PLC-12-532Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 171603 Permit Number: PLC -3 -12 -532
Scheduled Inspection Date: April 13, 2012
Inspector: Hernandez, Rafael
Owner:
Job Address: 8700 BISCAYNE Boulevard
Miami Shores, FL 33138-
Project: <NONE>
Contractor: PULLES PLUMBING COMPANY
Permit Type: Plumbing - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060201030
Phone: (786)251 -1234
Building Department Comments
RELOCATE AND REPAIR EXISTING BACKFLOWN
PREVENTOR AND CERTIFY IT
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
April 13, 2012
For Inspections please call: (305)762 -4949
Page 7 of 8
MIAMI - DADE
MIAMI -DADE WATER & SEWER DEPARTMENT
METER OPERATIONS & MAINTENANCE
CROSS CONNECTION CONTROL UNIT
1001 N.W. 11th STREET, MIAMI, FL 33136-9934
Phone (305) 547 -3046 Fax (305) 545-9555
SERVE • CONSERVE
1
ADDRESS OF DEVICE
OWNER CONTACT:
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
y 2041 &s e7 ever
ZLPjj fro /JJs
OWNER OF DEVICE /� % Q 1,� J�
PHONE 305 7s. / �.D / /IS /FAX
ADDRESS OF OWNER:
2
3
NAME OF TESTER:
TEST MAKEr
Pin
cerifficArr,s
MODEL NO: e
CERTIFICA. j�j0'
IXPIROI ATE:
Bus s4D 5:Pki
ZIP CODE:
SERIAL NO:
DATE LAST
SITE TUBE
YES / NO
4
LOCATION OF ASSEMBLY: Xenr
y
INITIAL TEST:
ANNUAL TEST:
SHUT OFF VALVE #1:
CLOSED TIGHT:
LEAKED:
SHUT OFF VALVE 12:
CLOSED TIGHT: !tee Ne
LEAKED:
HAZARDBERVIS,fr
�ELS
DATE OF TEST: ,+ /(V /0, y+q,
LINE PRESSURE.
METER NO.
METER READING:
PRESSURE STAB
NO
CHECK VALVE NO. 1
CHECK VALVE NO. 2
DIFFERENTIAL RELIEF VALVE
AIR INLET
CHECK VALVE
Closed Tight: X
Leaked:
Closed Tight: X'
Leaked:
FAILED TO OPEN*
FAILED TO OPEN•
LEAKED._
PRESSURE DIFFERENTIAL ACROSS CHECK
r PSI
PRESSURE /DIFFERENTIAL ACROSS CHECK
'` PSI
OPENED AT: PSI
OPENED AT:
PSI
HELD AT:
PSI
EMBLY FAI
THIS N AND NO
REMARKS / REASON FOR FAILURE (IF APPARENT):
N
cc
Zr
a
W
cc
CLEANED:
CLEANED:
CLEANED:
CLEANED.
REPLACED:
REPLACED:
REPLACED:
REPLACED:
V!
R.P.Z.A.
F•
CHECK VALVE NO. 1
CHECK VALVE NO. 2
DIFFERENTIAL RELIEF VALVE
AIR INLET
CHECK VALVE
Closed Tight: Closed Tight: FAILED TO OPEN'
Leaked:
Leaked:
FAILED TO OPEN:_
LEAKED: —
PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK
PSI PSI
OPENED AT:
PSI
OPENED AT:
PSI
HELD AT:
PSI
SIGNATURE OF CERTIFIED TESTER:
FOR OFFICE USE ONLY:
DATE:
b
Revised: 12/08/2003
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
2L i2
FBC 20
Permit No. VC) ] 27-0-52--
Master Permit No.
Permit Type: PLUMBING
540B ADDRESS: ' 7 00 313C4/'og. 8/i4
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #: ®6 6 21)/2930
Is the Building Historically Designated: Yes
Flood Zone:
XI OWNER: Name (Fee Simple Titleholder): L''� /31 c'704
?.o/ /✓kJ 89- /v-
Address:
Phone #: 3t f/ f` o o o I
City: /% -04147
Tenant/Lessee Name: Phone #:
Email:
State: Zip: 33 /Td'
€ CONTRACTOR: Company Name: �X� �� Phone #:. 3 � °.rs yi
Address: X115 i/ •e4/ 1'1,3 ,'
City: 0,0�76 n State: r� Zip: 3'3/ g'3
Qualifier Name: < /.0,..e- iaLL®s- Phone #: Ted ®as 4
State Certification or Registration #: T". � cis Certificate of Competency #:
Contact Phone #: ts rC Email Address: c' ioULz,,- , 0 v9 , f J.QJ ""
DESIGNER: Architect/Engineer: Phone #:
Vlllue o €, -Work for this Permit: $ / 3'> Square/Linear Footage of Work:
pe of Work: OAddress<_Rtllteration ONew epair/Replace ODemolition
Description of Work: Ie h c L'� /.s ' 11,C-le-le-me., if- '4..,0
******** * * * * * * * * * * * * * * * * * ** * ** * * * * * * * ** Fees************* * * * * *** *** * * * **** ** * *** * * * * ** **
Submittal Fee $ Permit Fee $ tiC' e CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: 1 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.
jd Signature
Owner or Agent
The foregoing instrument was acknowledged before me this a 7
day of 20 I,�., by ®gc# . o
who is personally kno o me or who has produced ra/ /4_,
As identification and who did take an oath.
NOTARY PUBLIC:
The foreg
day of
is
ssion Expires:
ms,
Contractor
ent w ackno edg -s befor
,20 ,by _ #i111_4,
ersonally known to me or who has produced'
2 , identification and who did take an oath.
PUBLIC: - -
an
g31
■
T
Y
Sign:
Print:
My Commis
,'',,, Slate °,. Notary Public _
• o $eP 23.2015
WI•tAy Corn mission # EE 12: `
'ss. CommfO qr Nat[o ra+ Notary
Assn
2l�FO X41` goofed
4un„
************************** ************************************************* ** * ***** ** ** * ** * ** ** *** * *******
APPROVED BY
(mil®
Plans Examiner
Zoning
Structural Review Clerk
(Revised3 /12/2012XRevised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
11 -07 -2011
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER 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:
PERSON:
FEIN:
11/07/2011 EXPIRATION DATE: 11/06/2013
PULLES
650502786
BUSINESS NAME AND ADDRESS:
PULLES PLUMBING COMPANY
8541 SW 133RD PL
MIAMI FL 33183 -4177
CARLOS H
SCOPES OF BUSINESS OR TRADE
1- CERTIFIED PLUMBING CONTRACTOR 2- PLUMBING
* *
IMPORTANT: 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 ant recover benefits or compensation under Ibis 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 certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
PLEASE CUT OUT THE CARD BELOW
QUESTIONS? 1850) 413 -16(
AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS COMPENSATION LAW
EFFECTIVE 11/07/2011 EXPIRATION DATE:
PERSON: CARLOS H PULLES
FEIN: 650502786
BUSINESS NAME AND ADDRESS:
PULLES PLUMBING COMPANY
8541 SW 133RD PL
MIAMI, FL 33183 -4177
SCOPE OF BUSINESS OR TRADE
1- CERTIFIED PLUMBING CONTRACTOR 2- PLUMBING
11/06/2013
F Pursuant to Chapter 440.05114), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.05112), F.S., Certificates of election to be
H exempt... apply only within the scope of the business or trade listed on
E the notice of election to be exempt
R
E 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 certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
IMPORTANT
QUESTIONS? (850) 413-1609
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TT BE EXEMPT REVISED 01-11
MIAMI -DADE COUNTY
TAX COLLECTOR
140 W. FLAGLER ST.
1st FLOOR
MIAMI, FL 33130
2011 LOCAL BUSINESS TAX RECEIPT 2012
MIAMI -DADE COUNTY - STATE OF FLORIDA
EXPIRES SEPT, 30, 20-12
MUST BE DISPLAYED AT PLACE OF BUSINESS
PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10
325238-4
uVtiffetwftliftle COMPANY
8341 SW 133 PL
33183 UNIN DADE COUNTY
FIRST- CLASS
U.S. POSTAGE
PAID
MIAMI, FL
PERMIT NO. 231
THIS 1S NOT A BILL — DO NOT P Y ' RENEWAL
STATErc 60186693 338813 -9
° 7RLLES MARIA
sec1T9vge fiNieftle CONTRACTOR
THIS IS ONLY A LOCAL
BUSINESS TAX RECEIPT. IT
GOES ran PERMTr THE
HOLDER TO VIOLATE ANY s:
''EXISTING REGULATORY OR
ZONING LAWS OF THE ;
COUNTY OR CTRES. NOR
' DOES IT EXEMPT ME
HOLDER FROM ANY OTHER.
PERMIT OR UCENSE
REQUIRED BY LAW. 1115 IS
NOT lA CERTIFICATION OF,
' THE HOLDERS QUALIFICA-
PAYMENT RECEIVED
MIAMI- DADE COUNTY TAX
COLLECTOR:
10/12L2011
02220008001
000082.50
SEE OTMER SIDE
WORKER /S
2
DO NOT FORWARD
PULLES PLUMBING COMPANY
CARLOS HUMBERTO PULLES
8541 SW 133 PL
MIAMI FL 33183
11111111111111111111111 I I 1111111111111111111111 1IMMI
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING HOARD (850) 487 -1395
1940 NORTH MONROE STREET
TALLAHASSEE FD 32399-0783
PULLES, CARLOS HUBERTO
PULLES PLUMBING COMPANY
8541 SW 133RD PL
MIAMI FL 33183
Congratulations! With this license you become one of the nearly one million
Floridians licensed by the Department of Business and Professional Regulation.
Our professionals and businesses range from arches 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
For information about our services, please log onto www.mytioridalicense.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 Effidently, 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 licensed
DETACH HERE
4MilifiLATION .
p� , SEQ#L1o054
DATE " "° """`BATCH NUMBER
05/28/2010 098166953 C 0056693"
The PLUMBING CONTRACTOR
Named below IS CERTIFrI
Under the provisions of chapter
Expiration date: AUG 31;t, 2012
PULLES, CARLOS HUB
PULLES _ PLUMBING CO
8541 < SW:' 133RD PL
MIAMI
ziTa
84/18/2011 15:14 9549211964
ACORD,. CERTIFICATE OF LIABILI
PRODUCER
Ace Underwriting Group
5305 W. Browaxd Blvd.
Plantation, FL 33317
954 -581 -0202
INSURED
Pulles Plumbing Co.
8541 Sw 133 Place
Miami FL 33183
COVERAGES
ACE UND GRP HWD
PAGE 18/21
rY INSURANCE DATEpasuourm
04/18/2011
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
INSURERA: Capacity Insurance Co.
INSURER B:
INSURER C:
INSURER D:
A. URER E
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 OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NOR
TYPE OF INSURANCE
POUCY NUMBER
GENERAL UABI IlY
COMMERCIAL. GENERAL u*siur '
1 CLAIMS MADE 13 occult
GENL AGGREGATE UNIT APPLIES PER;
POLICY nip. n Um
AUTOMOBILEUABIUTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
APP91230105
8J'J.,1.7
04/14/11
EACH OCCURRENCE
UNITS
31, 000, 000
FIRE DAMAGE (Ary ens lee) 5100, 000
HIED EXP (Any one pecan) 35,000
04/14/12 PERSONAL S ADV mum',
GENERAL AGGREGATE
PRODUCTS - GLOP AGO
31, 000, 000
02,000,000
s1, 000,000
COMBINED SINGLE LIMIT
(EeealBma)
BODILY INJURY
(Pv per onl
BODILY INJURY
(Per ecalded)
PROPERTY DAMAGE
GARAGE UAEIU1Y
RANY AUTO
EROESSLIABILITY
OCCUR El CLAIMS MADE
OEGUCTISLE
RETENTION s
WORKERSCOMPENSAnoN AND
EMPLOYERS UASIUTY
AUTO ONLY - EA ACCIDENT
3
oTHERTHAN
AUTO O
EA ACC
0
AGG
c
EACH OCCURRENCE
AGGREGATE
3
3
3
iii,
STAN-
3
D
ER
E.L EACH ACCINT
3
LL, DISEASE - EA EMPLOYEE
S
EL DISEASE . POIJCY LIMIT
DESCRIPTION OF GPERATIONSHACATIONSNEWCLESS $ESCLUSIONS ADDED BY ENDORSEMENT/SPECIAL WROVISSONS
CERTIFICATE HOLDER 1 1 ADDITIONAL INSURED: INSURER LETTER:
MIAMI SHORES
10050 NE 2 AVE
MIAMI SNORES FL 33138 -2382
FAX: 305-756 -8972
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUc ES DE CANCELLED BEFORE THE E%AIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRIITBN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
IMPOSE NO • CATION OH UABIUTY OF ANT KIND UPON THE INSURER. ITS AGENTS OR
REPRO
ACORD 25-S (7157)
o ACORD CORPORATION 1888