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PW-16-2913 Pert 10- 4- 913 'Public l _T ' st!OR£s Miami Shores Village 3 mitype Wks S� W� 10050 N.E.2nd Avenue g' Miami Shores,FL 3313&0000 .; Yt1DfaSfarea#�Qr� Public #i # rtS Imit Status.-APP ovtli'l `ties" Phone: (305)795-2204 ; ` xtoRtV� ni „ ls�itt l�l 1,211201#--d Expiration: 02/19/2017 Project Address Parcel Number Applicant 370 GRAND Concourse 1132060136040 MIAMI SHORES BAPTIST CHURI ” Miami Shores, FL 33138-2747 Block: Lot: Owner Information Address Phone Cell MIAMI SHORES BAPTIST CHURCH 401 NE 95 ST (305)758-0559 Miami Shores FL 33138 Contractor(s) Phone Cell Phone Valuation: $ 10,000.00 SITEWORKS INC (561)235-9575 Total Sq Feet: 0 Scanning: 1 Available Inspections: Inspection Type: Final Excavation Review Plumbing Review Plumbing Review Building Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $6.00 DBPR Fee InVO1Ce# PW-10-16-61792 $5.25 DCA Fee $5.25 10/26/2016 Credit Card $50.00 $329.50 Education Surcharge $2.00 11/21/2016 Credit Card $329.50 $0.00 Permit Fee $350.00 Scanning Fee $3.00 Technology Fee $8.00 Total: $379.50 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. Futhermore,I authorize the above-n m d co tra do the work stated. November 21,2016 Authorized Signature:Owner / Applicant / a or / Agent Date Building Department Copy November 21,2016 1 Miami Shores Villa a t e Y g Building Department ' 6 2016 ` 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 FAYI Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 its BUILDING Master PermitNo.CC 16- 1392) PERMIT APPLICATION Sub Permit No. 1>" w— 2x-113 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP t CONTRACTOR DRAWINGS JOB ADDRESS: �R7 O ( 0.+ C_0 0ccxK Y"Se • City: Miami Shores County: Miami Dade Zip: �k-:?>9i Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: __11 BFE: FFE: OWNER:Name(Fee Simple Titleholder): M\(�M\ S(10+(e_S � (�UYUh�flone#: ?SOS-'158-OSSGI Address: City: State Zip: Tenant/Lessee Name: Phone#: Email: �t 9 93 35LI 12.® � CONTRACTOR:Company Name: rE w�or kS ; 1 i)L . Phone#:5(D z3- 9 S_S Address: '2,5Ek0_1 N VQ 2 y'''°^ w0.� City:_F___2t_.�c-o.�0.i'OC, State: Zip: Qualifier Name: GGL<'�A Phone#:13 State Certification or Registration M P uC I�� JYc ab Certificate of Competency M DESIGNER:Architect/Engineer:Cam-e_'(-O� Phone#: _:3CK_ QXoS —1(n02 . Address:"-IAM SUJ 12`rjy City: KANb-N-n•, State: Zip: '33t Value of Work for this Permit:$ (!; Square/Linear Footage of Work: X Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work:_W e,\o rVl C.L j n Specify color of color thru tile: Submittal Fee$ 6J.W Permit Fee$ SJ P CCF$ •W CO/CC$ Scanning Fee$ �T 1 Radon Fee$ ��- !_ ^^ DBPR$ • 2G Notary$ Technology Fee$�_�� Training/Education Fee$ o� Double Fee$ Structural Reviews$ Bond$ G TOTAL FEE NOW DUE (Revised02/24/2014) 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�;01 � Signature OW ER rAGENT ` CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrumentwasacknowledged before me this _2Li_"_Uay of L-DC+nhe r 20 lb .by �y qday of 1O .0 ,20 by C . who is personally known o f'�Q,_C`I who is personally known o 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: Prinnza Print: rQ ('nf-�ZQ�'O_Z Seal: " Seal: , , ANDREWGONZALEZ ANDREW GONZALEZ :`r°� e`'� °' Notary Public-State of Florida Notary Public-State of Florida My Comm.Expires Oct 23..2017 My Comm.Expires Oct 23 2017 .,,° ``, �99** �nua� APPROV D f' " Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) FLORIDA DEPARTMENT OF STATE 1 p anti � Detail by Entity Name Florida Not For Profit Corporation MIAMI SHORES BAPTIST CHURCH, INC. Filing Information Document Number 717306 FEI/EIN Number 59-0700565 Date Filed 10/06/1969 State FL Status ACTIVE Principal Address 370 GRAND CONCOURSE MIAMI SHORES, FL 33138 Changed: 05/05/1999 Mailing Address 370 GRAND CONCOURSE MIAMI SHORES, FL 33138 Changed: 05/05/1999 Registered Agent Name &Address Jones, Steve H, Mr.- 1060 N. E. 92nd St. Miami Shores, FL 33138 Name Changed: 07/28/2014 Address Changed: 03/23/2016 Officer/Director Detail Name &Address Title V MITCHELL, ANTHONY D 125 N. E. 86TH STREET MIAMI, FL 33138 Title President JONES, STEVE 1060 N. E."92ND STREET MIAMI SHORES, FL 33138 Title D LUC, MARCEL 141 NW 100 ST MIAMI, FL 33150 Title D CHARLES, GAUDIN 831 N. E. 142ND STREET MIAMI, FL 33161 Title Secretary Turpin, Richard, III 25 N. E. 139th St N. Miami, FL 33161 Annual Reports Report Year Filed Date 2014 04/01/2014 2015 03/03/2015 2016 03/23/2016 Document Images 03/23/2016 -- ANNUAL REPORT View image in PDF format 03/03/2015 -- ANNUAL REPORT View image in PDF format 07/28/2014 -- AMENDED ANNUAL REPORT View image in PDF format 04/01/2014 -- ANNUAL REPORT View image in PDF format 02/14/2013 --ANNUAL REPORT View image in PDF format 04/17/2012 --ANNUAL REPORT View image in PDF format 03/16/2011 --ANNUAL REPORT View image in PDF format 03/09/2010 --ANNUAL REPORT View image in PDF format 04/20/2009 --ANNUAL REPORT View image in PDF format 03/31/2008 --ANNUAL REPORT View image in PDF format 05/08/2007 -- ANNUAL REPORT View image in PDF format 05/01/2006 --ANNUAL REPORT View image in PDF format 04/25/2005 -- ANNUAL REPORT View image in PDF format f 05/03/2004 -- ANNUAL REPORT View image in PDF format 04/30/2003 -- ANNUAL REPORT View image in PDF format 05/16/2002 -- ANNUAL REPORT View image in PDF format RICK SCOTT,GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOAR® v-r� CUC1225020 The UNDERGROUND UTILITY& EXCAVATION CO y Named below IS CERTIFIED >� Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2018 BAL, GARY G SITEWORKS INC 2907 N W 24TH WAY BOCA RATON FL 33431 Eg ISSUED: 06/19/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1606190001462 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CUG1225020. 4 The UNDERGROUND UTILITY&EXCAVATION CO �� x Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 BAL, GARY G SITEWORKS INC 2907 N W 24TH WAY a BOCA RATON ,FL 33431 ISSUED: 06/19/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1606190001462 Client#:20631 SITEWORK DATE(MMIDDIYYYY) ACORD.. CERTIFICATE OF LIABILITY INSURANCE 1 10/26/2016 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. -------------- IMPORA :If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terns 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 (AOI , T NAME: -.------- AX, _- 727 449-1267Bouchard Insurance CLW PHONE 72447-6481 NoLCNo.EA _ - 101 N Starcrest Dr. E-MAIL ADDRESS: cerouclts@bchardinsurance.com Clearwater,FL 33765 INSURER(S)AFFORDING COVERAGE NAIC# 727 447-6481 INSURERA:American Builders Insurance Com 11240 INSURED INSURER B: Siteworks Inc LINSURERD 21346 St.Andrew Blvd#305 Boca Raton,FL 33433 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR - __ TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM/DDIYYYY _ - A X COMMERCIAL GENERAL LIABILITY Y Y GLP013669004 11/06/2016 11106/2017 EACH OCCURRENCE £_1,000,000 ! DAMAGE TO RENTED CLAIMS-MADE 51OCCUR PREMISES_(E�occurrence) 3100,000 X PD Ded:250 MED EXP(Any one person) 359000 _ PERSONAL&ADV INJURY____31,000,00_0 GEN'L AGGREGATE LIMIT APPLIES PER* GENERAL AGGREGATE 32,000,000 - -- PRO- (� - -- POLICY )ECT I LOC PRODUCTS-COMP/OP AGG 32,0.00,000 OTHER: -- -- - A AUTOMOBILE LIABILITY GLP013669004 11/0612016 11/06/201 COMBINED SINGLE LIMITEa accident_ __ - _3500,000 _ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS X HIRED AUTOS X NON-OWNED (Par accident)PROPERTY DAMAGE AUTOS — 3 A X UMBRELLA LIAB X I OCCUR Y Y UMB014890405 11/06/2016 11/0612017 EACHOCCURRENCE 52,000,000 EXCESS LIAR L_LCLAIMS-1ADE AGGREGATE $2,000,000 ! _ DEDT I RETENTION$ 5 WORKERS COMPENSATION A Y WCV013665504 11/06/2016 11/06/201 X PER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNEWEXECUTIVE YIN E.L.EACH ACCIDENT 51,000 000 OFFICER/MEMBER EXCLUDED? ® NIA —-- (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $1,600,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) GARY G.BAL LICENSE NUMBERS:Underground Utility CUC1225020 and Fire Sprinkler Contractor V FPC12-000146 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE. ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S534095/M532425 VALSU hffAtiyater E sa CHIEF FINANCIAL OFFICER Cas*ia sinco BUREAU CHIEF Julius Malas DIVISION DIRECTO,R Keith VIcCarth%, SAFETY PROGRAM MANAGER FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF STATE FIRE MARSHAL 200 East Gaines Street -Tallahassee,Florida 32399-0342 Tel.850-413-3644 Fa:..850-=10-2467 CERTIFICATE OF COMPETF-NCV OFFICIAL COPY THIS CERTIFIES THAT: Gary G Bal 2907 NW 24th Way Boca Raton Fl.., 33431 BUSINESS ORGANIZATION: Siteworks,ine. Contractor V means a contractor whose business is limited to the execution of contracts requiring the ability to fabricate, install, inspect, alter, repair and service the underground piping for a fire protection system using water as the extinguishing agent beginning at the point of service as defined in the act and ending no more than I foot above the finished floor. Issue Date: 07/01/2016 Type: 09 i 14h 4r Class: 14 County: Palm Beach License/Permit 4: FPC 12000146 Expiration Date: 06130/201 8 Chief Financial Officer .......... ................................. Registration#: 16 00101061 CITY OF BOCA RATON Issue date: 11/14/15 201 WEST PALMETTO PARK ROAD BOCA RATON,FLA.33432-3795 REGISTRATION CERTIFICATION Registration paid 38.00 EXPIRES: 11/30/16 SITEWORKS, INC. BAL,GARY G Total paid: 38.00 SITEWORKS, INC. ****THIS ISNOT A BILL**** 21346 ST.ANDREWS BLVD 305 Note:Any changes in name;address, BOLA RATON FL 33433 suite,ownership,etc,will ire a new application within 1 S requdays. Class: CONTRACTOR,(B.P)FIRE PROTECTI Registration#: 16 00101063 CITY OF BOCA RATON Issue date: 11/18x'15 201 WEST PALMETTO PARK ROAD BOCA RATON,FLA.33432-3795 Registration paid: 38.00 REGISTRATION CERTIFICA,rION EXPIRES: 11/30/16 SITEWORKS, INC. Total paid: 38.00 BAL, GARY G ****THIS IS NO'I'A BILL**** SITEWORKS, INC. Note:Any changes in name,,address, 21346 ST. ANDREWS BLVD 305 suit,ownership,etc.will require BOCA RATON FL 33433 anew application within 15 days. Class:CONTRACTOR,(BP)UNDERGRD UTIL