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MC-16-2507 507 Miami Shores Village peIr1?#1~ ')-""B" 10050 N.E.2nd Avenue Nn/Atet�1n Miami Shores,FL 33138-0000 rel, .. Phone: (305)795-2204 Ami a�0 APpC�Vlp r. Expiration: 04/18/2017 Project Address Parcel Number Applicant 10090 N MIAMI Avenue 1131010210090 LUISA FERNANDA LUNA Miami Shores, FL 33150-1216 Block: Lot: Owner Information Address Phone Cell LUISA FERNANDA LUNA 10090 N MIAMI AVE (305)757-3133 MIAMI SHORES FL 33150-1216 Contractor(s) Phone Cell Phone Valuation: $ 500.00 FRIENDLY ROOFING AND A/C INC Total Sq Feet: 0 Tons: Available Inspections: Additional Info:INSTALLATION OF EXHAUST FAN AND CON Inspection Type: Classification:Residential Final Approved:In Review Rough Duct Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work: Underground Scanning:1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# MC-9-16-61289 DBPR Fee $2.00 09/09/2016 Credit Card $50.00 $58.60 DCA Fee $2.00 Education Surcharge $0.20 10/20/2016 Credit Card $58.60 $0.00 Permit Fee $100.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $108.60 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 nd zoning. Futhermore,I authorize the above-named contractor to do the work stated. October 20, 2016 Aut orized Signat wne / Applicant / Contractor / Agent Date Building Department Copy October 20,2016 1 " Miami Shores Village !Iv EPa0012016 Building Department E10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY. Tel:(305)795-2204 Fax:(305)756-8972 TH INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 201 q r BUILDING Master Permit No. C6 PERMIT APPLICATION Sub Permit No. 5 ❑BUILDING ❑ EL RIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBINGMECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP / CONTRACTOR DRAWINGS JOB ADDRESS: j O o 9 0 /u s���►`'"�& � City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Ltlfse, /"� Phone#: Address: 11 tt In q0 &I. 4,4am wa A4K- City: State: �� Zip: 315%) Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: f,f ..IL1i0 �� Phone#: :6'61 Address: 1 / f o '' ire r9 r le- City: C.C' State: Zip: Qualifier Name: /r, j 4 ` A 4 Phone#: State Certification or Registration#: ` A6 101559 Lt Certificate of Competency#: 1 0 DESIGNER:Architect/Engineer: v 4r C�' le-C./3 0C.4 � Phone#: 31�V ?7 Address: &6 '2_T_ �l°�"n: L`=(cep �r A> 4(Z City: ;c��• t'r State: rL- Zip: Value of Work for this Permit:$ 000 ` Square/Linear Footage of Work: Type of Work: ❑ Addition 5joeAlteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 1 %a4-r,l t..L.�,.,, J( G 1. .1 1CC' 'Zo 6X.s1� C�'L.e'- Was L Specify color �o-/f�color �thru tile: Submittal Fee$ Permit Fee$ 00•0(3 CCF$ d ' �o CO/CC$ 01 VA Scanning Fee$ '!;.M Radon Fee$ DBPR$ 2 ' Notary$ Technology Fee$ d- 80 Training/Education Fee$ n " Z� Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Bbnding 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 approved and a reinspection fee will be charged. 1141 Signature Signature O ER or AGENT CONTRACTOR The foregoing instrume t was acknowledged before me this The foregoing instrume t was acknowledged before me this day of ` �a 20_ f� ,by 2�' day of ,20 ,by who is personally known to �L'%A-- 4e-F/�� 4,who is personally 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: a'.re Sign: _ a Print: Print: -� Seal: BRENDA M DERI Seal: r.• , BRENDOEN ••41,gY P �i, Notary Public-State of Florida Notety PublicMy Comm.Expires Aup 19,2017 Dom•Commission#FF C MI 00�" a�°**say°�erix APPROVED BY Plans Examiner Zoning (16— Structural Review Clerk (Revised02/24/2014) � mow• ORbA oN�.� AI( ,P�� 3NAL'RIGUri ' TRUCI";[Nb�� V LICE }q ,.art. fh , �" gg 44Z, r�� 'w �f k�v v �. TOR ✓� � a„y' �' ""�>s� \w\, �" • • is ISSUED; 06/861'2016 DISPLAY AS REQUIRED BY LAW SEQ# L1 132.5 RICK SCf3TT,GOVERNOR KEN LAWSON,SECRETARY { DBPARTI7,t3P 811 ANIS pi !S#tIIL RULATIt31 CONS ' UD't 2 ',to L.�NSIf�#t i BSD a r x� AIR C0MDM0f0 C N I !S C'Ift DO j \ �1r tltP ��titS CitI° of �.aRi:� AUG 31tx� 77 \ ? All, vr- pArgyi IN F d \ ,La' r�9+� � �.�'�„�`� ��' s » ` ,w� �,,�->F °fit ir�a � � E ��ai, � irf � • i g MUM 08AMMIG DISPLAY AS REQUIRED BYLAW SEQ# L16MOD01210 . ANNE M. G A N N O N P.O.Box 3353,West Palm Bench,FL 33402-3353 LOCATED Ar* CONSTITUTIONAL TAX COLLECTOR www.pbctax.com Tel:(561)355.2264 19515 CAROLINA CIR �a ��� Beach " SOCA BATON, FL 33434-2612 Serving ��. TYPE Or WSINESS OWNER CIFFMFICATION 5 I RECEIPT AIDA.TE PAI® AMT AMID I BILL# 23.0148 AIR COAd1".7t'P[ONiNG CONTIR ELMALAH.SVIKA CAC1815504 I e1B.47M5-071W16 $27.50 1 B40145M This document is valid only when r+ pted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2016/2017 LOCAL BUSINESS TAX RECEIPT FRIENDLY ROOFING AND AJC INC 81-426 LBTR Number: 201100163 FRIENDLY ROOFING AND AJC INC EXPIRES: SEPTEMBER 30 2017 19515 CAROLINA CIR BOCA RATON,FL 33434-2612 This receipt grants the privilege of engaging in or rrlGullnlulrrllrrlrslsslrlr�Irrrrrllrslrl managing any business profession or occupation within its judsdichon and MUST be conspicuously displayed at the place of business and In such a manner as to be open to the view of the public. AN NEW GAN O N P.O.Box 3353,West Palen Beach,FL 33402-3353 **LOCATED AT** 0ONST11Tt1TIONAL TAX COLLECTOR www.pbctax.com Tel:(561)355-2264 serving Palm a�,���o 19515 CAROLINA CIR SOCA BATON, FL 33434-2692 Serving you. TYPE OF suswass I OWNER CERTIFICATION 0 1 RECEIPT XIMTE PAID AMT PZO BILL# 210081 ROOFING CONTRACTOR IELMkM SV(K7A CCC1327080 1 816.476938-011108!16 SUM 940145847 This document is valid only when receipte d by the Tax Collectors Office. STATE OF FLORIDA PALM BEACH COUNTY B2-426 201612017 LOCAL BUSINESS TAX RECEIPT FRIENDLY ROOFING AND AJC INC LBTR Number: 201100/64 FRIENDLY ROOFING AND A/C INC EXPIRES: SEPTEMBER 30, 2017 19515 CAROLINA CIR BOCA RATON,FL 33434-2612 This receipt grants the privilege of engaging In or rr��nrNrrlrrinllrrlrrlsrlrlrllnrrrllsJrl naginganybusinessprofessionoroccupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. '` C EO CERTIFICATE OF LIABILITY INSURANCE DATE(09/0088//22016016 Y) 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 pollcy(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 CONTAcT Noel Brown A032583 NAME• Brown Insurance Inc. PHONE 941-493-1886 FAX Ne; 941-497-6325 1872 Tamiami Trail S. ADDRESS; noel@brownins.net Ste G INSURERS)AFFORDING COVERAGE NAIC# Venice FL 34293 INSURER A. CENTURY SURETY COMPANY 36951 INSURED INSURER B• FRIENDLY ROOFING AND A/C,INC. INSURERC: 19515 CAROLINA CIRCLE INSURER D: INSURER E: BOCA RATON FL 33434 1 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. ILTR TYPE OF INSURANCE POLICY NUMBER MMPOLICY EFF �IoD LI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X GE TT1RE­KT—ED COMMERCIAL GENERAL LIABILITY PREM SES Ea occurrence $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Any oneperson $ 5,000 A L039002870-0 05/06/2016 05/06/2017 PERSONAL a ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 500,00 X POLICY PRO- LOC $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY OPER Y DAMAGE $ HIREDAUTOS AUTOS UMBRELLA LtAB OCCUR EACH OCCURRENCE $ EXCESS LUUB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERSLiMi COMPENSATION WC STATU-R S1 O R D EMPLOYERS'LIABILITY Y/N Y PROPRIETOR/PARTNER/EXECUTIVE F N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) ROOFING&AIR CONDITIONING CONTRACTOR STATE OF FLORIDA.SVIKLA ELMALAH LICENSE#CCC1327680 AND CAC1815584 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2ND AVE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES FL 33138 AUTHORtgD REPRESENTATIVE Noel Brown/AD32583 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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: 2/20/2016 EXPIRATION DATE: 2/19/2018 PERSON: ELMALAH SVIKA FEIN: 205395576 BUSINESS NAME AND ADDRESS: FRIENDLY ROOFING&A/C, INC. 19515 CAROLINA CIR BOCA RATON FL 33434 SCOPES OF BUSINESS OR TRADE: LICENSED ROOFING HEATING,VENTILATION, CONTRACTOR AIR-COND 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 Friendly Roofing & AC Inc 19515 Carolina Circle Boca Raton, FL 33434 Date: 08-23-16 State of f, County of �r r Before me this day personally appeared e. �- who, being duly sworn, deposes and says That he or she will be the only pe( s'on working on the project located: Sworn to (or affirmed) and subscribed before me this day of a 20by Personally know OR Produced Identification Type of Identification Produced BRENDA M DERI Notary Public-State of Florida •_=My Comm.Expires AuL 8,2017 Commission#FF 6731Borated Tkough i ary Assn. Print, Type or Stamp Name of Notary Q e ..,, Miami shores Village 'k7* �y� Building Department Zrm OR 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: O State of Florida County of Miami-Dade ,, The foregoing was acknowledge before me this Z; day of ,20_12� . By V1�5� ��u-� who is personally known to me or has produced as identification. Notary � l,- SEAL: BRENDA o�.,, BRENDA M DERI Notary Public-state of Florida My Comm.Expires Aug 19,2017 '�'' �;tg``°'Borated Through Nat! �l Notary Awn.