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PL-16-2312 '70 � .-� � 3 Miami Shores Village M P1?Iyj .PFTit ) Ir18 . �. 10050 N.E.2nd Avenue N u� Iljlofrfia. i9S1fd � tl }i Miami Shores,FL 33138-0000 3 l et r attW At 1P V, Phone: (305)795-2204 Expiration: 04/1 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: $ 3,500.00 f GENEREVE CONSTRUCTION&REMC (954)397-9134 G Total Sq Feet: 0 Type of Work:PLUMBING FOR BATHROOM RENOVATION Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning: 1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $2.40 Invoice# PL-8-16-61010 DBPR Fee $3.38 10/20/2016 Credit Card $ 196.16 $50.00 DCA Fee $3.38 Education Surcharge $0.80 08/16/2016 Credit Card $50.00 $0.00 Notary Fee $5.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $3.20 Total: $246.16 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 and zoning. Futheimore,I authorize the above-named contractor to do the work stated. October 20,2016 Au rued Sig Owner / Applicant / Contractor / Agent Date Building Department Copy October 20,2016 1 5 Miami Shores Village AVG 1 2016 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 �T14 FBC 20 1Q BUILDING Master Permit No.—Pill C-.,-�23 PERMIT APPLICATION Sub Permit NOTL I r- 2-31 ❑BUI ING F-1ELECTRIC ❑ ROOFING ❑ REVISION [:] EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP y � CONTRACTOR DRAWINGS JOB ADDRESS: t otr.c: P. •°u'` " '' 1. City Miami Shores County: Miami Dade Zip: 351fi) Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: IPhone#� OWNER:Name(Fee Simple Titleholder): LL �l.1 It 35 r S� Address: J10 J D �• i't ;kms.: /0yc, City: %) 0A^'i,'' State• Zi Tenant/Lessee Name: Phone#: Email: (,�@X1�""' J CONTRACTOR:Company Name: G- we_ Phone#: `�7 l �7-f/-% Address: 1 kb fety 4ife City: ` State: Zip: Qualifier Name: 6o /a nelo Phone#: S9 State Certification or Registration#: �-' C- 14)_ 15 J Sq Certificate of Competency#: DESIGNER:Architect/Engineer: •► -3 Are ti + 5 Phone#: Address: 6 Al;e- • ®� City: State: Zip: Value of Work for this Permit:$ 3,6af Square/Linear Footage of Work: Type of Work: ❑ Addition 0 Alteration ❑ New. ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee$ 0� Permit Fee$ S CCF$ .�2� CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ • 3 U Notary$ ° Technology Fee$ • Z10 Training/Education Fee$ �® Double Fee$ A�?— Structural Reviews$ Bond$ 10— TOTAL FEE NOW DUE$ (ReAsed02/24/2014) 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 approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before rrle this day of 11 1 J 20 ,by 16 day of ,20 G �' ,by who is personally known to da � 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. ti Sign: Print: Print: Seal: o�"'yp'�� BRENDA M DERI Seal: a°s `4+•• Notary Public-State of Florida ��� oe o Notary Public-State of Flaft My Comm.Expires Aug 19,2017 �° :• My Comm.Expires Aug fsi.2017 �= Commission*FF 048731 commission a FF 046781 li'do APPROVED BY �� �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY LQFkfDA: bP�RTMI IVrt a RIItN �,►_�Nb 0IIGNv,Ul.p► '1�1N ' c6 ��' 11C 'ttq,IID�it'121� I�LN�MNti R Miff I��P��.UI'rINrG Wif i t�� �' ':IrQlifr�&of Ufa t®r 489 F t f kac�rtlt�n=t�,�dt� :/kL1Q�'I; 2�1 t _k�it � ISSUED: 05/26/2016 DISPLAY AS REQUIRED BY LAW SEd# L1605260000685 016695 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY FL B T 7202554 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES GENEREVE CONSTRUCTION&REMODELING LLC IRENEW2L SEPTEMBER 30, 2017 1300 NE 200 TER Must be displayed at place of business MIAMI FL 33179 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED GENEREVE CONSTRUCTION&REMODELIM 010MBING CONTRACTOR BY TAX COLLECTOR C/O NELSON POLANCO CFC1429584 $75.00 07/12/2016 Worker(s) 1 CREDITCARD-16-039809 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualdications,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—Bade Code Sec 88-276. For more information,Visit www ndamldode aeV"Gollecter 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: 5/31/2016 EXPIRATION DATE: 5/31/2018 PERSON: POLANCO NELSON FEIN: 461467506 BUSINESS NAME AND ADDRESS: GENEREVE CONSTRUCTION&REMODELING LLC 1300 NE 200 TERRACE MIAMI FL 33179 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL LICENSED PLUMBING CONTRACTOR CONTRACTOR 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 GENEREVE Construction&Remodeling LLC Date:08/15/2016 State of: yi County of: Before me this day personally NN ersonall appeared ; . 450- �'�°"�e1'c' who, being duly sworn, deposes and says: That he or she will be the only person working on the project olcated at: /va 50 o Sworn to(or affirmed)and subscribede before me this S day of AL- .20�by Personally know OR Produced Identification Tyk1dent cation Produced BRENDA M DERINotary Public-State of FloridaMy Comm.EWrea Aug 1g,2017 Commission#FF 046731 'W"2mnWi-qu Genereve Construction&Remodeling LLC 1300 NE 200 Terrace Miami,FI 33179 (954)397-397-9134 email: info@genereve.com www.genereve.com ORIes s� Miami shores Village logo Building Department artment �n �e �NTE9 M8� 10050 N.E.2nd Avenue �LOR1pA 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: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this ®P— day of 20-Ll:;�_. By) •J t_<A Tom_ 4.,,r Ste- Luo-p, who is personally known to me or has produced asidentification. Notary: � SEALasL, r p& hio!ery'uLuc State of FbrirJe "� ea � �ry�:ii�a�,f 4.3f'JZ •tia �, w � Q p; ;ure•s•i�.��.�n�r 1:,37".� °OF �a '9i:a'�are's� c Li ?'ei a+`a,7".,J4:•„Fb,�''..,a'Y�'F.* AC40RE7® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmYr) 10/19/2016 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 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 NAMNT E:CT Maximo Dopazo CPIA Dopazo & Associates Inc PHONE (305)470-8500 No): (866)647-9673 8725 NW 18th Terr Ste 300 E-MAIL ADDRESS:max@dopazo.com INSURERS AFFORDING COVERAGE NAIC N Miami FL 33172 INSURER A:Accident Ins Co 11573 INSURED INSURER B: Genereve Construction and Remodeling LLC INSURER C: 1300 NE 200 TERR INSURER D: INSURER E: MIAMI FL 33179 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1692014778 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AODL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER D M D X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE ToRENTE A CLAIMS-MADE rx-1 OCCUR PREMISES Ea occurren $ 100,000 CPP0016286-02 09/19/2016 09/19/2017 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 JECT POLICY 0 PRO r LOC PRODUCTS-COMP/OP AGG $ 1,000,000 % OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS (Per (dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEC I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTEE ANY PROPRIETOR/PARTNER/EXECUTIVE Ya N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER 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/LOCATIONS/VEHICLES (ACORD 101,Addidonai Remarks Schedule,may be attached H more space Is required) GF24EPXL CONTRACTOR & PLUMBING CONTRACTOR STATE OF FLORIDA LICENSES CGC 1521162 CFC 1429584 . CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE BLDG DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE M Dopazo CPIA/MAD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)