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DS-17-401 Permit NO. D5-2-17-401 ,SaoRes�� Miami Shores Village Permit Type:Driveways/Sidewalks/Slabs 10050 N.E.2nd Avenue NW ' Work Classification:Addition/Alteration Miami Shores,FL 33138-0000 Perill Permit Status:APPROVED Phone: (305)795-2204 FtORIV Issue Date: 2/16/2017 Expiration: 08/15/2017 Project Address Parcel Number Applicant 129 NW 96 Street 1131010250100 Miami Shores, FL 33138- Block: Lot: ERIK SACCOMANI Owner Information Address Phone Cell ERIK SACCOMANI 129 NW 96 Street MIAMI SHORES FL 33150- 129 NW 96 Street MIAMI SHORES FL 33150- Contractor(s) Phone Cell Phone Valuation: $ 1,000.00 CONSTRUCTION DEVELOPER GROUI (305)215-1988 ___ _ _ __._ _ _......_.. ....... ...._...,...__....._. Total Sq Feet: 100 Approved: In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:NEW APPROACH Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning:2 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# DS-2-17-62961 $2.25 02/16/2017 Credit Card $ 117.10 $0.00 DCA Fee $2.25 Education Surcharge $0.20 Notary Fee $5.00 Permit Fee $100.00 Scanning Fee $6.00 Technology Fee $0.80 Total: $117.10 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRIC PLUMBING, MECHANICAL,WINDOWS,DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDA : I certify th a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and ning. Futh I authorize the above-named contractor to do the work stated. February 16, 2017 A Datey1lorized S;pKalure:Owner / Applicant / Contractor / Agent Building Department Copy February 16, 2017 1 Miami Shores Village ��` � • Building Department CPITV 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 Tel:(305)795-2204 Fax: (305)756-8972 :iF INSPECTION LINE PHONE NUMBER:(305)762-4949FBC 2 BUILDING Master Permit No. PERMIT APPLICATION sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION F-1 RENEWAL ❑PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION FD SHOP CONTRACTOR DRAWINGS JOB ADDRESS: � 6 th City: Miami Shores County: Miami Dade Zip: I r� Folio/Parcel#: Is the Building Historically Designated:Yes NO V Occupancy Type: Load: �Construction Type: I/ Flood Zone: BFE: FFFE: OWNER: Name(Fee Simple le Siimple�Tit eholder): ��I(1� � t �1� Phone#: Address: �� t)W "[6 5 / City: y`�q I ar7 t'1\/fL State: FL Zip: Tenant/Lessee Name: / Phone#: Email: K de-c74 ��f i CONTRACTOR:Company Name: (/��IrPhone#: Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ IM-00 Square/Linear Footage of Work: -Soe Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ,(�. f,A,))/� ❑ Demolition f Description of Work: WtbA10 � A R / Specify color of color thru tile: •- Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) { 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 approve and a reinspection fee will be charged. t Signature Signature Ror AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of20 1 by day of 20 by SOCCCOV f"OnImho is personally known to who is personally known to me or who has produced S?SS" 2 g 'a S_Lass me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: �(LSign: Sign: Print: "''``�• MAH Print: MMISSIOGG 044802 Seal: -Fg q-7eondeXP RES:November 2,2020 Seal: d Thru Notary Public Underwriters APPROVED BY ll/ / Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) OR % .%r_1 s Miami Shores Village -,,, ,_,,, Building Department 10050 N.E.2nd Avenue �toRNp Miami Shores, Florida 33138 Tel:(305)795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT K /J!` NAME:— fi I ri/`�� DATE: ADDRESS: Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,F.S 489.103(7).And I have read and understood the following disclosure statement,which entitles me to work as my own contractor;I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor.You have applied for a permit under an exception to the law.The exemption allows you,as the owner of your property,to act as your own contractor even though you do not have a license.You must supervise the construction yourself.You may build or improve a one-family or two-family residence.You may also build or improve a commercial building at a cost of$25,000.00 or less(The new form states 75,000).The building must be for your own use and occupancy.It may not be built for sale or lease.If you sell or lease a building you have built yourself within one year after the construction is complete,the law will presume that you built for sale or lease,which.is a violation of this exemption.You may not hire an unlicensed person as a contractor.It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances.Any person working on your building who is not licensed must work under your supervision and must be employed by you,which means that you must deduct F.I.C.A and with-holdings tax and provide workers'compensation for that employee,all as prescribed by law.Your construction must comply with all applicable laws,ordinances,buildings codes and zoning regulations. Please read and initial each paragraph. 1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner-builder permit under an exemption from the law.The exemption specifies that 1,as the owner of the property listed,may act as my own contractor with certain restrictions even though I do not have a license. i Initial lo 2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial 3. 1 understand that,as an owner builder,I am the responsible party of record on a permit.I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name.I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits andccontracts. Initial (i 4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding.I may also build or improve a commercial building if the costs do not exceed$75,000.The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease.If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete,the law will presume that I built or substantially improved it for sale or lease,which violates the exemption. Initial f: 5. 1 understand that,as the owner-builder,I must provide direct,onsite supervision of the construction. Initial 6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence.It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance. Initial 1 ' 7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner-builder permit that erroneously implies that the property owner is providing his or her own labor and materials. I,as an owner-builder,may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property.My homeowner's insurance may not provide coverage for those injuries.I am willfully acting as an owner-builder and am aware of the limits of my insurance coverage for injuries to workers on my property. Initial 8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done.Any person working on my building who is not licensed must work under my direct supervision and must be employed by me,which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act(FICA)and must provide workers compensation for the employee.I understand that my failure to follow these may subject to serious financial risk. Initial C 9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide by all applicable laws and requirement that govern owner-builders as well as employers.I also understand that the Construction must comply with all applicable laws,ordinances,building codes, and zoning regulations. Initial 10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,the United States Small Business Administration,and the Florida Department of Revenues.I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http:/http://www.m�loridalicense.com/dbpr/pro/cilb/index.htmi/dbpr/pro/cilb/index.htmi Initial 11. 1 am aware of,and consent to;an owner-builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: 7q Initial 12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the information that I have provided on this disclosure. Initial Licensed contractors are regulated by laws designed to protect the public.If you contract with a person who does not have a license,the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court.It is also important for you to understand that,if an unlicensed contractor or employee of an individual or firm is injured while working on your property,you may be held liable for damages.If you obtain an owner-builder permit and wish to hire a licensed contractor,you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued,this disclosure statement must be completed and signed by the property owner and returned to the local permitting agency responsible for issuing the permit.A copy of the property owner's driver license,the notarized signature of the property owner,or other type of verification acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this day of 6&Ay, 20 By��� 1 S����Yl t who was personally known to me or who has Producedther �ice�nsel —5S I -05Z. --© as identification. MAHARAI K.GONZALEZ ' = MY COMMISSION#GG 044602 EXPIRES:November 2,2020 OWN NOTARY "''sof F; Bonded Thru Notary Public Undenwiteno • 6862 N.W.7th STREETWM 20a EOAE(3jNaTaEPHOS2664-2960 XiuuPurVe�hrs Inc.. SURY'y tl-oof10A76-1 - FAX:(305)2M-0229 q oNawN sr: uir LAND SURVEYORS SHEET Na 2 OF 2 IaERMIT #_ BOUNDMYSURVEY Miami Shores Villag a 1..26' APPROVED BY DEPT �I 111III IWV 1 2Gti ' C] �' ED g ZONING OT-7 1,Ot 6 B CK-3 RL 0) BLd EP7 w DY: - - --- - _-' 0 w 1-210`x- Ir SUBJECT TO CCtvl CE WITH ALL FEDERAL . p I STAXE AND l'GUniY LES AflD REGULATIONS F m u J 15ALLEY(N.A.P.) _ i NO CAP_.. 73.00' NO CAP h j Z L L -D *1+101 6'W.F. 90°7Z JO' F W F- J 0.10-CL. rats ram 1.50 CL y Lu 2 — s�_ W ��� W z (3 w w 1&4' a,r J a_ o o m POOL b <1 NJ m (f) U) 5'C.L.f, mss TQLF: 1 :,,JACUZM'. UJJIM COP Cg Permit no.Ap_1"6 Z99 Date e,2_fZ® 12 8 12.59' �� IVti-d Haft atni- e 13.47 ra.0 LOT-10 �W,F, 3.1T LOT-11 �— BLOCK•d ZO.bS Lor-9 BLOCK-3 TWO STORY POOL BLOCK-3 RES.#129 PUMP G ' r. GAR � GARAGE=10.81' w 0.2 FLOOD VENT=10.80' tr r3,r p rasa 1.01'CL ° 35.85 4 7 M. 13.4 M T� J ase con cre Ikway J7 u SE TA�IGo � 90.12 'a d 9.47+0°• atar F.I.P 112•. 6' NGT., •79.00' ,F:IP4lZ' LNUC�X'�( NO CAP 0 t- Pe, -i no. ch Date: 14 Z-0 $ > O tlI 3nlf 1 faQB OU11ty 1e PVMT.ASPHALT $ liss a Ln Health De M" ism ia.r. Puhnent �• �- j--- Q P N.W. 96th. ST., 15'MEDIAN j}� ✓' 16'ASPHALT PvMT. SURVEYORS NOTE: There may be Easements recorded in the Public Records not shown an this Surwy. •Tho purpose of this Survoy is for uao in obtu union Tido Insurmwe and Pneneing and n hsuld not be u64d fOr COnctruetbn Purposes PERMIT# CONTRACTOR: SUBMITTAL DATE: S J ADDRESS: acl iv LQ -l NAME: RESUBMITAL DATES: PROJECT TYPE;__ ZONING_------~-'� 1 FIRE STRUCTURAL IMPACT FEES ELECTRICAL HRSIDERM PLUMBING N MECHANICALBLDG j Miami Shores Villages- , Building Department I MAR 2 013 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 �\ Tel: (305)795.2204 Fax: (305)756.8972 �- _'=•-_ '______ INSPECTION'S PHONE NUMBER: (305)762.4949 _ v FBC 20 BUILDING Permit No. $1 3 PERMIT APPLICATION Master Permit No. Permit Typ< BUILDING ROOFING JOB ADDRESS: W City: Miami Shores c County: Miami Dade Zip: l Folio/Parcel#: 'fl ,3461 -D25 -ooQ Is the Building Historically Designated: Yes NO (/ Flood Zone: OWNER:Name(Fee Simple itleholder):� `� 1�'f�"� lr-;Tkk Phone#: 7 •f? "/I Address: City: State: IZ Zip: Tenant/Lessee Name: l /l``,�., Phone#: / Email: r G 0ov6 kuL // /&6a ZoCt Z_ Cq Zo c) CONTRACTOR: Co �5^1L�/mpanyName: C4G/G��ON /b. &_rOU/7 Phone#: �ul 6 �/ d Address: D O N S 7'` 2 0 3 8/ N. 4,; City:n\) T")�V State: /— Zi 3 ,34D P� Qualifier Name: /-�. Sof Q,J Phone#: '714 �`/�/ (a8 State Certification or Registration#: 6C6 #1!5.0,q 9?5 Certificate of Competency#: Contact Phone#: /__T�1_�- 60 i6l Email Address: DESIGNER: Architect/Engineer: Phone#: o � Value of Work for this Permit: $ o© yy -Square/Linear Footage of Work: /0059P Type of Work:._❑Addition ❑Alteration iL ew ❑Repair/Replace ❑Demolition `Description of Work: ./ 0 cDhh -7-0 jae - !Y f Color thru tile: Submittal Fee 950,, Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ A } Bonding Company's Name(if applicable) Bonding Company's Address City State Zip / Mortgage Lender's Name(if applicable) /j �1) ,.ld�. �W�� Mortgage Lender's Address 2bol bI.SAC6 WE E CWQ City HMf AQ-61_ State LEW a:% � Zip 090,��-7 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: 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 ' sue the absence of such posted notice, the inspection will not be approved and a runs "ction fee will be charged. Signature Signatu Owner or Agent Contractor The foregoing instrument was acknowl dge re me this The foregoing instrument was acknowledged before me this day of M&// '201 ,byiG day of ,20 ,by �PtJr3� who ' perso111 ally own to or who has produced who i ersonally kno o me or who has produced -O �aLaication and who did take an oath. as identification and who did take an oath. NOTARY UB IC: NOTARY PUBLIC: I t.Los e t Elotid15 1 Sign: s Se 23'20 Sign: Print: r _htY ss,o�� ,Notary .0. Print: Print:. 1t' 31, :':e'°' ' gondedSh� My Commission Expire ''= MY COMMISSION 0 EE1Qgg,4g My Commissi 'Expires: -,9,E'„F., , �? EXPIRES May 29.2016 ��o� see�wsa APPROVED BY Plans Examiner v`t' Zoning a Structural Review Clerk (Revised 5/2/2012)(Revised 3/12/2012))(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) TAX RECEIPT 2013 FIRST-CLASS TAX COLIECTbR ," MU11�N COSTATE OF FLORIDA - U.S.POSTAGE tA0 W.FLA¢IlEfi STS �EXPIAS3 SEPT:30,2013 PAID It<t FLOOR YEib�11T PLACE OFBUSINES8 MIAMI,FL MUUh1l,Pl 33130 NT1f� CilAP,TEi�;GAf:ART.9 310 o PERMfT NO.231 A' f�� - 617845-3 THIS IS NOT A BILL—DO NOT PAY RENEWAL BuVWIAU MNEVELOPER GROUP CORP STATfflCKET9-04895644289-1 20381 NE 30 AVE 414 33180 CITY OF AVENTURA OWMSTRUCTION DEVELOPER GROUP COR WORKER/S s°`1W%MM BUILDING CONTRACTOR 1 THIS q ONLY A LOCAL W BUSESS TAX RECEIPT.R DOES NOT PERWT THE HOLDER TO VIOLATE ANY no LAWWS OF THHE DO NOT FORWARD COUNTY oft CRIES. NOR DOES IT AW TMOTHER E "OWER F1tOMANY CONSTRUCTION DEVELOPER GROUP CORP PERINT OR LCEIM GUSTAVO ASMAN REQUIRED NOT A cERxnRTPLAW.THS 20381 N E 30 AVE 414 TIM lcAnoN ow EASO1"""'C°'Toolts. AVENTURA FL 33180 PAYMEI(T RECEIVED MIAl"ADE COUNTY TAX COLLECTOR 09/05/2012 09010292001 i,Iii,I�i)IIIIiilIll,li,,,,,,iilililillliilillllliili,IiiIi 000045.00 SEE OTHER SIDE 06-07-2012 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: 07/12/2012 EXPIRATION DATE: 07/12/2014 PERSON: ASMAN GUSTAVO FEIN: 043709495 BUSINESS NAME AND ADDRESS: CONSTRUCTION DEVELOPER GROUP CORP 20381 NE 30TH AVE #414 AVENTURA FL 33180 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED GENERAL CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 05114), 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 440.05112), 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 440.051131, 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 ur 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 DWC-251 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW D chapter. EFFECTIVE: 07/12/2012 EXPIRATION DATE: 07/12/2014 Pursuant to Chapter 440.05(11), F.S.. Certificates of election to be PERSON: GUSTAVO ASMAN H exempt... apply only within the scope of the business or trade listed on FEIN: 043709495 E the notice of election to be exempt. R BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt constnuc roN DFvELCPFR GRO P CORP and certificates of election to be exempt shall be subject to revocation 203HI NE 30'il aVF 04.4 if, at any time after the filing of the notice or the issuance of the AvEN-URA, rL 33180 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 SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this �ERT:F ED GENERAL '.ON-RA,'TOR section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 AC bP DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/08/2013 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). CONTACT PRODUCERNAME:- PHONE ANTONIO ZALDIVAR � I NAME:_ First Class Insurance Market (A//CNNo.Ext): (305)441-2997 Fax .` -MAIL -- -- (A/C,No) _ (305)441-6443 - 4101 NW 9th Street ,_ADDRESS —fcimc@aoi.com- Miami,FL 33126 �— —___—_INSURER(S)AFFORDING COVERAGE NAIC#_ Phone (305)441-2997 Fax (305)441-6443 },INSURERA_ ATLANTIC CASUALTY INSURANCE COMP ! INSURED I INSURER B: —_ L CONSTRUCTION DEVELOPER MOUP CORP _tNSURERC:120454 WEST DIXIE HWY i INSURER D: I - - AVENTURA FL,33180 INSURER E: 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 i — IADDLiSUBRI POLICY EFF POLICY EXP LIMITS LTR-.' TYPE OF INSURANCE i)NSR WVD——.__.._POLICY NUMBER_. (MM/DDS)(MM/DD/YYYY� —____. GENERAL LIABILITY j I I EACH OCCURRENCE $ 1,000,000.00 i DAMAGE TO RENTED 1/ COMMERCIAL GENERAL LIABILITY 1 PREMISES.(Ea occurrence) „$ 100,000.00 I (Any one person) $ 5,000.00 MED EXP r CLAIMS-MADE ;�/ OCCUR 106592012 - _ _ A r , 06/11/2012 06/11/2013 PERSONAL a ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG j $ 2,000,000.00 1 L_.POLICY ;__i jE __ i:= LOC i $ —_ _. AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO j 1 ; BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ( I 1 AUTOS i AUTOS 1 i PROPERTY DAMAGE -) NON-OWNED j er accident $ j HIRED AUTOS 1._, AUTOS j _( l_._._..._.___—.__..__�__—____— I UMBRELLA LIAB OCCUR ! EACH OCCURRENCE $ EXCESS LIAB — $ CLAIMS MADE AGGREGATE L...i DED LJ RETENTION$ ' $ WC WORKERS COMPENSATION TORY LIMITS_ _%__ER. AND EMPLOYERS'LIABILITY Y/N j ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? "?1 N/A l (Mandatory in NH) i ! E.L.DISEASE-EA EMPLOYEE$ If yyes,describe under --- .. i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) i I i I CERTIFICATE HOLDER - --- - - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Miami Shores THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 N.E 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 I AUTHORI RE iIII T _ ----------- _ ESENTATNE 1988-20 10 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)QF The ACORD name and logo are registered marks of ACORD i AC# 6158908 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#L12061100821 . - LICENSE NBR 106/11/20121110423870 CGC1504895 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapters,;4;8.9 FS,;- . Expiration date : AUG 31, 2014 `� , - ASMAN, GUSTAVO ADRIAN A _ CONSTRUCTION DEVELOPER GROUP CORP, 20381 NE 30TH AVENUE #414 AVENTURA FL 33180 f RICK SCOTT KEN LAWSON ' GOVERNOR SECRETARY 1 i DISPLAY AS REQUIRED BY LAW Rick Scott Mission: Governor To protect,promote&improve the health of all people in Florida through integrated � (a John H.Armstrong,MD, FACS state,county&community efforts. HEALTH LTH State Surgeon General&Secretary Vision:To be the Healthiest State in the Nation March 19, 2013 Gustavo Asman 20381 NW 96 Street Miami, FL 33150 RE: Contingency Letter Application Document No:AP1100294 Centrax Permit Number: 13-SC-1460166 OSTDS Number: 129 NW 96 St Miami, FL 33150 Lot:10 Block:13 Subdivision: Dear Applicant: This will acknowledge receipt of an application dated 03/11/2013 for a permit to use an existing onsite sewage treatment and disposal system located on the above referenced property. Proposed driveway approach on parkway. From a review of your completed application, it has been determined your existing system is adequate for the proposed use. If you have any questions on this matter, please call our office at(786) 3154444. Sincerel , Carl a Enclosures cc: Florida Department of Health www.FloridasHealth.com in DADE COUNTY TWITTER:HealthyFLA 1725 NW 167 St,Opa Locka,FL 33056 FACE BOOK:FLDepartmentofHealth PHONE:(305)623-3500.FAX:(305)623-3645 YOUTUBE:fldoh