RC-16-3009 �'ermt `, �' A �, 3009
Miami Shores Village ParmitT -Fig" �i ' (+a)1000 N.E.2nd Avenue NE or-Iff-In '��
M ams Shores,FL 33138-0000 �i ClF7 5i t r 01?.AdctitionlAfte ral on
h�q Phone: (305)795-2204
1l Expiration: 05/2712017
Project Address Parcel Number Applicant
790 NE 91 Street Number: 8 1132060390080
R GREGORY CHARLES
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
R GREGORY CHARLES 790 NE 91 ST#8
MIAMI FL 33138-3250
Contractor(s) Phone Cell Phone Valuation: $ 1,600.00
GILPIN CONSTRUCTION INC (786)709-8123
Total Sq Feet: 40
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review
Final PE Certification
Date Denied: Drywall
Type of Construction:RENOVATING BATHROOM Occupancy:Other Miscellaneous
Stories: Exterior: Window Door Attachment
Front Setback: Rear Setback: Tie Beam
9
Left Setback:
Right Setback: Final
Bedrooms: Bathrooms: I Framing
Certificate Status: Insulation
Plans Submitted:Yes
Certificate Date: Additional Info:RENOVATING BATHROOM Truss Insp
Columns
Bond Return: Classification:Residential Foundation
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Window and Door Buck
CCF $1.20 Fill Cells Columns
DBPR Fee $2.00 Invoice# RC-11-16-61907 Wire Lathe
DCA Fee $2.00 11/03/2016 Credit Card $50.00 $71.20 Review Electrical
Education Surcharge $0.40 11/28/2016 Check#:2605 $71.20 $0.00 F.Termite Letter
Notary Fee $5.00 F.Elevation Certificate
Permit Fee $100.00 Review Planning
Scanning Fee $9.00 Review Mechanical
Technology Fee $1.60 Review Building
Total: $121.20 Review Plumbing
Declaration of Use
Review Structural
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNER IDAOT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constru on d zoning. Futhermo e,I t orize t e above-named contractor to do the work stated.
". November 28,2016
Autho Ignature:0 n / Applicant / Contractor / Agent Date
Building Department Copy
November 28,2016 1
2 �1t� -mrd
11
Miami Shores Village
Building Department
10050 N.E.2nd Avenue,Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
• FBC 201L�
BUILDING Master Permit No. �. I (0 ��
PERMIT APPLICATION • sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING F-1REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP
/- CONTRACTOR / DRAWINGS
JOB ADDRESS: �B AP(,�. C j �F' Ja -� dyPis' =4..
City: Miami Shores County: Miami Dade Zia: !
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): JQQN a v!P h�r��09y �(-fQp�ar�hone#: 6 Z�T
Address: '!a±g® M Lam+
City: i arra I Swm ey— State: yx" Zip:
Tenant/Lessee Name: Phone#:
Email:
%
CONTRACTOR:Company.Name: ��' aN S\Q>,,1,�1p1J Phone#:
Address: a Q% Ort N 4,5 • Z4 &4A.
�n
City: � ��� State: V""� Zi p:
Qualifier Name: Z?� ate . �b...T 1 Phone#: �'$Rai Z
State Certification or Registration#1 �S 6.� ,� Certificate of Competency#:
DESIGNER:Architect/Engineer: C t1C $x �E"c �• V c Phone#:
Address: OVX,%. 14 - �L-R�'C"� �t �A}1�at..t City: ` O State:J�A.Zip: % 452
6
Value of Work for this Permit:$ to 4a.CA 4s c4 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: a VC10 al-NiNS°'a ��h< l°i W"L o cxl. "
Specify color of colo��rppthru tile:
"
Submittal Fee$ J V Permit Fee$ �yVLJ CCF$ ® CO/CC$
Scanning Fee$ (( ,,,, Radon Fee$ C� DBPR$ 'Z- Notary$ �•®�
Technology Fee$ U O Training/Education Fee$ 0 �,`4 0 Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 2 C2
(Revised02/24/2014) •Z 0
Bonding Company's Name(if applicable)
Bonding Company's Address
City ArAK State Zip
Mortgage Lender's Name( applicable)
Mortgage Lender's Address A9 /d,.
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 cgnstruction and zoning. •
'b r
"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, NOTICEOF,COMMENCEMENT."
Notice to Applicant. As a condition to the issuance of a building permit with gn estknate&value eneeding$2500, the Jplicant must
promise in good faith that a copy of the notice of commencement ynd 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 commencerriefit 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 Signatur
OWNER or AGENT CONTRACTOR
Tp.egoing instrument was acknowledged before me this The foregoing instrument was acknowledgedYbefore me this
lday off r NU ft�Y 20 jb ,by 3 .day of �O V�hn k.V 20 tk) by
Q`e�1Y\a14 Ck�yk\�0- who is personally known to P 11r4f�► (�(� �jt %,'q1,4who is personally known to
me or who lhps produced +1 Jr1y`Q� C�(Y1S`� as me or who'has produced'Dr iy ty- 1 Cgig"Q as
identification and who did take an identification and who did take a
NOTARY PUB NOTARY ELIC:
Sign: Sign:
Print: 6 Print: A
tiIVANADY PRIETO yANADY PRIETO
Seal: ` MY COMMISSION#FF 214031 Seal: """ Ga',
*= MY COMMISSION#FF 214031
EXPIRES:March 25,2019
Bonded Thru Notary Public Undenwitars EXPIRES:March 25,2019
_y Bonded Thru Notary Public Underwriters
r
$w�mnm-tea--
k*#k
APPROVED BY ( Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
11/28/2016 11:48 9549560555 COVER ALL INSURANCE PAGE 01101
.Co'R7� CERTIFICATE OF LIABILITY INSURANCE DATE(MMMDNWY)
11/2812016
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),AUTHORIXED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certlflcate holder is an ADDITIONAL INSURED,the poliay(1es)must be endorsed. If SUBROGATION IS WAIVED,subject to
the ternsand conditions of the policy,Certain policies may requite an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Ilou of such endorsement(s).
CONTACT
VRODUCER
FAX
IEEL INSURANCE AGENCY -P-MAIL ,�� 954 856.0006 iwc ; 94)956.0555
DMIAI COVERALL INSURANCE ti-MAIL reellnsuren ahoo.com
5800 W.ATLANTIC BLVD. -1 Nw u4 RERtg1+sl aEE s COveRAo
MARGATE FL 33063 ARCH SPECIALTY INSURANCE CO. 21199
INSURED INS URFR B
CILPIN CONSTRUCTION INC. ILvsus �
20109 NW 34 AVENUE suRER D t.
MIAMI FL 33056 �> E
INSURER
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
CER7IFIGATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANG8 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 AoUL R POLICY FFP POLICY E><P Llp(ITS
LTRTYPE OF INSURANCE C FR
X COMMERCIAL GENERAL UABRAV EAC OCCI)R CE A 1 I)4I)00�
DAMAOa TO RENTED 140 004
A CLAIMS-MADE T OCCUR n11 A
AGI-0034882-00 3/1112016 3111/2017 MED EXP A one neon 15.000
PE SONAL& DV INJURY e 1 000 004
GEML AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE 000
2 000,
C7 ❑LOC PRODUCTS-CQMProP Ad $2,000,000 000 400
POLICY a PE
OTHER: COMBINED SINGLE LIMIT S
AUTOMOBILE LIAWL ITY anti
BODILY INJURY(Per person) S
ANY AUTO
ALL OWNED
SCHEDULED BODILY INJURY(Per scddent) A
NON
UTOS ED PROPERTY DAMAGE A
HIRED AUTO AUTOS
UMBRELLA LIAR OCCUR EACH OCCURRENCE 9
MECESS LLAO 0641M3-MADE AGGREGATEDED I $
A
TE I'ER OS{.
WORKERS CDMPENBATION
AND EMPLOYERS'LIABILLTY
ANY PROPRIETORIPARTNERM(ECUTIVE E.I. CH A IDEM 9f
OFFICERIAAEMBCR EXCLUDED? NIA
E.L DI9EA5£-EA EMPLOYE
(Mandatory In NH)
(I GRI N OF RATI ow E L Dte=ASE-POLICY LIMIT S
br1DE30mi T1oN OF OPERATIONS I LOCATIONS I VEHICLES (ACORD Ial.Addhienel Remarks$49hudU19,may be attached K mora space I►ra4UIMd)
GENERAL A ROOFING CONTRACTOR
LIC#CGC1506B38
CERTIFICATE HOLDER CANCELLATION
MIAMI SNORES VILLAGE SHOULD OF A80VE DESCRIBi�POLICIES BE CANCELLED BEFORE
THE EXPI TI TEF O NOME WILL BE DELIVERED IN
i4050NEZNDAVENUE ACOORDAN �W'T�OLICNS.,.- :.._ -•-•
MMI SHORES FL 33138 `
AUTHORIZED REPRESENTATIVE
FAX 305-756-6946
®1888-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are mglstered marks of ACORD
Report Vie�t,'er Pae i
JFFI:AT WAT ER
CHIE,z FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
—CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATIONLAW—
CONSTRUCTION INDUSTRY EXEMPTION
a 'Co oensaton
This ce-itfiesthat the individual listed below has ele,--ed',o b exempt Florida Workers m. iaJv.
EFFECTIVE DATE: 5!9/2015 EXPIRATION DATE: 51312017
PERSON: GILPIN JOHN
FEIN: 043T,,8504
BUSINESS NAME AND ADDRESS:
GILPIN CONSTRUCTION INC
20109 N W 34 AVE
MIAMI GARDENS FL 33056
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL LICENSED ROOFING
CONTRACTOR CONTRACTOR
F:S..NOt000 Of Wm*-M be
ZI.,Soppe of b�rnew or�- e!15�on the`o If '.�ofmo��o
If Lqei=m to be�em' srmll!)e sIbpe�—!o r�--if at any zrrne after the ifin o`he no<e or lie is—r
E QUESTIONS (850Y-13--,CC9
DFS F2-DWC-252CE.R--1FCA7E0F ELECTION TO BE EXEMPT.R—�ASED 06-1-3
Miami hore
sV illy e
9
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 Exemtion
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 oompany (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 untrl 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,partPart-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this Z�day of bpk 20 11,By �ea'�natd C_harl�es 1 u�t�.r�
o who is personally known to me or has produced
'Dr' ' `\.
identification.
Notary: YANADY PRIETO
ti .rte
MY COMMISSION#FF 214031
SEAL: tea• a EXPIRES:March 25,2019
Bonded Thru Notary Pubfic Underwriters
GILPIN CONSTRUCTION, INC.
John M Gilpin,ACM-ENG;MSC CM.(FIU)-PRESIDENT.
CGC 1506838 1 CCC 1327878 1 HI-3383 1 MRSA-1311 1 MRSR-1519
Contractor Declaration Report
Date: 11/2/2016
State of Florida
County of Dade
Befor me this day personally appeared John M. M. Gilpin who being duly sworn, deposes and says that he will
be the only person'working on the project located at 790 NE 91st s #8, Miami Shores, FL 33138.
Sworn to and subscribed before me this day.30day of , 2016, by
John M. M. Gilpin, General Contractor
Personally know /
or Produced Identification V
Type of Identification Produced *b1r'1W1r [I MS'A.
4Print, pe or Stamp Name of Notary YANADYPRIETo
*; + MY COMMISSION#FF 214031
EXPIRES:March 25,2019
Bondad Thru Wry Public underwriters
20109 NW 34th Ave,Miami Gardens, FI 33056-1745
(786)709-8123 1 Fax: (305)623-4506 1 citisen0l@yahoo.com
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
'CGC 1506838 ISSUED: 09/11/2016
CERTIFIED GENERAL CONTRACTOR
GILPIN, JOHN M
GILPIN CONSTRUCTION INC
IS CERTIFIED under the provisions of Ch.489 FS.
Expiration date : AUG 31,2018 L1609110003029
STATE OF FLORIDA
$ DEPARTMENT OF BUSINESS
PROFESSIONAL REGULATION AND
CCC 1327878 ISSUED: 09/11/2016
CERTIFIED ROOFING CONTRACTO
GILPIN, JOHN M R
GILPIN CONSTRUCTION INC
IS CERTIFIED under the provisions of Ch.489 FS
Expiration date; AUG 31,2018
L1609110002963
r.
I
000790
Local Business Tax Receipt
Miami—Dade County, State of Florida
—THIS IS NOT ABILL—DO NOT PAY �ILBT
5263470
• BUSINESS NAME/LOCATION RECEIPT NO.
EXPIRES
GILPIN CONSTRUCTION INC RENEWAL SEPTEMBER 30, 2017
20109 NW 34 AVE 5500310 Must be displayed at place of business
MIAMI GARDENS FL 33056 Pursuant to County Code
Chapter 8A—Art.9&10
OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED
GILPIN CONSTRUCTION INC 196 GENERAL BUILDING CONTRACTOR BY TAX COLLECTOR
Worker(s) 1 CGC1506838 $49,50 10/12/2016
CREDITCARD-17-000949
This Local Business Tau Receipt only confirms payment of the Local Business Tax.The Receipt is not a license,
permit,or a certification of the holders qualifications,to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec Ila-276.
For more information,visit www.miamidade.gov/taxcollector
iy
No. 3 Dorchester Walk,
Petit Valley,
Trinidad, West Indies.
Contact: (868) 299-4734.
5`" August, 2011.
TO WHOM IT MAY CONCERN
This letter is to confirm that I, Randolph Gregory Charles, of the above
address, am the owner of Apartment 8, 790 North East, 91" Street, Miami, Florida,
33138, United States of America.
I hereby authorize my uncle, Reginald Charles Fuller, of No. 10750 North
West, 22°d Avenue Road, Miami, Florida, 33167, United States of America, to be
my agent for my said Apartment.
I also hereby authorize the said Reginald Charles Fuller to carry out all
renovations, repairs and/or alterations to my Apartment including changing
cupboards; electrical installations, wiring and/or file works or whatsoever is
required. Reginald Charles Fuller is also authorized to sign on my behalf any
relevant documentation required for obtaining any permit(s) for the said
renovations, repairs and/or alterations to be done to my Apartment.
If any further information is required, I can be contacted at my address
and/or telephone number in Trinidad.
Randolph Gregory Charles
Signed by the above-named Randolph Gregory Charles (Republic of Trinidad and
Tobago Driver's Permit No. 153724 E) in my presence at Second Floor, No. 55
Edward Street, Port of Spain, Trinidad, West Indies, thisday of August, 2011.
q T