD BATH.
Infractio Passed Comments
INSPECTOR COMMENTS
Passed
Failed
Inspector Comments
SEWER PIPE CONNECT
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
False
January 30, 2013
For Inspections please call: (305)762 -4949
Page 25 of 31
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 182004 Permit Number: PL -11 -12 -2226
Scheduled Inspection Date: March 06, 2013
Inspector: Hernandez, Rafael
Owner: GLINN, MacDAM & DENISE
Job Address: 1201 NE 102 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: PSG PLUMBING SERVICES, INC
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132050250160
Phone: (305)796 -7304
Building Department Comments
REPLACE FIXTURES AND NEW THIRD BATH.
Infractio Passed Comments
INSPECTOR COMMENTS
False
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comm
March 05, 2013
For Inspections please call: (305)762 -4949
Page 13 of 43
1 R®►7 r -- CERTIFICATE OF LIABILITY INSURANCE
°A 0/299//112
PRODUCER Excellence Insurance Agency
3801 SW 107 Avenue
Miami, FL 33165
Phone (305)226 -3900 Fax (305)226 -3997
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED PSG Plumbing Service, Inc.
3892 NW 125 Street
Opalocka, FL 33054
1
INSURER A: Granada Insurance Company
INSURER B: Progressive insurance Company
INSURER c: Guarantee Insurance Company
INSURER D:
INSURER E:
COVERAGES
INSURER F:
THE POLICIES OF INSURANCE LISTED 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 CONDMONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MISR
LTR
Arm
INSRD
TYPE OF INSURANCE
POLICY NUMBER
0185FL00031657-0
POLICY EFFECTIVE
DATE (MMIDDIYY)
11/18/12
POLICY EXPIRATION
DATE (NBiA1DD/YY)
11/18/13
UMITS
A
GENERAL LIABILITY
EACH OCCURRENCE
1,000,000
M COMMERCIAL GENERAL LIABILITY
PREMISES (Ea (Ea )
100,000
M
❑
❑ CLAIMS MADE n OCCUR
MED EXP (Any one person)
5,000
PERSONAL & ADV INJURY
1,000,000
■
GENL
5.
GENERAL AGGREGATE
1,000,000
AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PROJECT ❑ LOC
PRODUCTS - COMP /OP AGG
1,000,000
B
❑
AUTOMOBILE LIABILITY
❑ ANY AUTO
06288837 -3
02/18/12
02/18/13
COMBINED SINGLE LIMIT
(Ea accident)
❑ ALL OWNED AUTOS
SCHEDULED AUTOS
❑ HIRED
BODILY INJURY
(Per person)
10,000.00
AUTOS
❑ NON OWNED AUTOS
Comp $500.00 Ded
v COII $500.00 Ded
BODILY INJURY
{ ardent)
20,000.00
PROPERTY DAMAGE
(Per accident)
10,000.00
❑
GARAGE LIABILITY
❑ ANY AUTO
❑
AUTO ONLY - EA ACCIDENT
OTHER THAN EA ACC
AUTO ONLY: AGG
11:1
EXCESS/UMBRELLA LIABILITY
❑ OCCUR ❑ CLAIMS MADE
❑ DEDUCTIBLE
• RETENTION $
EACH OCCURRENCE
AGGREGATE
C
WORKERS COMPENSATK)N AND
EMPLOYERS'LIABIUTY
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER / MEMBER EXCLUDED?
I yes, describe under
SPECIAL PROVISIONS below
WC325785
11/18/12
11/18/13
[] WC STATU- 1 OTH
TORY UM S ER
E.L. EACH ACCIDENT
100,000
El. DISEASE - EA EMPLOYEE
100,000
E.L. DISEASE - POLICY LIMIT
500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
General Contractor.
PtnTirl"ATC u•• n -1,
Miami Shores Village Building Dep
10050 NE 2 Ave
Miami Shore, Fl 33138
I
ACAPn '94 »nnarnQi nc
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED ,x'„ RESENTATIVE
71 144-4..A.,
AC D CORPORATION 1988
61'
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC2o
Permit Type: PLUMBING
Permit No. ?Li? 2
Master Permit No. \� 2 �' 2`��
OWNER: Name (Fee Simple Titleholder): flax.. A ar ( Phone#: `3 ‘D, g g 3, g o6
Address: 1 0 k L �— 10 Z- 6a _
City: c \--be(' 5 State: V C.-
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: I C) k j� F ' 0 S t•
Zip: �Z' , 0
City: Miami Shores
County:
Miami Dade
Zip: ' 1 '53
Folio/Parcel #:
Is the Building Historically Designated: Yes NO
Flood Zone:
0
CONTRACTOR: Company Name: PS 6 P 10 1 ao � - Phone #: ?0s 7 9 b °73 0 y
Address: 3 eqz A l J2 S-5 '1- �"
City: .Of(xC.c9 %fi— State: P4C-4. k Zip: 33'0 s K
Qualifier Name: f c'e nS eS t' a cs� ,..,-"_4„, Phone #:
State Certification or Registration #: 0 F er. / 6/2.6.0a5"7 Certificate of Competency #:
Contact Phone#:.7 6 — 3/. � Email Address:
DESIGNER: Architect/Engineer: Phone#:
m
c Iteration
\ C e
'.''Value otWork forthis Permit: $ J 0
Type of Work: °Address
Desch ion of Work:_
49 6
!y
Square/Linear :oota of Work:
°Neese air/Re lace
.e
P P
4.
°Demolition
* * ** ��x�x� *** * *** *�x *�x**** ****�rx�� * *** *****Fees * ***1x i4* * �** *****
Submittal Fee is-Ii-
Permit Fee $ J ou
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
* * * * * * * * * * * * * * * * * * * * * **
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ 1 6 .54
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 FI.RCTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 ipproved and a reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this 2
day of N , 20 it, bin ACAPAIYI
who is personally known to me or who has produced
As identification and who giflAmtian oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
* say ********+s***** * * *** *+x*+x***
APPROVED BY
Signature
✓contractor
The foregoing instrument was acknowledged before me this J"
day of , l -V , 20 a, by
who is personally known to me or who has produced p1.
as identification and who did take an oath.
My Commission Expires:
46'f.-
********************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
26—P2--Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk