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RC-16-2043iPECTION RECORD Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 POST ON SITE Permit NO. RC -7-16-2043 Permit Type: Residential Construction Work Classification: Alteration I Issue Date: 12/1/2016 Expires: 05/30/2017 INSPECTION REQUESTS: (305)762-4949 or Log on at https://bldg.miamishoresvillage.com/cap REQUESTS ARE ACCEPTED DURING 8:30AM - 3:30PM FOR THE FOLLOWING BUSINESS DAY. Requests must be received by 3 pm for following day inspections. Residential Construction Parcel #:1132060440420 Owner's Name: HECTOR and CARMEN LOPEZ Job Address: 726 NE 92 StreetSuite: 4-L Bond Number: Miami Shores. FL __ __ ___ate_ _ ...=, 7._: k..,—. -,ZA,:1.,k.7Zi.IV,.ti. 1,..�. Contractor(s) THE LAKOTA GROUP INC Phone Primary Contractor (954)455-3030 Yes Owner's Phone: (305)588-5821 Total Square Feet: Total Job Valuation: 565 $ 25,000.00 WORK IS ALLOWED: MONDAY THROUGH FRIDAY, 8:OOAM - 7:OOPM. SATURDAY 8:OOAM - 6:OOPM. NO WORK IS ALLOWED ON SUNDAY OR HOLIDAYS. BUILDING AND ROOFING INSPECTIONS ARE DONE MONDAY THROUGH FRIDAY. NO INSPECTION WILL BE MADE UNLESS THE PERMIT CARD IS DISPLAYED AND HAS BEEN APPROVED. PLANS ARE READLY AVAILABLE. IT IS THE PERMIT APPLICANT'S RESPONSIBILITY TO ENSURE THAT WORK IS ACCESSIBLE AND EXPOSED FOR INSPECTION PURPOSES. NEITHER THE BUILDING OFFICIAL NOR THE CITY SHALL BE LIABLE FOR EXPENSE ENTAILED IN THE REMOVAL OR REPLACEMENT OF ANY MATERIAL REQUIRED TO ALLOW INSPECTION. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. ®k `ib r-tilL- r r 4 l STRUCTURAL INSPECTION DATE Foundation INSPECTION RECORD INSP Stemwall Slab Columns (1st Lift) Columns (2nd Lift) Tie Beam Truss/Rafters Roof Sheathing Bucks Windows/Doors di. Interior Framing Insulation r7 Ceiling Grid Drywall Firewall {/1l6'17 A Wire Lath Pool Steel Pool Deck Final Pool Final Fence Screen Enclosure Driveway Driveway Base Tin Cap Roof in Progress Mop in Progress Final Roof Shutters Attachment Final Shutters Rails and Guardrails ADA compliance DOCUMENTS Soil Bearing Cert Soil Treatment Cert Floor Elevation Survey Reinf Unit Mas Cert Insulation Certificate Spot Survey Final Survey Truss Certification STRUCTURAL COMMENTS ZONING INSPECTION DATE Zoning Final ZONING COMMENTS INSP ELECTRICAL INSPECTION DATE INSP Temporary Pole 30 Day Temporary Pool Bonding Pool Deck Bonding Pool Wet Niche Underground Footer Ground Slab Wall Rough Ceiling Rou Rough Telep o e Rough Telephone Final TV Rough TV Final Cable Rough Cable Final Intercom Rough Intercom Final Alarm Rough Alarm Final Fire Alarm Rough Fire Alarm Final Service Work With FINAL ELECTRICAL COMMENTS FIRE INSPECTION Final Sprinkler Final Alarm FINAL DATE INSP PLUr INSPECTION BING DATE INSP Rough Water Service 2nd Rough e: -.x -f(1, Top Out /, -L-/ . . Fire Sprinklers / Septic Tank Sewer Hook-up Roof Drains Gas LP Tank Well Lawn Sprinklers Main Drain Pool Piping Backflow Preventor Interceptor Catch Basins Condensate Drains HRS Final FINAL/'(/ PLUMBING COMMENTS MECHANICAL INSPECTION DATE INSP Underground Pipe Rough Ventilation Rough Hood Rough Pressure Test Final Hood I Ventilation Final ' . +I Heater Final Vacuu FINAL ANICAL Co , . ENTS �'1/4 0"\2\\2p1U BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC 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 204` �ctu L c��� 26 16 Master Permit No. Sub Permit No. ❑ ROOFING BY: JUL 2 ref stilk ❑ REVISION ❑ EXTENSION PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION 24' ' / � CONTRACTOR JOB ADDRESS: /2 P 72 4'L City: Miami Shores County: Miami Dade Zip: ❑ RENEWAL ❑ SHOP DRAWINGS Folio/Parcel#: 11 ' VQ -05 ' 044' 41-0 Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: OWNER: Name (Fee Simple Titleholder): 14e C °r C1, Phone#: Address: % al to _/'1 (. s '1 2 S54-4 (A l— City: Iyl ►UW�d SflO €-S State: Ft Tenant/Lessee Name: l Email: �i,j CIee , 7 -Q �'1N��� 1 - Low, Phone#: NO FFE: Sas 6-- a� Zip: 33)3 k CONTRACTOR: Company N`afie:e1.4t.1.(441(ortJVC Address: l4 55" • la AA/D4,s, C,' l3GV j2 CityM4A/ 1I'Jfl' L!! f I3L'AO / • , -State: f40 /P4 Qualifier Name: Vv� �1 ✓� State Certification or Registration #: C ! ddrag 11 Phone#t7r'4 r = 3030 Zip:334a9 Phone#q'!' t ` 4/ %"g'GlG' DESIGNER: Architect/Engineer: Address: qt5rbW 1 Value of Work for this Permit: $ Type of Work: ❑ Addition Description of Work: t.� (APO r Certificate of Competency #: Phone#: CityLat.0* State: Square/Linear Footage of Work: Alteration ❑ New ❑p p Zip: V0/46 Re air/Re lace ►� �emo`ition titiOlgt kVA. (1 DrAik 'ff....>4415+1\ rAtAeLO 014 motsut cztee-Th`vai-6, 44toLGkviee6 Civtitor) 0 Specify color of color thru C) tile: U� Submittal Fee 45 �- ° -. Permit Fee $ CCF $ 1 C" CO/CC $ 0 ,- �__im; , v Scanning Fee $ q / �t�� Radon Fee $ 1 I • 2- 5 DBPR $ 1 1 . Notary $ ,n.Z Technology Fee $ Training/Education Fee $ n- Double Fee $ Structural Reviews $ Bond $ ,ffM11•.......® TOTAL FEE NOW DUE$ '• '-l-4 'St) INV.411W fri r2.) -6t' I/v1'Gk (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. [F.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 anti 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 OWNER or AGENT The foregoing instrument was acknowledged before me this 13 day of —SV U•)a— , 20 ,bo , by Hrt C'1V2 t--oPF'7- , who is personally known to me or who has produced ' % 1!2 as identification and who did take an oath. NOTARY PUBLIC: � 111111// j� •. b Sign: m? % Sign: Print: . ' Print: Seal:. •�` Seal: -•%••• , ****************************4****/111,11 14i0%**************************************************************** Signatu • . CONTRACTOR The foregoing instrument was•acVnowledged' oefor"e me thi's ' day pf Sly 1. , 20 lcc. , by A o isersonall known to ift p Y me or who has.produced 172L�- as identification and who dicttake an oath. 01111110111111 NOTARY PUBLIC: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 DOMASH, WAYNE THE LAKOTA GROUP INC 3140 S OCEAN DR APT 1008 HALLANDALE BEACH FL 33009 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfioridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and team more about the Departments initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! RICK SCOTT, GOVERNOR (850) 487-1395 STATE OF FLORIDA DEPARTMENT 'OF BUSINESS AND PROFESSIGL.'REGULATION CGC1513839 �` r, UE 08/08/2016 CERTIFIED G DOMASH, WA, THE LAKOTA CONTRA_ Ta IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31, 2018 L1608080001231 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The GENERAL CNTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 DOMASH, WAYNE THE LAKOTA GROUP! 3140 S OCEAN DR HALLANDALE BEA .. r �. •i�ciu. ' ,... ' �", : ;�s:�, ;a":;� , Fc '.:�C a -_; ?..• lw .b TraggiMMTIMffg, BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115-5. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 'VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016' zaw DBA: Business Name: LAKOTA GROUP INC THE Owner Name: WAYNE DOMASH Business Location: 1835 E HALLANDALE BCH BLVD HALLANDALE Business Phone: Rooms Seats Employees 1 Receipt #: GENERALS8 CONTRACTOR Rosiness Type:C<RACTOR) Business Opened:07/11/2007 State/County/Cert/Reg:CGC 1513839 Exemption Code: Machines Pr fessionals Number of Machi For Vending Business Only • Tax Amount Transfer Fee r.,... NSF Fee Penalty - -----v. a ,.--- Prior Years Collection Cost Tots! Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within .Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: WAYNE DOMASH 1835 E HALLANDALE BCH BLVD HALI,ANDALE, FL 33009 Receipt #13B-14-00009694 Paid 08/06/2015 27.00 AWRU® �, CERTIFICATE OF LIABILITY INSURANCE DATE jMWDOIYYWI 07/13/2016 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 pofcy(ies) 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). PRIER AQUA INSURANCE GROUPIE 701 S. 21ST AVENUE d4 HOLLYWOOD FL 33020 INSURED ii The lakota group 1835 E Hallandale Beach Blvd #632 , Hallandale FL 33009 cONTACr Ingrid Rivero NAME: >>� ... (954) 241-2782 FAX (954) 241rr1783 (AIC. No. Eat): lox, No r, A ss: Ingndr.aquairts@gmail.com INSURER(S) AFFORDING COVERAGE NAIC 0 BisuRER A : International Insurance Comp INSURER B : INSURER C INSURER D : INSURER E : 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 NSR ADOL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE )Psn o,vn POLICY NUMBER IMMIDD/TYYY1 IMAM QIYYYYI LIMITS X!COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 X CLAMS -MADE OCCUR PREM SESO(EaENTED occurrence) AMAGE • MED EAP .Any one person: S 100.000 s 5000 A IGO6C004844 02/03/2016 02/03/2017 PERSONAL & ADV INJURY $ 1.000.000 GEN'L AGGREGATE LIM'T APPLIES PER GENERAL AGGREGATE $ 1.000.000 POLICY PRO- JECT Lcc PRODUCTS -COMP10vAGG S 1.000.000 OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIA�JTY IEa acodent) $ ANY AUTO BODILY INJURY IPer person S ALLOWED SCHEDLI ED BODO' INJURY(Per acodeM) S AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accrcfem: S UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS -MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS' UABILITY Y 1 STATUTE ER _ .. ANY PROPRIETOR PARTNERrE%ECUTIYE OEPICER:MEMBER EXCLUDED, ` N 1 A E L EACH ACCIDENT $ l (Mandatory In NH) . E L DISEASE - EA EMPLOYEE S 1' yes des[rb8 under DESCRIPTION OF OPERATIONS rem A E L DISEASE - POLICY LlM'T S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addittolnl Remarks Schedule. may be attached ft more space Is required) License: CGC1513839 Job Performer To: Owner Hector Lopez Address: 226 NE 92 St Miami. FL 33138 CERTIFICATE HOLDER CANCELLATION Miami Shore Village Building Department Permit 10050 NE 2nd Ave Miami Shore Village. FL 333138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD n /t 100% .IEFFAIWATER CHEF FINANCIAL OFFICER STATE OF FLORSIA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORK' (CATION • • CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WONKY' COMPEM3A110N LAW • • CONSTRUCTION INDUSTRY EXEMPTION - This certifies that the irtdii listed below has elected to be exempt from Florida Workers' CAS law. EFFECTIVE.DATE: 10/22/2016 PERSON: DOMASH FEIN: 260141225 BUSINESS NAME AND ADDRESS: THE LAKOTA GROUP INC EXPIRATION DATE 10/22/2018 WD►YNE 1835 EAST HALLANDALE BEACH BLVD HALLANDALE BEACH FL 33009 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pouliot to Chapter 440A6(14).F-8, an caw da oupuallmwho Moab exemption (multi dopier ppy�ip a certificate at similes wider Via aedon oar not ismer beee#wmapsaaem mktIie dabs. Puma bampler 440.05(121dder8mb be earapt. opptortly rai9ascope ails Winos ebds bled co the nolo, atWWInb be sompt Pueurt4IO0(3tFNolen d*Adonis be bald d b e t ab Kay the areat named onto rawer walk:lab no tomer ®teia�bl ahiamice a DF8-F2 0 -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 06-13 QUESTIONS? (850}113-1609 k The Lakota Group Inc. 1835 E Hallandale Beach Blvd, Suite 632 Hallandale Beach, FL 33009 954-455-3030 (Office) 954-558-9695 (Cell) CGC # 1513839 Date: 7 ffq /ZGI&, State of C-IoQtt'* County of M i irrAi - 1 be Before me this day personally appeared sworn, deposes and says: WAytv -1)0iiiishwho being duly That he will be the only person working on this project located at '12 to PJ Z ' -1- • }' y L. M► n� koees $ L 3313 Sworn t r affirmed) and subsc %ped before me this 1 g day of 2016, by `f. '\ bvi 4-51. Personally known Or produce identification �C '�LIVf-TL- Type of identification Print, Type or Stamp of Notary Jnc- Miami Shores Village 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 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, parttime employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this 19 day of By \--\_r — . c -r Scnnq\►) Notary: SEAL: ,201 . who is personally known to me or has produced w as identification. STELLA HORAN Notary Pubile State of Florida Commission # FF 197803 My Contin. Expires Peb 9, 2019