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RC-16-1384 (3)r(„al ott\i(a BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ❑ ROOFING MAY 19 2016 30croc.4... FBC 2011 ' Master Permit No. Fr 1 v - 1 SELI , Sub Permit No. ❑ REVISION ❑ EXTENSION El RENEWAL E3 PLUMBING ❑ MECHANICAL EI PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1 s 1 6 [QC 10 / SittcET City: Miami Shores County: Follo/Parcel#: 11 - 22_31- 031 - d 3 6 0 Miami Dade Zip: 33/ 3 9 Is the Building Historically Designated: Yes NO Occupancy Type?" 1-'1:. Load: Construction Type: C.12,6 Flood Zone: 415= ' BFE: FFE: pH1►1r4y OWNER: Name (Fee Simple Titleholder): Ont) (0 1- c-flOAP g o c Phone#: 98‘ - v 77 - 9 '2O Address: lc/ (, NC= ((4 7 l ST2ct' City: 141 I Priv` I Sf/52E3 State: FL0(0/i Zip: 5. 3/ 3 Tenant/Lessee Name: Phone#: Email: dCCLe. g)OLb/C4S iIOWNrvtowef. CONTRACTOR: Company Name: F162 r0A- ONE GL- /l'A_ CUtTeriG%(Jes Phone#: 305 --SUS" yew— Address: 'a 2 O 447 C%% ('2E?K City: p02-#1 M/ / State: rL Qualifier Name: r2U&2T FLE1411m6. Zip: 3'/f/ Phone#: 3o 5- - SOS' 4/O/1 i State Certification or Registration #: C6- I SZ cf 7 o Certificate of Competency #: U DESIGNER: Architect/Engineer: /I/r)( L-OLFt Aga -OTC -ZS- Phone#: 'O r 2 GC 7 (6 - / Address: 107 t%1= (76 5 ► City: !V/►^ 5/f& t z State: Fe_ Zip: 33 13 8 Value of Work for this Permit: $ 3 21 ow Square/Linear Footage of Work: 5 31. Fr 2 - Type Type of Work: ❑ Additioni❑ Alteration ❑ New Repair/Replace ❑ Demolition i+f Description of Work: fwvC, Prik,0 AeL-1f1'(-C 0 g. - PL -001Z CJ N VAST" 510. (6A(D 0vLC a 70 gerTW , :PC Specify color of color thru tile: r Submittal Fee $ S Ql ®C) Permit Fee $ �GO CCF $ (9 t • CO/CC $ )) - Scanning Fee $ 1 'CA.. Radon Fee $ t *• DBPR $ 1'4 • Q Notary $ 0 Technology Fee $ 2-S • 00 Training/Education Pee $ (4C) Double Fee $ Structural Reviews $( 20_ O t2,0 (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ I / .! 2_ • 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, trcertified cupy of the Iecordectnotice of commencement mast gusted at thelonite 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 �,i(; _/gnature OWNS or AGENT The foregoing instrument was acknowledged before me this 1 day of a " c , 20) (® , by DA Via 4 l..0 rolyn 514,,T , who is personally known to me or who has produced 1'10"'4=14. DL as identification and who did take an oath. NOTARY PUBLIC: APPROVED BY (Reviseda2/24/2014) The foregoing instalment was sa clay civil- fi 1( ewi zi /CONTRACTOR me or who has produced acknowledged before me this 20 a , by who is personally known to identification and who •'d take an oath. NOTARY ' UBLIC: Sign: P.M`` . .,gyp �I EA3krel 17. t rM 12.2ots 1,10. FF 21967 i Q ****** I Ntr p of 4t.%#41******************************** Plans Examiner's/ Hm� .0- /.1 Kevi c< as Zoning Structural Review Clerk DCIV LHVVO1JIV, JCLiNC INR T STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LFENSE NUMBER The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 FLEMING, ROBERT F FLORIDA ONE GENERAL CONTRACTORS, INC. 2205 ARCH CREEK DRIVE NORTH MIAMI FL 33181 ISSUED: 08/11/2014 001598 DISPLAY AS REQUIRED BY LAW Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 7100704 BUSINESS NAME/LOCATION FLORIDA ONE GENERAL CONTRACTORS INC 2205 ARCH CREEK DR NORTH WWI FL 33181 OWNER FLORIDA ONE GNRL CONTRACTORS INC Workers) RECEIPT NO. RENEWAL 7378664 SEQ # 11408110001287 LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 9A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 GENERAL BUILDING CONTRACTOR CGC1520690 PAYMENT RECEIVED BY TAX COLLECTOR 2 545.00 08/24/2015 CHECK2I-15-116497 This Loeel Business Tax Receipt only confirms payment of the Local Business Tan. The Receipt is not a license. panttit or a certification al the holder s qmlificabens, to da business. Nelda must comply with any governmeatel or nongovernmental regulatory taws and requirements which apply to the business. The RECEIPT NO, above must be displayed on alt commercial vehicles - Miene-Dela Code Sec ha -276. Fat more information, visit g nmittiamidade,guvttnnpuNoctar FLORI14 OP ID: NR ':A or R"m CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/19/2016 '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 BUTLER, BUCKLEY, DEETS INC. 6161 BLUE LAGOON DR., STE 420 MIAMI, FL 33126 William S. Bodenhamer CONTACT NAME: WILLIAM BODENHAMER A/C. No. Est):305-262-0086 FAX No): 305-262-0198 E-MAILDRLSS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Maxum Indemnity Company LIABILITY COMMERCIAL GENERAL LIABILITY INSURED FLORIDA ONE GENERAL CONTRACTORS INC. 2205 ARCH CREEK DR MIAMI, FL 33181 INSURER B: FUBA WORKERS' COMP BDG3014069-01 INSURERC: 05/17/2017 INSURER D : $ 1,000,000 INSURER E : $ 100,000 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. INSR LTR TYPE OF INSURANCE ADOL INSR SUER wvn POLICY NUMBER POUCY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY BDG3014069-01 05/17/2016 05/17/2017 EACH OCCURRENCE $ 1,000,000 DAMAGES (EaRENTEDoccurrence) PREMISES ( $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE 7 POLICY LIMIT APPLIES O- JET PER: LOCP PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE JPER ACCIDENT) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A 106-54998 06/18/2015 06/18/2016 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CGC 1520690 Executive Supervisor - CERTIFICATE HOLDER CANCELLATION Village of Miami Shores 10050 NE 2 Ave Miami Shores Village, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 07-12-2016 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: 07/12/2016 EXPIRATION DATE: 07/12/2018 PERSON: FLEMING ROBERT FEIN: 455164463 BUSINESS NAME AND ADDRESS: FLORIDA ONE GENERAL CONTRACTORS INC 2205 ARCH CREEK DRIVE NORTH MIAMI FL 33181 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR * 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 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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 13WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW 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: 07/12/2016 EXPIRATION DATE: 07/12/2018 PERSON: ROBERT FLEMING FEIN: 455164463 BUSINESS NAME AND ADDRESS: FLORIDA ONE GENERAL CONTRACTORS INC 2205 ARCH CREEK DRIVE NORTH MIAMI, FL 33181 SCOPE OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR IMPORTANT OPursuant to Chapter 440.05(14), 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 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on Rthe notice of election to be exempt. 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. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. MC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Florida General contracts nJ (305)505-4015 1 � State of Florida County of Dade August 29,2016 Florida One General Contractors 2205 Arch Creek Drive North Miami, Fl. 33181 CGC # 1520690 Floridalgc@gmail.com Ph.: 305 505-4015 Before me this day personally appeared Robert Fleming who being duly sworn, deposes and says: That he or she will be the only person working on the project located at 1516 Ne 104 st, Miami Shores, FL Sworn to (or affirmed) and subscribed before me this 29th day of August, 2016, by Personally know i✓ Or by produced I.D. Type of I.D. produced 91��i-e r Ztc-e-9 se- - 13 4 Miam Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation 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: C.t Own State of Florida County of Miami -Dade The foregoing was acknowledge before me this 69 Z.day of By /4ii/m ` n0/9 who ersonally known to m ,20/6 ra' mmi 1St JESSE WALTERS Notary Public - State of Florida M Comm. Expires Sep 23, 2016 Commission # tE 837922 or has produced Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number Expiration: 02/25/2017 Applicant 1516 NE 104 Street Miami Shores, FL 1122320320360 Block: Lot: DAVID SHOAF Owner Information Address 1516 NE 104 ST MIAMI SHORES FL 33138-2666 Phone Cell Contractor(s) Phone CeII Phone FLORIDA ONE GENERAL CONTRACT (305)505-4015 Valuation: Total Sq Feet: $ 32,000.00 532 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: REMOVE AND REPLACE DAMAGE Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: Bond Return : Occi Exte Rear Setback: Right S Bathr Certificate Stat Additional Info': Classification:M TR/7:. CT ,,,,,,,,,„... iwi. Fees Due CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Plan Review Fee (Engineer) Plan Review Fee (Engineer) Scanning Fee Technology Fee Total: Amount $19.20 $50.00 $14.40 $14.40 $6.40 $960.00 $120.00 $120.00 $12.00 $25.60 $1,342.00 Pay Date Pay Type Invoice # RC -5-16-59858 08/29/2016 Check#: 001661 $ 1,292.00 $ 50.00 05/19/2016 Check #: 001629 $ 50.00 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Fill Cells Columns Final PE Certification Window Door Attachment Framing Insulation Drywall Screw Window and Door Buck Review Planning Review Mechanical Review Plumbing Review Building Review Building Review Electrical Review Electrical Review Electrical Review Structural Review Structural 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 ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above-named co or to do the work stated. August 29, 2016 Authorized Signature: Owner / Applican / Cont r- or / Agent Building Department Copy Date August 29, 2016 1