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DS-16-3187os 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Pe Permit NO. DS -11-16-3187 ■Permit Type: Driveways/Sidewalks/Slabs Work Classification: Repair Permit Status: APPROVED mit Issue Da :11/22/2016 Expiration: 05/21/2017 Parcel Number Applicant 123 NE 97 Street Miami Shores, FL 33138-2332 1132060132440 Block: Lot: JUAN R. DEL RIO Owner Information Address Phone Cell JUAN R. DEL RIO 123 NE 97 Street MIAMI SHORES FL 33138-2332 123 NE 97 Street MIAMI SHORES FL 33138-2332 Contractor(s) Phone CONCRETE SERVICES PUMP & FINIS CeII Phone Valuation: Total Sq Feet: $ 1,200.00 400 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Work: REPLACE AND REMOVE BROKEN SIDEW Bond Return : Scanning: 3 Additional Info: Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.00 $2.00 $0.40 $100.00 $9.00 $1.60 $116.20 Pay Date Pay Type Amt Paid Amt Due Invoice # DS -11-16-62144 11/22/2016 Credit Card $ 116.20 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Planning Review Building 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 rtify th construction and zoning. the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating ize the above-named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy November 22, 2016 ate November 22, 2016 1 **- 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 RECEIV iD NOV 2 2 2016 FBC 201 11 - BUILDING BUILDING Master Permit No. S 11- 16 -315'7 PERMIT APPLICATION Sub Permit No. (BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION E] RENEWAL [PLUMBING El MECHANICAL PUBLIC WORKS Ej CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 123 NE 97th Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-013-2440 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: -Name (Fee Simple Titleholder): Juan R. del Rio Phone#: 786-506-9592 Address:123 NE 97th Street City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Concrete Services Pump & Finish, Inc. Phone#: 305-218-2467 Address: 10061 SW 44 Street city: Miami State: FL Zip: 33165 Qualifier Name: Hector Roman Phone#: State Certification or Registration #: CRC057635 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $1,200 `t± Type of Work: ❑ Addition ❑ Alteratii ❑ New Q Repair/Replace Demolition Description of Work: Replace and remove brokensidewalk. Square/Linear Footage of Work: 400 SQ. FT. Specify color of color thru tile: Submittal Fee $ Permit Fee $ (C6 - O CCF•$ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ ""Fond 9! TOTAL FEE NOW DUE $ k 1 1 6 • (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. 1 understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: 1 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 po • at the job site ce, the for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of suc inspection will not be approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this / day of IVOIYM602, , 20 __ _, by (»* Del OD , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLI Sign: /. Print: Seal: APPROVED BY (Revised02/24/2014) RTOPERFZ * MY COMMISSION # FF 208065 EXPIRES: March 10, 2019 Bonded Thru Budget Notary Services Signature CONTRA The foregoing instrument was acknowledged before me this a' I day ofQ�� �!ONJEM tt , 20 1 V , by -0,Z)Z-, who is personally known to me or who has produced as identification and who did take an oath. NOTARY P C: Sign: Print: Seal: pligs REZ * MY COMMISSION # FF 208065 EXPIRES: March 10, 2019 J'+,t.oF Fvdr'o Bonded Thru Budget Notary Sentra *************************************************************************** CU Plans Examiner Structural Review Zoning Clerk • LOT 13 1 LOT 12 BLOCK 18 BLOCK 18 7 LOT 11 BLOCK 18 LOT 10 BLOCK 18 1/2" COMMON WALL 0' 10' 20' 1 inch = 20' ft. ON PL O 0 REMAINDER OF LOT 17 SC0CK-18— In ;. ; ;';;:93.30' (R&M) :::: :: :::::::::.:ALLEr • .'::'::: :'::: : •11.50' .0 f O o tri 1.50' r)5 - pi. E 43.30' OF a LOT 18 ( LOT 18 BLOCK 18 1 BLOCK 18 4,5''-• • •1 a 5.7' o C N• 0 N .s ," CONC .4 03.0 O `D10.83' pi /2 20.83' 0.84' 11.50' a..1 3' .812 1a5 1515.80' 060' 22.90' 13.50' O CONC cci 16.00' 213. ONE STORY RESIDENCE # 123 16.00' 0 to f\ 3.0' 9.70' 0 3.10' CO - 15.50' r o U o o {BAST Q. BEARING) w 11-2.7CP O SCO U , , cEi.B.1 D W EI. P. 1/2" -COfle v7 � N 0 0 6.40' CONC 0.70 6.50' 4.5' 9.20' 21.05' F.I.P. 1/2" 0.07' 0.42' 0 el LOT 19 O BLOCK 18 i^. 0 0 it1 CV 0' m CONC . DRIVE 4. 10.0* 22.0' PARKWAY /4 G"`) .-FLP, kr IK -- (o p(a4 : ; _ ; ; ; ; ; :• . ; : ; ; ; ; ;:•;•;•:•:•;•;•;•.•;•.•:•;•.•.•.• •.• 75' RIGHT–OF–WAY (BY PLAT).'.'.'.'.'.'.'.'..;;;;;;;;;;;;;i; ;;;;_;;.;;;;.;. ...................................... LL l MJ!-77f1L I !-Ji VL M1 1V ! ........................ ................ ;= ;= N. E. 97th STREET: ........................................................................................................... POINTS OF INTEREST: CONC DRIVE CROSSES LOT LINE. MAP OF BOUNDARY SURVEY Property Address: 123 NE 97 ST MIAMI SHORES, FL 33138 nlineLand SURVEYORS, INC. 15271 NW 60 AVE, Suite 206 Miami Lakes, FL 33014 www.OnlineLandSurveyors. Com SURVEYOR'S CERTIFICATIOHI: 1 HEREBY CERTIFY THAT THIS "BOUNDARY SURVEY' ISA TRUE AND CORRECT REPRESENTATION OF A SURVEY ECTION. THIS COMPLIES WITH THE MINST NDAR{QS,,AAS SET GI2YH �19THE STATS 04 • • FLORIDA BOARD OF P SIONAL SU'"•?. _r RS A J i MAPPER I CHAPTER 5/-17.051, FLORIDA ADMINISTRATIVE CO p;:' U; SUANT TO SEC ell F I CJ f SIGNED MIGUEL ESPINO STATE OF FLORIDA 4i2024 FLORIDA STATIPTES. • ..• • • .. • •. • •• . • • •• ... .• • •• • • 1OR TFIE WRM • • • • • • • • • •P.S.M. No.�5101 • �• • •• • • • • NOT VALID WITHOUT AN AUTHENTIC ELECTROVIC SI4NAKURE AND AUTHENTICATED ELECTRONIC SEAL AND/OR THIS MAP IS NOT VALSDWITHOUT THES1tAME AND dt4IGINAL • RAISED SEAL OF A LICENSE SURVEYOR AND MAPPER. • • • Survey Date:8/16/2016 Survey Code:O-28105 Page 1 of 2 Not valid without all pages. re= + x • :..- kik3 1'T 23 Northeast 97th Street s _,1 - .-sgyt• s iJll tit sYS a ',�- j = LOCATION MAP N.T.S. PROPERTY FRONT VIEW CERTIFIED TO: FLOOD INFORMATION: JUAN FIDELITY COLUMBUS ITS'SUCCESSORS INTEREST ROSBALDO DEL RIO NATIONAL TITLE INSURANCE COMPANY CAPITAL LENDER LLC AND/OR ASSIGNS AS THEIR MAY APPEAR. 1 Community Number: VILLAGE OF MIAMI SHORES 1 120652 Panel Number: 12086C0302L Suffix: L Date of Firm Index: 9/11/2009 Flood Zone: X Base Flood Elevation: N/A Date of Survey: 8/16/2016 LEGAL AMENDED IN DESCRIPTION: LOT 17, LESS THE WEST 6.7 FEET THEREOF, AND ALL OF LOT 18, BLOCK 18, AN PLAT OF MIAMI SHORES SECTION NO. 1, ACCORDING TO THE MAP OR PLAT THEREOF, AS RECORDED PLAT BOOK 10, PAGE 70, OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA. ® PROPERTY UNE Surveyor's Legend Lf_., STRUCTURE c� 0 TREE L.M.E. LAKE or LANDSCAPE MAINT !SMT. ESMT. EASEMENT CONC. BLOCK WALL R.C.E. ROOF OVERHANG EASEMENT D"E DRAINAGE EASEMENT P.P, POWER POLE x CHAIN-UNK or PARE FENCE P.P. POOL PUMP L.S.E. LANDSCAPE SUFFER ESMT. mem. CATCH BASIN EASEMENT WOa FENS PL PLANTER OR PROPERTY UNE L.A.E. LIMITED as n .ACCESS Unit-TYC.U.E. COUNTY Unit-TY ESMT. L0. IDENTIFICATION 1EL. TELEPHONE FACILITIES _0_4_0_ IRON FENCE I.E./E,E INGRESS/ EGRESS ESMT. B.C. BLOCK CORNER U.P. UTUTY POLE U.E. UTILITY EASEMENT a E.U.B. ELECTRIC UTUTY BOR — — — — EASEMENT B.... BEARING REFE.2lNCE ENO. OR F FOUND IRON PIPE/ t CENTRAL ANGLE or DELTA SEP. SEPTIC TANK — CENTER UNE PIN AS NOTED ON PLAT D.F. DRAIN FIELD LB/ UCENSE N - BUSINESS R RECORD OR RADIUS RAD. RADIAL AC AIR CONDITIONER ////// L5# LICENSE -SURVEYOR WOOD DECK CALC CALCULATED POINT N.R. NON RADIAL CSW CONC SIDEWALK DWY DRIVEWAY SET SET MONUMENT TYP. TYPICAL i _ " CONCRETE • CONTROL POINT I.R. IRON GAR. GARAGESCR. SCREEN I.P. IRON PIPE i ■ CONCRETE MONUMENT N&D NAIL & DISK ENCL ENCLOSURE ELEV ELEVATION ASPHALT PK NAIL PARKER-KALON NAIL N.T.S. NOT TO SCALE P.T. POINT OF TANGENCY F.F. FINISHED FLOOR D.H. DRILL HOLE i P.C. POINT OF CURVATURE ® WELL T.O.B. TOP OF BANK i BRICK/TLE P.R.M. PERMANENT REFERENCE MONUMENT rr FIRE HYDRANT E.O.W. EDGE OF WATER P.C.C. POINT OF COMPOUND CURVATURE HOLE E/P OR E.O.P. EDGE OF PAVEMENT I P.R.C. POINT OF REVERSE CURVATURE O M.H. MAN / , WATER F.O.B. POINT OF BEGINNING 0.H,L. OVERHEAD LINES C.V.G. CONCRETE VALLEY GUTTER BUILDING SETBACK UNE P.O.C. POINT OF COMMENCEMENT Tx TRANSFORMER B.S.L. CATV CABLE TV. RISER S.T.L. SURVVEYY 11E UNE -- - APPROXIMATE EDGE OF WATER P.C.P. PERMANENT CONTROL POINT W.M.WMWATER METER M FIELD MEASURED PA POOL EQUIPMENT R/W RIGHT OF WAY P PLATTED MEASURMENT R.O.E. PUBLIC UTILITY EASEMENT X/ CONC CONCRETE SLAB COVERED AREA D DEED C.M.E. CANAL MAINTENANCE EASEMENT C CALCULATED A.E. ANCHOR EASEMENT GENERAL NATES; 1) LEGAL DESCRIPTION PROVIDED BY OTHERS. 12) EXAMINATION OF THE ABSTRACT OF TITLE WILL HAVE TO BE MADE TO DETERMINE RECORDED INSTRUMENTS, IF ANY, AFFECTING PROPERTY. 3) THE LANDS SHOWN HEREON WERE NOT ABSTRACTED FOR EASEMENT ORFLTA OTHER RECORDED ENCUMBERANCES NOT SHOWN ON THE PLAT. THE PURPOSE OF THIS SURVEY IS FOR USE !N OBTAINING TITLE INSURANCE 1 AND FINANCING AND SHOULD NOT BE USED FOR CONSTRUCTION, PERMITTING DESIGN, OR ANY OTHER PURPOSE WITHOUT THE WRITTEN CONSENT OF ONLINE LAND SURVEYORS INC. 5)UNDERGROUND PORTIONS OF FOOTINGS, FOUNDATIONS OR OTHER IMPROVEMENTS WERE NOT LOCATED. 6) ONL Y VISIBLE AND ABOVE GROUND ENCROACHMENTS LOCATED. 7) FENCE OWNERSHIP NOT DETERMINED. 8) WALL TIES ARE TO THE FACE OF THE WALL. 9) BEARINGS ARE BASE ON AN ASSUMED MERIDIAN. 10) BOUNDARY SURVEY MEANS A DRAWING AND/OR GRAPHIC REPRESENTATION OF THE SURVEY WORK PERFORMED IN THE FIELD, COULD BE DRAWN AT A SHOWN SCALE AND/OR NOT TO SCALE. NO IDENTIFICATION FOUND ON PROPERTY CORNERS UNLESS NOTED. 11)DRAWN 12) NOT VALID UNLESS SEALED WITH THE SIGNING SURVEYORS EMBOSSED OR ELECTONIC SEAL. 13) DIMENSIONS SHOWN ARE PLAT AND MEASURED UNLESS OTHERWISE SHOWN. 14) ELEVATIONS IF SHOWN ARE BASED UPON N.G.V D. 1929 UNLESS OTHERWISE NOTED. 15) THIS IS A BOUNDARY SURVEY UNLESS OTHERWISE NOTED. 16) THIS BOUNDARY SURVEY HAS BEEN PREPARED FOR THE EXCLUSIVE USE OF THE ENTITIES NAMED HEREON, THE CERTIFICATIONS DO NOT EXTEND TO ANY UNNAMED PARTIES. - Florida Land • - * • • _ i t • 4 -AffiteIla Member4) Printing to Scale:e"from Ga9E en Ones: = Page Pvp:%) None 1. Select"No Scaling 2. Deselect "Auto-Rotate and Center" 3. Select 'Choose paper source by PDF page size" (z> Aoto$o atc and Center 1 - 3 Choose paper source by PDE cage sZe T FIELD WORK: 8/15/2016 . • • • • BY: V.P • • • • - • • • • 51 FIC • • • • • CHECKED BY' M.E • • P� • • FINAL REVISION: 08/16/2016. • •:., • �° COMPLETED: • 5 A.% • • • • • • tTE .� • •'idR. D4 • SCALE: 1" = 20'• . 4• • •• • • • • • SOA 41 SUR•EYOV • • SURVEY CODE: 0-28105 • • • X04 • 15271 NW a0 AVE,Suite !06 • Miami : )FL 339T4-0121 . 7nIineLand Phone: (305) 910-0123 Fax: (305) 675-0999 `URVE ORS,iNC. www.OnlineLandSurveyors.Com Survey Date:8/16/2016 Survey Code:O-28105 Page 2 of 2 Not valid without all pages. 000079 ler Local Business Tax Receipt Miami -Dade County, State of Florida -THIS 1S NOT A BILL - DO NOT PAY 6267140 BUSINESS NAME/LOCATION CONCRETE SERVICES PUMP & FINISH INC DOING BUS IN DADE CO MIAMI FL 33000 OWNER CONCRETE SERVICES PUMP & FINISH Worker(s) 2 RECEIPT NO. RENEWAL 6532155 IT -3 I \ l EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SUB -BUILDING CONTRACTOR CRC057635 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 07/07/2016 CREDITCARD-16-036898 This Local Business Tax Receipt only conrums payment of the Local Business Tax. The Receipt is not a license, permit, or • certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to Me business. The RECEIPT N0. above must be displryrcd on all commercial vehicles - Miami -Dada Code Sec Ib -276. For more information, visit wynv.miamidade.govRaxcollectot BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2016 THROUGH SEPTEMBER 30, 2017 DBA:CONCRETE SERVICES PUMP & FINISH Business Name: INC Owner Name: ROMAN HECTOR Business Location: 10061 SW 44 ST MIAMI DADE COUNTY Business Phone: 954-370-2651 Rooms Seats Employees 2 Receipt If:GENERAL3 CONTRACTOR Business Type:CONTRACTOR) Business Opened:n/13/200a State/County/Cert/Reg:CRCO 5 7 6 3 5 Exemption Code: Machines Professionals (RES IDE THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: ROMAN HECTOR 10061 SW 44 ST MIAMI, FL 33165 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 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. 2016 - 2017 Receipt #WWW -15-00137507 Paid 07/07/2016 27.00 For Vending Business Only Number of Machines: Vending Typo: Tax Amount Transfer Fee NSF Fee Penally Prior Years Collection Cost Total 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 WHEN VALIDATED Mailing Address: ROMAN HECTOR 10061 SW 44 ST MIAMI, FL 33165 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 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. 2016 - 2017 Receipt #WWW -15-00137507 Paid 07/07/2016 27.00 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: 8/25/2016 EXPIRATION DATE: 8/25/2018 PERSON: PEREZ ALBERTO FEIN: 651050231 BUSINESS NAME AND ADDRESS: CONCRETE SERVICES PUMP & FINISH INC. 10061 SW 44 ST MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: LICENSED RESIDENTIAL CONCRETE OR CEMENT CONTRACTR WORK - FLOG 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 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: 7/22/2015 EXPIRATION DATE: 7212017 PERSON: ROMAN HECTOR L FEIN: 651050231 BUSINESS NAME AND ADDRESS: CONCRETE SERVICES PUMP & FINISH INC 10061 SW 44 STREET MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: CONCRETE OR CEMENT WORK - FLOO Pursuant to Cheater 440.05(14), F.S.. an dicer ora oorporetion who eleds exemption ham this deplsr by Cling ■ certificate of election under this section may not recover bsnslltt or compensation under this chapter. Purwsat to Chapter 440.05(12), F.S.. CertiAcetes of Mention to be exempt... apply only within the scope of the business or trade fisted on the notice of election to be exempt. Pursuant to Chapter 440.05(13). F.S.. Notoes of election to be exempt end certificates of election to be exempt strati bo *object to revocation 11, et any time air the Aling of the notice or the issuing of the Carfiflcate. the person named on the notice or certificate no longer meets the requkemente of this scion for issuance of a certificate. The department *hail revoke a CFS-F2-DINC-252 CERTIFICATE OF ELECTION TO SE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 AcORce CERTIFICATE OF LIABILITY INSURANCE DATE(MMroO/YYYY) U ANCE l 11,17116 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 policy(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 — Yes Insurance Agencies, Inc. ! 9507 Bird Road Miami, FL 33165 Phone (305) 225-5757 INSURED • Fax (305)223-8158 CONTACT Madeline Estrada NAME: --_- {PHONE 305 225-5757 ADDRESS: madeline©yesins.com FAX INC, No): __ _ _INSURER(S) AFFORDING COVERAGE INSURER A : Granada Insurance Company INSURERS : Concrete Services Pump & Finish, Inc (GL) INSURER C : 10061 SW 44 St INSURER 0: _ Miami, FL 33165(305) 218-2467 _INSURER E — INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: (305) 223-8158 NAI; 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 ITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS _. ICY EXP _ INSR' ADDLSUBR — - — -- EFF LTR , TYPE OF INSURANCE . _ INSR..INVD .._.. POLICY NUMBER ; ( MNDYIYYYY) (M LINIDD/YYYY) - LIMITS GENERAL UABLITY EACH OCCURRENCE v'1 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE t!; OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- -_JECT AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS LOC SCHEDULED AUTOS HIRED AUTOS AUUTTOSWNED UMBRELLA LIAB OCCUR N N 0185FL00007290 j DAMAGE TO RENTED PREMISES(Eaoccurrence) S MED EXP (Any one person) S 03/06/2016 03/06/2017 •PERSONAL & ADV INJURY i S GENERAL AGGREGATE- ! EXCESS LIAR CLAIMS -MADE '. DED. .. RETENTIONS_ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? - N 1 A (Mandatory In NH) 11 yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule. if more space Is required) Concrete Paving Description of Operations: Lic# CRC057635 CERTIFICATE HOLDER Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138 ACORD 25 (2010105) QF CANCELLATION PRODUCTS - COMP/OPAGG 1,000,000.00 100,000.00 5,000.00 1,000,000.00 2,000,000.00 $ 2,000,000.00 ._iCEa a dED SINGLE LIMIT S — BODILY INJURY (Per person) S BODILY INJURY (Per accident)] S _(Per accident) PROPERTY DAMAGE S EACH OCCURRENCE AGGREGATE . WC STATU- --i OTH- TORY LIMITS--' ER. E -L. EACH ACCIDENT S E .L. DISEASE - EA EMPLOYE S - E.L. DISEASE - POLICY LIMIT S 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 REPRESENTATN Madeline Estrada ©1988-20 O ACORD CORP a '•r ION. All ri reserved. The ACORDname and logo . = registered marks 'f ACORD STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1335 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ROMAN, HECTOR LUIS CONCRETE SERVICES PUMP 10299 RAYBURN COURT SPRING HILL FL 34608 FINISH INC 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.myflortdaticense,com. There you can and more information about our divisions and the regulations that impact you, subscribe to department newsletters and team more about the Department's initiatives. Our mission et 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 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CRC057635 ISSUED: 06/13/2016 CERTIFIED RESIDENTIAL CONTRACTOR ROMAN, HECTOR LUIS CONCRETE SERVICES PUMP & FINISH IN IS CERTIF$C.b under the provisions or Ch.409 FS. Eters/den este • AUG 3t,2Qre Lte0b1300011e9 DETACH HERE KEN LA VV , SECRETARY STATE OF FLORIDA DEPARTMENT t3F BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The RESIDENTIAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 480 FS. Expiration, date: AUG 31, 2018 ROMAN,HECTOR LUIS CONCRTE SERVICES PUMP & FINISH INC 4475 SW 95TH AVE DAVIE FL 33328 issu sDISPLAY AS REQUIRED BY LAW