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RF-16-114 ' Miami Shores Village �JAN 14 2016cE�vEr� Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 $Y• Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 BUILDING GA 1N���Y E D Master Permit No. PERMIT APPLICATION 'ZE- )I ��!!ll���iii 6 Sub Permit No. ❑BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [—]PLUMBING F-1 MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLA CONTRACTOR JMNFn JOB ADDRESS: 310 NE 98 Street � City' Miami Shores County: Miami Dade Zip: 33� 3 Folio/Parcel#: 11-3206-013-5720 Is the Building Historically Designated:Yes NO X Occupancy Type: R"'>- Load: Construction Type: it 04& Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder):Claudia Moore Phone#:330-268-2314 Address:310 NE 98 Street City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name. n/a Phone#: Email: cmoore310@gmail.com CONTRACTOR:Company Name: c.1 e--4- � I Phone#: Address: �10�D� 1� � ✓�+N� l CkL. M City: ,v 1 �' State: T: � Zip: //�� � :3�-'-7 Qualifier Name: 71N�0 �-�-. �'�N-Z Phone#:� 1 r State Certification or Registration#: c—cj-- (�.3 l Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: i slue of Work for this Permit_$A'6,0C • Square/Linear.Footage_of_Work:� Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ 10•b CO/CC$ Scanning Fee$ 12�(�Radon Fee$ - v DBPR$ 2 ,Notary$ Technology Fee$ _Training/Education Fee$ ��bo Double Fee$ Structural Reviews$ Bond$ c TOTAL FEE NOW DUE$ O • D (Revised02/24/2014) c, Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address { p City State �ti l` a Zip 44.0.4.4+ 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 AFFIDAVIT:prI certify that all the foregoing information is accurate and that all work will be done in compliance with all yr ' V 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. 1 Signature 0 as k ca � Vry SDt _ Signature OWNER or AGENT CONTRA YOR The forgoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this V day o 20 / (4 tby..� %0 day of Jill 20 k(O by �IAL10\A--M0 whs personally k own to A LJVtZ.E 2le-I_IO who i ersonally know to Lime or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Si Sign. Print: S c Print: 1Vke=x P Seal: Seal: �' IVIS REY 4BYMt MY COMMISSION if 3,201 25 tate of Florida EXPIRES:August 03,201 S ck EE 13 _V� APPROVE ' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) sNOR� L�{ ., Miami shores Village Building Department '�CORIU� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ✓ COPY OF QUALIFIER'S STATE LICENCES B._�COPY OF LOCAL BUSINESS TAX RECEIPT C. _COPY OF LIABILITY INSURANCE* Y `X= D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT, D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ■rr•a■rrrrrr urr a rrr■rrrrrrrrrrrrrrrrrrrrrrrrrrr�rrrrrrrrrrra�rrrrrrrrrrrrrrrrrrrrrrrrar BUSINESS NAME: BUSINESS ADDRESS: I(C31��- l�lj t1'Y trf1GGC CITY (Y11C1I'"nI STATES ZIP I�f BUSINESS PHONE: f `7��)s -' S FAX NUMBER( ) CELLPHONE( ) QUALIFIER'S NAME: P'4ndt-Iff -ZIr"10 QUALIFIER'S LIC NUMBER: CC-C 15 50 t 8 5 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ZENO,ANDRE DECKTITE ROOFING AND WATERPROOFING, INC. 16104 KILMARNOCK DRIVE MIAMI LAKES FL 33014 Congratulations! With this license you become one of the nearly r.._..- one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range jSTATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. PROFE,. ; GULATION Every day we work to improve the way we do business in order to CCC13301135 .09/07/2014 serve you better. For information about our services,please log onto www.myfloridalleense.com. There you can find more information CERTIFIED R about our divisions and the regulations that impact you,subscribe :=fi ZERTI ANQR eg Ar to department newsletters and learn more about the Department's initiatives. DECKTITE R OOFING f , y Our mission at the Department is:License Efficiently,Regulate Fairly. °r� `• We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the`"provisions of Ch.489 FS. and congratulations on your new license! Expiration date;AUG 31,2016 L14OW70002962 .s DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD' CCC1330185 The RQOFING CONTRACTOR ~ Namedbelow IS CERTIFIED Under the provisions of Chapter 48.9 FS. Expiration date: AUG 31, 2016 ZENO,ANDRE ,.. . `'� ' ;.�. . ❑ DECKTITE ROOFING PROOFING, INC. } 16104 KILMARNOCKI:7 #= '"'++ "�' ;:� " ,k ' ` x MIAMI LPtKES , ;114 Z. 5 S 1..� � yam. • •.w..niT9Yt= t�asr r..•.v Y•�.4 ri„`� : .'* a1.Z.... x ISSUED: 09/07/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1409070002962 003M Local Business Tax ll ceipt Miami-Dade County, State of Florida -THIS IS NOTA BILI: - DO NOT PAY LBT ': 7131527 \1___ - __1/ I WS1NESS NAME&OCATION RECEIPT NO. DECKTITE ROOFING,&WATERPROOFING INC RENEWAL SEPTEMBERE30, 2016 16104 KILMARNOCK DR 7408685 Must be displayed at`place of business MIAMI LAKES FL 33014 Pursuant to County Code Chapter BA-Art.9&10 OWNERF SEC.TYPE OF BUSINESS PAYMENT RECEIV@D DECKTITE ROOFING&WATERPROOFING ,196 SPECIALTY BUILDING CONTRACTOR PA ME COLLECTOR Worker(s) j CCC133t}185 $45.00 09/23/2015 CREDITCARD-15-048597 This Local Business Tex Receipt only confirms payment otthe Local Business Tax.The Receipt is not a license, permit ora certification of the holder's qualifications,to do businoss. Holder mustcomplywith any governmental or nongovernmental regulatory laws and requirements which apply to the business. 'The RECElpf N0.above must be displayed on all commercial vehicles Miapn-pada Code Sec 6s-276. For Fnoro IIIfOr111Bt10a,VI31t miamidyde_�6hXc0Itww' --t t I i v I l Y k. _ DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/11/2016 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(ies)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 CONTACT NAME: Jon Rock The Contractors Choice Agency PHONE E (800)918-3584 (A/C No:(877)684-9951 PO Box 13645 E-MAIL ADDRESS: g Jon@n insuranceonline.com INSURERS AFFORDING COVERAGE NAIC# Chandler AZ 85248 INSURERA:Preferred Cont. Ins. Co. RRG 12497 INSURED INSURER B: Andre Zeno, DBA: Decktite Roofing & Waterproofing INSURERC: 16104 Kilmarnock Drive INSURER D'. INSURER E: Miami Lakes FL 33014 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1331920337 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 ADDLITYPE OF INSURANCE IVSD WVD UB POLICY NUMBER POLICY EFF MM/DD EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 A CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ PC93095-02 3/18/2015 3/18/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY❑ PRO ❑LOC PRODUCTS-COMP/OPAGG $ 1,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate Holder is additional insured, and included in Primary Coverage, and Waiver of Subrogation per endorsement. CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Robert Rock/JON - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r9m4011 Additional Named Insureds Other Named Insureds Decktite Roofing & Waterproofing Inc. Doing Business As OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC AC---IN CS r CERTIFICATE OF LIABILITY INSURANCE rOl/12/2016 ATE(MM/DDYYYI) 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 lies)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 CONTACT NAME: PHONE A/C,No,Ext): 1-800-277-1620 x4800 FAX A/C,No): 727 797-0704 FrankCrum Insurance Agency,Inc. E-MAILADDRESS: 100 South Missouri Avenue INSURERS AFFORDING COVERAGE NAIC# Clearwater FL 33756 INSURER A: Frank Winston Crum Insurance Co. 11600 INSURED INSURER B: INSURER C: FrankCrum L/C/F DeckTite Roofing and Waterproofing,Inc. INSURER D: 100 South Missouri Avenue INSURER E: Clearwater FL 33756 INSURER F: COVERAGES CERTIFICATE NUMBER: 351535 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMBS LTR INSRD WVD (POLICY (MM/DDNYVV) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea mcunence CLAIMS-MADE =OCCUR MED EXP(Any one Person) $ PERSONAL 8 ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO ALL OWNED SCHEDULED BODILY INJURY Per arson $ AUTOS AUTOS BODILY INJURY(Per aaidmt) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA UAB OCCUR EACH OCURRENCE $ EXCESS LIAR H CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND WC201600000 01/01/2016 01/01/2017 X WC STATUTORY OR A EMPLOYERS'LIABILITY Y/N LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—] N/A E.L.EACH ACCIDENT 1 0D0 0D0 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1 000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks,Schedule,if more space is required) Effective 07/21/2014,coverage is for 100%of the employees of FrankCrum leased to DeckTite Roofing and Waterproofing,Inc.(Client)for whom the client is reporting hours to FrankCrum.Coverage is not extended to statutory employees. CERTIFICATE HOLDER 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. Miami Shores Village AUTHORIZED REPRESENTATIVE 2nd Ave Miami Miami Shores,FL 33138 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD