BPP-16-2805 (2) L"
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X33 �Y j 3 3 T
�s4 0 s Miami Shores Village �` � � a� t �11151�^)IEQt,
g`� 10050 N.E.2nd Avenue NW �� C Neil4►�.
Miami Shores,FL 33138-0000
Phone: (305)795-2204
� Expiration: 05/1612017
Project Address Parcel Number Applicant
162 NW 109 Street 1121360100220
CANOR PATO CARLA GRISONI
Miami Shores, FL 33168-4317 Block: Lot:
Owner Information Address Phone Cell
CANOR PATO CARLA GRISONI 162 NW 109 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 24,000.00
ROSMEL POOL INC (305)592-7900 Total Sq Feet: 930
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review Fence
Date Denied: Final
Type of Work:Swimming Pool Occupancy:Private Pool Deck
Additional Info:NEW POOL AND DECK Bond Return: Wall Steel
Classification:Residential Scanning:4 Review Electrical
Review Mechanical
Review Plumbing
Review Plumbing
Review Planning
Review Structural
Review Building
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Building
Bond Type-Contractors Bond $500.00 Invoice# BPP-10-16-61669
CCF $14.40 10/17/2016 Check#:13550 $50.00 $1,372.00
CO/CC Fee $50.00
DBPR Fee $10.80 11/17/2016 Check*13631 $1,372.00 $0.00
DCA Fee $10.80 Bond#:3253
Education Surcharge $4.80
Permit Fee $720.00
Plan Review Fee(Engineer) $80.00
Scanning Fee $12.00
Technology Fee $19.20
Total: $1,422.00
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.
OWNER FFIDAV : I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constr ton and Futhe re,I authorize the above-named contractor to do the work stated.
November 17, 2016
Authorize Signature:OwnerU/ Applicant / Contractor / Agent Date
Building Department Copy
November 17,2016 1
Miami Shores Villi.. -
�\ age
BuildingDepartment OCT 2016
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 J " '
FBC 20 Yq
BUILDING Master Permit No. }`�j� 10-2WJ
PERMIT APPLICATION Sub Permit No.
Eg4ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: "W loci tit
City: Miami Shores County Miami Dade Zip• J'J'loy
Folio/Parcel#: 1 • 21 21(a•®1 ®- tp?,a® Is the Building Historically Designated:Yes NO_ o
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): 0-4o%no a V-,n+tom Phone#: SOS• ZI o ®►OCA}
Address: i to 7_ tJNJ 11041% St
City: S ho r —State: F 9 Zip: b k
Tenant/Lessee Name: 1`I f Ra Phone#:
Email:
CONTRACTOR:Company Name: Qi2zjj, ?kx*5 In Phone#: '105-159Z-190C3.
Address: X13 25 5-t • #k 1 D'6
City: -�. _� State: F11— Zip: 31'l
Qualifier Name: Vo.v- Jr. Phone#: 2%an 2%.5"2- t90
State Certification or Registration#: C°�G 145to$D4 Certificate of Competency#:
DESIGNER:Architect/Engineer: Axj&noi n 0.atnP.j0L-, /E '740q 4, Phone#: � 5-• 1 •®3�'
Address: M1,45- 'cF-'hA City: State: VL.. Zip:
Value of Work for this Permit:$ Z*'+fC)00 Square/Linear Footage of Work: �L�
Type of Work: El Addition ❑ Alteration(( E] New ❑ Repair/Replace El Demolition
Description Work: N`E'Vj C01 i>CL-
I
Oe) 30 + Leo sp�T::4--
Specify color of color thru tile:
Submittal Fee$ • Permit Fee$ Lv "� CCF$ } CO/CC$ • w
Scanning Fee$ Radon Fee$ L r DBPR$ ` Notary$ m
Technology Fee$ Training/Education Fee$ Double Fee Y7Structural Reviews$ C)• Bond$ G-M- M
TOTAL FEE NOW DUE$-q;7�2�
(Revised02/24/2014)
Bonding Company's Name(if applicable) I�►
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable) AJ 14,
Mortgage Lender's Address Qat 1 A
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/ Signature
Gatti
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of20 1 Cr ,by I'?-- day of S 20\ ,by
whgts ersonally know�o (- I lo 0% twh is p sonally known,to
me 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:
Sign: Sign: 4I -t/al/ u
Print: C-C;t— nC Z Print: 0.53�- 7'l
Seal: � l��� Seal: MAH o nor ac;
E{PE S ��
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/ J� l /Y
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
l
(Revised02/24/2014)
SHR s�s
��•� a�� Miami shores Village
Building Department
R 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 erage 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. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,you may be
Rersonally liable for the worker compensation iniuries of any person allowed to work under this permit Please check with your
insurance carver since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner CQntractor
Print Name. �=- T_ r� Print Name: 44
Signature:_ - -- Signature:
State of Florida) State of Florida )
County of Miami-Dade) County of Miami-Dade)
Sworn to and subscribed before me this 1 Z Sworn to and subscribed before me this 1
day of- La�7 aCa ,200--, day of <:�p. le_� ` ,20�.
-n
By FL-" C� c c^$ ti iia�1 BY i✓1 ✓ n2 Z
e}t_ i a1i_otn r (SE k
(SEAL)
T of Id p� cc __ T 0-1 etttifica '8 -
n I'
ht CPF C �e9 I ti-ly 1n 2017
L-
017 Ea au Thu Ian^,y pu! r Undervite s
i ,I
iELA
Date: 2b2-C I �,o
State of
County of II e
Before me this day personally appeared A who, being duly sworn deposes
and says:
He or she will be the only person working on the project located at:
Sworn to(or affirmed)and subscribed before me this 0 Q;i- day of
Personally known
Or produced identification
T Te,p dentification produced
qEZ
MY CG�,'i,o n I,,;rr
�ai7N' FFC,...�9
I E't'PES May IS 017
Rin d Thu tic ry r Ucdarwrters
Print,Type or Stamp Name f Notary
8045 NW 36 Street-Suite 540 Doral-FI 33166 Sales 305-592-7900
Fax 305-592-7997 www.rosmelpools.com
CPC-1456804
S,jOR° Gs!
t
� iamishoresVillage
-
Building Department
��ORIDA 10050 N.E.2nd Avenue
Miami Shores. Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SWIMMING POOL OWNER'S CERTIFICATION
Date 12- 12CA �
Miami Shores Village
Building & Zoning Department
Attention: Building Official
I certify that I am the legal owner of the property described as
C® + >1>- 2
1 o- �W'A 'til icaarnI-Shocc-,
In accordance with Section 33-12(f), Code of Metropolitan Dade County, I certify that
understand and agree that the swimming pool to be constructed at the above address cannot
be used or filled with water until separate permit has been obtained for an approved safety
barrier, and such barrier erected. inspected and approved.
I further understand that this certification, however, does not eliminate the need for
obtaining a permit and erecting and approved barrier prior to final inspection and use of the
pool.
Legal Owne J S�_ �D
Note: This certification is to be submitted with a swimming pool permit application in duplicate.
Miami Shores Village
"" Building Department
10050 N.E.2nd Avenue
1pRTDA Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
NOTICE OF REQUIREMENTS
RESIDENTIAL SWIMMING POOL,SPA AND HOT TUB SAFETY ACT
I (We) acknowledge that a new swimming pool, spa or hot tub will be constructed or installed at
162- wq S i��r�v5�►tr<-,,I L iami Shores, FL, and hereby
affirm that one of the following methods will be used to most the requirements of Chapter 515,
Florida Statues and the Florida Building Code R4101.17.
Please initia�ffie method(s)to be used:
The pool will be equipped with an approved safety pool cover that comp lies with ASTM
F1346-91. (Submit Manufacturer's Specifications).
A continuous,one-piece(child)barrier meeting the requirements of Florida Building Code
R4101.17.1.15 will protect the pool perimeter.The plans shall show the fence location and method of
attachment,including one end that shall not be removable without the aid of tools.(Submit Manufacturer's
Specifications).
A combination of non-dwelling walls and fences(screen enclosure,child fence,masonry
fence walls,chain link or wood fence,etc.)will protect t he pool perimeter.The plans must specify t he type
and location of all non dwelling walls. Florida Building Code,R4101.17.1
Any combination of protection which incorporates dwelling walls with openings directly into the
pool perimeter and all windows and doors will be equipped with exit alarms complying with Florida Building
Code, R4101.17.1.9(Submit Manufacturer's Specifications).
Any combination of protection which incorporates dwelling walls with openings directly into the
pool perimeter and all doors will be equipped with a self-latching device with positive mechanical
latching/locking installed a min.54"above the threshold. If this option is selected,submit plans showing all
types and location of all perimeter protection.The plans must also show the location and type of all
openings,and the hardware type for each location.(Submit Manufacturer's Specifications).
In accordance with the Code,the pool may not be filled with water without compliance with the
Private Swimming Pool Safety Requirements,and upon expiration of the permit,the pool shall be
presumed to be unsafe.I understand that not having one of the above installed will constitute a
violation of Chapter 515,F.S.,an d will be considered as committing a misdemeanor of the second
degree,punishable as provided in Section 775.082 or Section 775.083 F.S.This form must be signed
by the owner/agent andIm-
CONTRACTORS
ontractor.
� SIGNATURE AND DATE NER'S SIGNATURE AND DATE
Alit f`y'z klatt�& -�01L— Pk-r-4
CONT CTOR'S NAME(PLEASE PRINT) OWNER' NAME(PL ASE PRINT)
�v' A� �' "
NOTARY P - NOTARY PtJBLIC
P'u^FICLSA%1,K1 !NEE
lvd FF OXJRA
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J3 ,� �Di7�6
Jcden�t rs Fu c Ti P tar Llnue ttiers
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y XORBs Gf!
M Miami shores Village
Building Department
�l0'' 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RESTRICTIVE COVENANT PROTECTIVE POOL ENCLOSURE
KNOW ALL MEN BY THESE PRESENTS:
WHEREAS,the undersigned Cl-t-VAL r ����= is/are the fee
simple owner(s)of the following described property situated and being in Miami Shores Village,Florida:
Address: 1 I e 7 PsJ,,,a9 Y Qi S-V- Shire=,. FL 31:�4408
Whereas,the undersigned owner(s) C_"c-r P�nA-m
desire to utilize said Lot(s)as a single building site,and the undersigned owner(s)do(es)hereby declare and agree as follows:
I. That the property will not be used in violation of any ordinances of Miami Shores Village or Miami-Dade
County now in effect or hereinafter enacted.
it. That the purpose of the covenant is to induce Miami Shores Village to issue a permit for a pool where the
required enclosure is not on the subject property where the pool is located.
III. That if any of our adjoining neighbors remove any portion of their fence or wall,or if our/my property shall fail
to meet code requirements for pool barriers,we,as owners will immediately install a protective enclosure to
meet code requirements and will obtain a permit for such fence.
IV. That,[/we,as owner(s)hold Miami Shores Village harmless for any negligence or injury that results from not
having the enclosure.
V. If enclosure belongs to said property,I agree to maintain&or replace said enclosure in the event that is
damaged or removed by any case.
NOW,THEREOF,for good and valuable consideration,the undersigned do(es)hereby declare that he/she will not
convey or cause to be conveyed the title to the above property without requiring the successor in title to abide by all terms and
conditions set forth herein.
FURTHER,the undersigned declare(s)that this covenant is intended and shall constitute a restrictive covenant
concerning the use,enjoyment and title to the above property and shall constitute a covenant running with the land and shall be
binding upon the undersigned,his/her successors and assigns and may only be released by Miami Shores Village,or its
successors,in actor ante f said Village then in effect /
OWNER S PRINL_ OWNER SING&PRINT
I Hereby Certify that on this day personally appeared before me ,n s 4��'-Vo and has produced ID
# IF I_ X p as identification and he/she acknowledge that he/she executed the foregoing,freely and voluntarily,
for purposes there in expressed.
SWORN TO AND SUBSCRIBED before me on this 1 day of 0,
N TARY PUBLIC 1'AT IDA
(Revised 05/2209
N1aAC0Sn r,k,i NE"
(' r MY(_'0,,M6SIUIN#FF 008989
X11 EA;IRE&Nia,y 15,2017
( Bondeu 7hru Notary Pwl.Unr)eruvr,ters
6
Inspection Worksheet
` Miami Shores Village LZ
10050 N.E.2nd Avenue Miami Shores, FL � '
Phone: (305)795-2204 Fax: (305)756-8972 G
Inspection Number: INSP-269033 Permit Number: BPP-10-16-2805
Scheduled Inspection Date: December 07,2016 Permit Type: Pools/Whirlpools/Hot Tubs
Inspector: Naranjo, Ismael Inspection Type: Wall Steel
Owner: CARLA GRISONI, CANOR PATO Work Classification: New
Job Address:162 NW 109 Street
Miami Shores, FL 33168-4317 Phone Number
Parcel Number 1121360100220
Project: <NONE>
Contractor: ROSMEL POOL INC Phone: (305)592-7900
Building Department Comments
NEW POOL AND DECK Infractio Passed comments
POOL 330 SQFT DECK 600 SQFT INSPECTOR COMMENTS False
Inspector Comments
Passed
Ea
Failed
Correction
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
December 06,2016 For Inspections please call: (305)762-4949 Page 11 of 29
i
ANTONIO CANELAS,P.E.
LIC.No. 74099
7815 SW 24 ST SUITE 1 l l
MIAMI FL,33155
305 261 0321
Miami Shores Village Date 12-05-16
Building and Zoning Department s
Miami Shores,Florida.
Reference: Soil Statement (If 9 V
Residential Swimming Pool
Property of: Canor Pato
162 NW 109 ST
Miami Shores,FL 33168
To Whom It May Concern:
Soil Statement:
A field visual inspection was conducted on 12-05-16 of the swimming pool excavations for the
above-referenced property.The existing site has been observed and evaluated,and we conclude that
the conditions are similar to those upon which the design was based (allowable bearing capacity
equal to 2000 psi. In addition, we conclude that the soil is adequate to support the Required
Bearing Pressure of 650 PSF imposed by the new swimming pool.
If you should have any questions regarding this matter,please do not hesitate to contact us.
Sincerely,
GEN 0*0
° N®. 74099
* eo,?/ 0
STATE OF .'tv s
ORAV
12-05-16 ,,114NAL10%%%%
Antonio Canelas,P.E.
Lic #: 74099
Attached: Photographs of Excavation
//','0�7,...• •red.�.
Picture #1
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ANN
ino Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
SWIMMING POOL OWNER'S CERTIFICATION
Date ► 2t
Miami Shores Village
Building&Zoning Department
Attention: Building Official
I certify that I am the legal owner of the property described as
`'�'�°' �s �`a a °�o�► ,oQ -�,� located at
I �� r��,�, � GC� �-t Iii�<-,►ry.:��ti®.-�,s i �=i.� .�I�s�
In accordance with Section 33-12(o, Code of Metropolitan Dade County, ...
I;cet�ify that� ••••••
understand and agree that the swimming pool to be constructed at the above addr ' '000••• ••••••
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1 further understand that this certification, however, does not eliminate theneed for :...:% •••• •
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Legal 0 er
Note:This certification Is to be submitted with a swimming pool permit application in duplicate.
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U.S.DEPARTMENT OF HOMELAND SECURITY E@a�YAT'®N CERTIFICATE OMB NO. 1660-0008
FEDERAL EMERGENCY MANAGEMENT AGENCY Expiration Date:July 31,2015
Natimul Fir<d Inwrancc Prowem IMPORTANT:Follow the instructions on pages 1-9.
SECTION A-PROPERTY INFORMATION FOR INSURANCE COMPANY USE
Al. Building Owner's Name CANOR PATO CARLA GRISONI 16-0448375 YM Policy Number:
A2. Building Street Address(inclucing Apt.,Unit,Suite.and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number:
162 NW 109 S?
City MIAMI SHORES State FL ZIP Code 33168
A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description.etc.)
DUNNINGS MIAMI SHORES EXT 6 PB 51-31 LOT 6 BLK 213 LOT SIZE 75.000 X 122-11-2136-010-0220
A4. Building Use(e.g.,Residential Non-Residential.Addition.Accessory.etc.) RESIDENTIAL
A5. Latitude/Longitude:Lat. N2,535229" Long. WBO°12'04" Horizontal Datum: ❑NAD 1927 J,NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number A
A8. For a building with a crawlspace or enclosure(s): A9.For a building with an attached garage:
a) Square footage of crawlspace or enclosures) 1600+- sq ft a) Square footage of attached garage NIA sq ft
b) No.of permanent flood openings in the crawlspace or 15 b) Number of permanent flood Openings In the attached garage
enclosure(s)within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade NIA
c) Total net area of flood openings in A8.b 11672- sq in c) Total net area of flood openings in A9.b N/A sq in
d) Engineered flood openings? ❑Yes X1 No d) Engineered flood openings? ❑Yes XNo
SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
B1. NFIP Community Name&Community Number B2.County Name B3.State
MIAMI SHORES-120652 MIAMI-RADE FL
B4. Map/Panel Number B5.Suffix B6.FIRM Index Dale B7.FIRM Panel Effective/ B8.Flood Zone(s) B9.Base Flood Elevations)(Zone
Revised Date A0,use base flood depth)
12086C 0302 L 09/11/2009 09/11!2009 X N/A(NGVD 1929)
B10.indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item 139:
❑FIS Profile XF1RM ❑Community Determined ❑Other/Source:
Bll.Indicate elevation datum used for BFE in Item B9: XNGVD 1929 ❑NAVD 1988 ❑Other/Source:
B12.is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes E(No
Designation Date: /NA /N' ❑CBRS ❑OPA
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Building elevations are based on: ❑Construction Drawings" ❑Building Under Construction* ErFinished Construction
'A new Elevation Certificate wJl be required when construction of the building is complete.
C2. Elevations-Zones Al-A30,A..AH,A(with BFE),VE,Vl-V30,V(with BFE),AR.AR/A.AR/AE,AR/A1-A30.AR/AH,AR/AO.Complete Items
C2.a-h below according to the building diagram specified in Item A7.in Puerto Rico only,enter meters.
Benchmark Utilized: N-566 Vertical Datum: NGVD 1929
Indicate elevation datum used for the elevations in items a)through h)below. XNGVD 1929 ❑NAVD 1988 ❑Other/Source:
Datum used for building elevations must be the same as that used for the BFE. Check the measurement used.
a) Top of bottom floor(including basement,crawlspace,or enclosure floor) 11 . 30 feet ❑meters 000000
b) Top of the next higher floor 12 . 87 feet •❑meters •
c) Bottom of the lowest horizontal structural member(V Zones only) N/ A feet n meters • •••• ••
•,�,•••• •••• ••••••
d) Attached garage(top of slab) NI A Meet a�rneters •
e) Lowest elevation of machirery or equipment servicing the building 11 28 feet [ 000ors 0 :••••
(Describe type of equipmert and location in Comments) • ••••••
f) Lowest adjacent(finished)grade next to building(LAG) 12 feet [ "Olers i• •
• • ••• • •••••
g) Highest adjacent(finished)grade next to building(HAG) 11 24 feet '[,$�eNs • •
h) Lowest adjacent grade at lowest elevation of deck or stairs,including N/ A feet b mel'ers ••i
structural support • ••• • •
•
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION. • • • • •
•••
This certification is to be signed and sealed by a land surveyor.engineer,or architect authorized by law to certify elevation •• *see
• •
information.I certify that the information on this Certificate represents my best efforts to interpret the data available.
i understand that any false statemen:may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001. �.•�P\�.C: LOA,,,
�°j Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a 4.�F"�`j$E N(j4��
El Check here if attachments. licensed land surveyor? Yes E]No ,.:G 2300 Fp,
Certifier's Name License Number - -
EFRAIN C.LOPEZ 2300&LB 7538 -
Title Comparty Name
P.L.S. D'AVILA&ASSOCIATES SERVICES,INCSTATE of l
Address city State ZIP Code '"��� r-LORIOA �.
14750 NW 77 CT,STE 204 MIAMI LAKES FL 133016
Signature a Date Telephone �'v, Sur eyes
i 04/27/2016 305 953-2600
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ELEVATION CERTIFICATE,page 2 a�.�:
IMPORTANT:In these spaces,copy the corresponding informatian from Seation A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or F0.Route and Box No. Policy Number:
162 NW 109 ST
City State ZIP Code Compary NAIC Number:
MIAMI SHORES FL 33168
SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(i)community official,(2)insurance agent/company,and(3)building owner.
Comments C.2.E REFERS TO AIR CONDITIONER MACHINERY SERVICING BUILDING LOCATED AT REAR OF THE SUBJECT
PROPERTY
LATITUDE AND LONGITUDE OBTAINED BY GPS/FLOOD ZONE DETERMINATION IS FURNISHED BY FEMA
L.C.O.R= 10.66'; H.C.O.R=10.83'
Signature GU Date /27/2016
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE),complete items EI-ES.If the Certificate is intended to support a LOMA or LOMR-F request.complete Sections A,Band C.
For Items E1-E4,use natural grade.if available.Check the measurement used.In Puerto Rico only,enter meters.
El.Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade(HAG)and the lowest adjacent grade(LAG).
a)Top of bottom floor(including basement,crawls pace.orenclosure)is ❑feet ❑meters ❑above or ❑below the HAG.
b)Top of bottom floor(including basement,crewlspace.or enclosure)is ❑feet ❑meters ❑above or ❑below the LAG.
E2.For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),
the next higher floor(elevation C2.b in the diagrams)of the building is ❑feet ❑meters ❑above or ❑below the HAG.
E3.Attached garage(top of slab)is ❑feet ❑meters ❑above or ❑below the HAG.
E4.Top of platform of machinery and/or equipment servicing the building is ❑feet ❑meters ❑above or ❑below the HAG.
E5.Zone AO only:If no flood depth number is available.is the top of the bottom floor elevated in accordance with the community's floodplain management
ordinance?❑Yes ❑No ❑Unknown,The local official must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA issued or community-issued BFE)or
Zone AO must sign here.The statements in Sections A.B.and E are correct to the best of my knowledge.
Property Owner or Owner's Authorized Representative's Name
Address City State ZIP Code
Signature Date Telephone
Comments
❑Check hese if attachments.
SECTION G-COMMUNITY INFORMATION(OPTIONAL) • • • •••• •
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A.B,0►(or E),and •
G of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8-Gt%.q%RArto Rico$A?linter metM••••
G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a IiceirldbMMyor,engineer,or archit,oi•••:
who is authorized by law to certify elevation information.(indicate the source and date of the elevation data in Ula Camments area below.)
ffi • •
• 0000•
G2. ❑ A community official completed Section E for a building located in Zone A(without aFEMA-issued or community-is•9u��i g�E}or Zon••
Z,:*.AO•••.
G3. ❑ The following information(items G4-G9)is provided for community floodplain management purposes. **Go** •• • 90%**
• • • •
G4. Permit Number G5.Date Permit Issued G6.Date Certificate Of Com I nee Occupancy Issued • •
I 000.0• • •
G7. This permit has been issued for: ❑New Construction ❑Substantial Improvement . • • • ••••i•
0000••
G8. Elevation of as built lowest floor(including basement)of the building: ❑feet ❑meters iJatum• • • •
G9. BFE or(in Zone AO)depth of flooding at the building site: El feet ❑meters Sa>3um • 00!!*
• •
G10.Community's design flood elevation: ❑feet ❑meters Datum 0000 0-
Local Official's Name Title
Community Name Telephone
Signature Date
Comments
r J
ELEVATION CERTIFICATE,page 3 Building Photographs
See Instructions for Item A6.
IMPORTANT:In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number.
162 NW 109 ST
City MIAMI SHORES State FL ZIP Code 33168 Company NAIC Number.
If using the Elevation Certificate to obtain NFIP flood insurance,affix at least 2 building photographs below according to the instructions
for Item A6. Identify all photographs with date taken; "Front View' and "Rear View"; and, if required, "Right Side View" and "Left Side
View." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as
indicated in Section A8.If submitting more photographs than will fit on this page,use the Continuation Page.
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