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PL-16-774Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 �Q-C 11,1b5 Inspection Number: INSP-268127 Permit Number: PL -3-16-774 Scheduled Inspection Date: September 29, 2016 Inspector: Hernandez, Rafael Owner: Job Address: 118 NW 103 Street Miami Shores, FL 33150 - Project: <NONE> Contractor: AT QUALITY PLUMBING INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)676-2225 Parcel Number 1131010220030 Phone: (786)258-4564 Building Department Comments PLUMBING REPAIRS / BATHROOM 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 Comments CREATED AS REINSPECTION FOR INSP-255412. DANIEL CANCELLED 9/26/16 C... 1 •ietne nlnace Holl• /1Ac1749-41Q&Q Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -3-10-774 Permit Type: Plumbing - Residential Work Classification. Addition/Alteration Permit Status: APPROVED Issue Date: 3/28/2016 Expiration: 09/24/2016 Parcel Number Applicant 118 NW 103 Street Miami Shores, FL 33150- 1131010220030 Block: Lot: EACH MORNING LLC Owner Information Address Phone Cell EACH MORNING LLC 118 NW 103 Street MIAMI FL 33150- (305)676-2225 118 NW 103 Street MIAMI FL 33150- Contractor(s) AT QUALITY PLUMBING INC Phone (786)258-4564 Cell Phone Valuation: Total Sq Feet: $ 1,800.00 0 Type of Work: PLUMBING REPAIRS / BATHROOM Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $3.38 $3.38 $0.40 $225.00 $3.00 $1.60 $237.96 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -3-16-59128 03/28/2016 Credit Card $ 187.96 $ 50.00 03/23/2016 Check #: 1021 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 ELECTRICA __ _ BING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: ify th. foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zonin horize the - • •'ve-named contractor to do the work stated. March 28, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy March 28, 2016 1 ��'\��b Miami Shores Village els Building Department BUILDING PERMIT APPLICATION 0BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 Master Permit No. Sub Permit No. JPLUMBING 0 MECHANICAL 0PUBLIC WORKS D CHANGE OF CONTRACTOR JOB ADDRESS: 1,18 NU) 1o3 S FBC 2119 5411 ❑ EXTENSION ❑RENEWAL ▪ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: evrAD Load: NO Construction Type: Flood Zone: BFE: FFE: (ea) zLo- OWNER: Name (Fee Simple Titleholder): CN tvicaroWG Address: tISZ�- SO ote .5-41.120t- -' D City: ti i4Mi State: `R---•• Phone#: Zip: 33 0 3 Tenant/Lessee Name: Phone#: Email: _DA%-41vLk e� 2PP"s 1 Q -'►A• cog CONTRACTOR: Company Name: 7� ."7-4A/7 ply 9/i!17, e, Phone#: 6.245gZ/�Z��/ Address: rj e,Tum itz- /' /fit lG= /�1 .5 2 - City: /�%A7,0/ y-� State: Qualifier Name: /0/: }LIS Zip: 1 Phone#: V6 State Certification or Registration #: t e /LVAeg 2Z Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ /000.0 Q' Square/Linear Footage of Work: Type of Work: ❑ Addition 23 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 4-- 1-0+1l e ' 6 R /4/*Co-i S Specify color of color thru tile: CCF $ ! 20 'C� Radon Fee $ 3 - 3 v DBPR�$, 8 Notary $ ( Technology Fee $ 1 EC) Training/Education Fee $ 0 • TMJ Submittal Fee $ Scanning Fee $ Permit Fee $ .,2 CO/CC $ Structural Reviews $ (Revised02/24/2014) Double Fee $ p Bond $ TOTAL FEE NOW DUE $ I e 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 OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this P 2 day of V''+RvG ("'- , 20 / Ce by r) :2 day of j22fi27C i- , 20 f G by 9-'4 •7 ,J who is personally known to / i S ,/ L''� , who is ersanally known to me or who has produced as me or who has produced as Signature CONTRACTOR identification and who did take an oath. NOTARY PUBLIC: Sign. Print: Seal: identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: •***************************************************************** *********** APPROVED BY (Revised02/24/2014) Plans Examiner Structural Review Zoning Clerk .‘i STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 TEJERA, ALEXIS AT QUALITY PLUMBING INC 6055 W 19TH AVE APT # 320 HIALEAH FL 33012 =----Eongraturatiorrs! lMtirthis-licon;.e-you becomeone of the -nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about 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, and congratulations on your new license! DETACH HERE RICK SCOTT GOVERNQR (850) 487-1395 STATE OF FLORIDA DEPARTMENT. OF BUSINESS AND PROFESSIONAL::REGULATION CFC1428820 <:'';:' ';.SUED ":.07/01/2014 • CERTIFIED Pi_t9 BINIti'CONT ApT0R TEJERA, ALExh':,:• • ..� AT QUALITY PLJMBINVG.INC;'w% =r � 1S CERTIFIED under the.provlsions of Ch.489.FS. Expiration date : AUG31, 2016' L1407010001265 • KEN LAWSQN, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION. CONSTRUCTION INDUSTRY LICENSING BOARD The PLUMBING CONTRACTOR Named below IS. CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 TEJERA, ALEXIS AT QUALITY PLUMBING fNCwp' ' 6055 W 19TH AVE APT#.320 . - .• HIALEAH FL 33912 .001 tt-n_ e.••••• . 00222D Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY (7154131 BUSINESS NAME/LOCATION AT QUALITY PLUMBING INC 6055 W 19 AVE 320' HIALEAH FL 33012 OWNER AT QUALITY PLUMBING INC Worker(s) RECEIPT NO. RENEWAL 7431000 LBT SEC. TYPE OF BUSINESS 196 PLUMBING CONTRACTOR CFC1428820 EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter BA - Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $45.00 08/03/2015 CREDITCARD-15-039548 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is nota license, penult or a certification of the holder's qualifications. to do business. Holder must comply with any governmental or nongovenmiental regulatory laws and requirements which apply to the bosinesa. The RECEIPT N0. above -must be I dis payed on all commercial vehicles - Mlami-Dade Code Sec Ba -276. :"T"" For more infonnafion, visit fyww.miamidade.goy/texcollector ACORD From Del Toro Insurance 1.305.262.3364 Mon Mar 21 15:13:45 2016 EDT Page 1 of 1 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 03/21/2016 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(sl, PRODUCER Del Toro Insurance Agency#16 18511 SDixie Hwy . Cutler Bay, FL 33157 5-8676. Fax X3.05)262.3364 CONTACT CT AleAs Teiera PHONE 786-258-4564 .FAAX NoY - ••••'•••••—•---- .18511. E-MAILSIK - INSURER SPAFFORDING COVERAO& •NIM`' lust! FRn:_GRANADA INSURANCE COMPANY ....................:.... _*A MERR:...,,..,. 1Etyla ;.Phone , INSURED A.T. Quality Plumbing Inc 6055 W 19th Ave #320 Hialeah FL 330.12. . _:, INcr,Psrrr INsllr_coft.___....._......................._... __..._... _..................-..............v... ..............._... _.' INSURE? .. _ II' 1 000 000.00 SIMMER F• r 6,11 • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE EXCLUSIONS AND.CONDITION$ OF SUCH POLICIES. LIMITS LISTED BELOW HAVE BEEN ISSUED TERM OR CONDITION OF ANY CONTRACT INSURANCE AFFORDED BY THE POLICIES SHOWN MAY HAVE BEEN RE nnl my N IMc1FR TO THE OR DESCRIBED UCED BY P POLICY EFF a • , . 12/14/2015 INSURED NAMED OTHER DOCUMENT HEREIN D. CLAIMS POLICY EXP 12/14/2016 . ABOVE FOR THE POLICY WITH RESPECT TO IS SUBJECT TO ALL THE PERIOD WHICH THIS TERMS, INSRADDI•SUBR J•Ta' . ' Trg OF INSUIjA(•1¢E l.liln 1Etyla A COMMERCIAL GENERAL LIABILITY 01 85F L00077542 - 0 .. FAC -I 1VV9IRPFNCF .. _ II' 1 000 000.00 PREMISES r 6,11 CLAIMS -MADE Mi OCCUR I I , r" NAM EXP (Anv one oerson s 5.000.00 MI pEF3.SDNAL-R-BnV IN* IRY_ /_1 {K52,000.00 x 1 000 000 00 GI-E,NI'L AGGREGATE LIMIT APPLIES PER- POLICY J PEC U LCC 1 1 OTHER , rFNFRAI. Arsr•RFGATF -; •. i. - ,. - lei . i 11 - h IIP a SINGLE Limn* IFRaccplL_._...._.._._._._._.___.. S r.2 td,. s.4 ._..__ .............._...___..._._..,, $ AUTOMOBILE LIABILITYCOMBINED J ANY AUTO ALL OWNED OS I SCHEDULED HIRED Al1TOSAUTN03wNFD BODILY INJURY (Per person) BODILY INJURY'Per accident) S War PROPERTY Y rfi— s FACH nr.CIIRI Nr.F UMBRELLA LIAB OCCUR EXCESS LIAB I nl AIM MAnr.. :. 5 co 7 nun n RFTFNTYVeIS - WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANY PROPRIETOR/PARTNERIEXECUTIVE— OFFICER/MEMBER EXCLUDED? I (Mandatory In NH) If yes. describe under DESCRIPTION OF OPERATIONS beim N IA ' U P RTUTE C DTH- e EL EACH ACCIDENT . S F L mSEACE; FA EMPLCWF 3 E L. DISEASE • POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule. If more space Is required) License number: CFC 1428820 Miami Shores Village Bldg Dep. 10050 NW 2nd Ave Miami Shores, FL 33138 ACORD 25 (2014/01) QF , CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ANGEL DEL TORO © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHIEF 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: 5/31/2015 PERSON: TEJERA FEIN: 461406499 BUSINESS NAME AND ADDRESS: AT QUALITY PLUMBING INC EXPIRATION DATE: 5/30/2017 ALEXIS 6055 W 19TH AVE APT 320 HIALEAH FL 33012 SCOPES OF BUSINESS OR TRADE: CERTIFIED PLUMBING PLUMBING NOC AND CONTRACTOR DRIVERS Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... 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 certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?.(850)413-1609 AT QUALITY PLUMOING 6055 W 19th live # 320 Hialeah, FL 33012 Tuesday, March 22, 2016 Sate of Florida County of Miami Dade Before me this day, appeared Alexis Tejera who, being duly sworn, deposes and says: That he will be the only person working on the project located at 118 NW 103 Street, Miami Shores Sworn and subscribed before me this 22nd of March of 2016 by Alexis Tejera. Produced Valid Driver's License. Daniel A. Kaxadewsa NOTARY PUBLIC STATE OF FLORIDA .""..,-0; Commit FF177683 Expires 11/18/2018 Notice to Owner — Workers' Com p Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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 coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner Mgt** k° ,eo let State of Florida County of Miami -Dade The foregoing was acknowledge before me this 22 day of i70r' , 20 ( . By -y j.= - d-ty % ,L t who is personally known to me or has produced as identification.