REV-17-1304BUILDING
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
^(-4TVTED
M 1 1 017
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FBC 20 4
Master Permit No. DS -11-16-3187
PERMIT APPLICATION Sub Permit No. �-) t �' -13(3(1
BUILDING El ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑ RENEWAL
El PLUMBING ❑ MECHANICAL r'UBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 123 NE 97 Street
City: Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#:1132060132440
Is the Building Historically Designated: Yes NO X
Occupancy Type: residential Load: Construction Type: Driveway Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Juan R. Del Rio Phone#: 3057264334
Address: 123 NE 97 Street
City: Miami ShoresState: FL Zip: 33138-2332
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Concrete Services Pump & Finish, Inc. Phone#: 3052182467
Address: 10061 SW 44 ST
City: Miami State: FL Zip: 33165
Qualifier Name: Hector L. Roman
Phone#: 3052182467
State Certification or Registration #: CRC057635 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: -%:_i (44 9 . Square/Linear Footage of Work: 600 SO PT
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: Install 4"+3000 PSI plain concrete in 5'-0" sections with a 4 1/2" space between sections.
Specify color of color thru tile:
Submittal Fee $
TTT T Permit Fee $ CCF $ CO/CC $ i '
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ 0
TOTAL FEE NOW DUE $ ( f G- c-..
Z
(Revised02/24/2014)
-RVHi3O'I
oat) -
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: 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 commence ent st be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. in the • bsence f such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
ep-
me,„
Signature
OWNER or AGENT
Signa
CTOR
The foregoing instrument was acknowledged before me this The forego) was acknowledged before me this
03 day of May , 20 17 by 02 day of May , 20 17 , by
Juan R. Del Rio , who is personally known to Alberto Perez , who is personally known to
me or who has produced as me or who has produced as
Identification and who did take an oath.
NOTARY PUBLIC:
Sigr
Print: `�
Seal:
MY COMMIbb1ON # H-92/989
ff'•,;: EXPIRES October 15, 2019
1401398-o 0; FMrKiallota vicsppn
Tee
identification and who did take an oath.
NOTARY PUR6iIC:
Sign:
Print:
Seat:
Afe
lv ��
LI
T PEREZ
MY COMMISSION #,FF927989,
.a,x:•. EXPIRES October 15.2019
(407 398-0153 Flod0s1400a ySer ics.cc
***************************r** **** ** #*Iii*****R***********E****iii****************#********** *********■
Plans Examiner t ---)D
� s--70
P Zoning
APPROVED BY
(Revised02/24/2014)
Structural Review Clerk
•
ACORx7 CERTIFICATE OF LIABILITY INSURANCE
'hr. --05/10/17
DATE (MM/DD/YYYY)
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 Fax (305) 223-8158
CONTACT
NAME: Madeline Estrada
pee . Ext), (305)225_5757 FAX , Not; (305) 223-8158
pee
madehne@yesins.00m
INSURER(S) AFFORDING COVERAGE
NAIC+t
INSURER A: Granada Insurance Company
N
INSURED
Concrete Services Pump & Finish, Inc (GL)
10061 SW 44 St
Miami, FL 33165 (305) 218-2467
INSURER B :
03/02/2017
INSURER C :
EACH OCCURRENCE
INSURER D :
m COMMERCIAL GENERAL LIABILITY
El In CLAIMS -MADE N OCCUR
II
INSURER E :
$ 100,000.00
INSURER F :
$ 5,000.00
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.
INSR
LTRINSR
TYPE OF INSURANCE
ADDLSUBR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(AAM/DD/YYYY)
LIMITS
A
GENERAL LIABILITY
N
N
0185FL00093390
03/02/2017
03N2/201$
EACH OCCURRENCE
$ 1,000,000.00
m COMMERCIAL GENERAL LIABILITY
El In CLAIMS -MADE N OCCUR
II
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ 100,000.00
MED EXP (Any one person)
$ 5,000.00
PERSONAL & ADV INJURY
$ 1,000,000.00
❑
GENERAL AGGREGATE
$ 2,000,000.00
GEN'L AGGREGATE UMIT APPLIES PER:
• POLICY • 31C7 • LOC
PRODUCTS -COMP/OP AGG
$ 2,000,000.00
AUTOMOBILE LIABIUTY
ECOMBINED aBntlSINGLE UMIT
$
• ANY AUTO
❑ALL OW NED SCHEDULED
AUTOS MI AUTOS
111 NON -OWNED
HIRED AUTOS • AUTOS
❑ •
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTYDAMAGE
(Per eccidentl
$
$
• UMBRELLA UAB • OCCUR
❑ EXCESS LIAB • CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE
$
❑ DED 0 RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' UABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
gm WC STATU- N$ ER
E.L EACH ACCIDENT
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes describe under
DESCRIPTION OF OPERATIONS below
E.L DISEASE - EA EMPLOYE
$
E.L DISEASE -POUCY UMIT
$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
Concrete Paving
CERTIFICATE HOLDER
CANCELLATION
Miami Shores Village
10050 NE 2nd Ave
Miami Shores, FL 33138
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
Madeline Estrada
ACORD 25 (2010/05) QF
®1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
r� + T+i,,'J
1 1 2017
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20• ai A.
1 inch 20' (t es
REMAINDER OF `-1
LOT 17 t7
BLOCK 18 O.
41+3000 . i14
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123NE97ST
1 SHORES. FL 33138
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nlineLand
SURVEVORS,INC.
15271 NW BO AVE, Suite 208
(Miami Lakes, FL 33014
1NWYV.ordIrte anaurveyDIS.Co D
ISIBYEMUSSEWEEATIM HEREBY CERTIFY THAT ?INS 10V.IDAATSURVEY' SA TIRE
AND CORRECT REPRESENTATION OFA SURVEY PREPARED UNDER LAY DIRECTOR THS
CO UES INITAI THE ,j STANDARDS. AS SETRORTHBYTHE STATE OF
FLORIDA BOARDS= -• _• AMD WAFER wCIMATBT swiss, FLORIDA
AO01 WSTRATI E ••,.; Tv ,; 0207/. FLORIDA STATUTES.
SIGNED
MIGUEL
STATE OF FLORIDA
HOT VALE YATHOU r AN AUTHENTJC ELECTRONIC SIGNATURE AID AU T tIENTICATED
ELECT Mao SEK ANIMA THIS NAM IS IYJT VALID WITHOUT THE SKINARIRE AND MORAL
RAISED *00113111301130 SURYEYOR ANO NAPPER.
Survey Date:811812016
Survey Code:O-28105
Page 1 of 2 Not valid without all pages.
Survey Date:8/16/2016
Survey Code:O-28105
Page 2 of 2 Not valid without all pages.
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PROPERTY FRONT -
LQCATION MAP N.T.S.
CERTIFIED TO;
JUAN ROSBALDO DEL RIO
FIDELITY NATIONAL TITLE INSURANCE COMPANY
COLUMBUS CAPITAL LENDER LLC
ITS'SUCCESSORS AND/OR ASSIGNS AS THEIR
INTEREST MAY APPEAR.
• • • i
FLOOD INFORMATION: • • •
•••• 4.
Community Number: VILLAGE OF MIAMI SHORES.
120652 • • • • ••..
Panel Number 12086C0302L • •l
Suffix: L
Date of Firm Index: 9/11/2009
Flood Zone: X
Base Flood Elevation: NIA
Date of Survey: 8/16/2016
f LEGAL DESCRIPTION: LOT 17, LESS THE WEST 6.7 FEET THEREOF, AND ALL OF LOT 18, BLOCK 18, AN
AMENDED PLAT OF MIAMI SHORES SECTION NO. 1, ACCORDING TO THE MAP OR PLAT THEREOF, AS RECORDED
1 IN PLAT BOOK 10, PAGE 70, OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA. i
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— PROPERTY UNE Surveyor's Legend
/ 3 STRUCTURE
CONN. BLOCK WALL a TREE LIKE LAM or LAIMSCAPE RANT. E!EI: ESUT. EASEMENT
—2— O1AN-IRR m 1lR2E FENCE YJ PP. ••1•31 Pa"R.D.E.ROv =HANG EASEMENT DE ORAINAM EASEMENT
P.P. POOL PIMP LB.E LANDSCAPE BUFFER ESNT. =
WOOD FEND ®C8' CA7O1 &AIM PL PLANTER OR PROPERTY UNE L.A.E. L.53703 ACCESS EVMM9T
N N
GU.E COMM Y UTILITY ESN. IA 10.. T'c1EPN0E FAMINES
- • NMI FENCE LE/EE. KROiESS/ M.U.
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00000KENTIRCADON010
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— — — — EASDIENT 010. OR 0 PARED NON AWE/ RAN. REARING REFEREN4E $. SEPTIC TAM
— - — CENTER ; 0. PN AS NOTED ON RAT 5 CENTRAL ANSUE U DELTA D. DRAM FeD f
020 4LJNST 5 - BU9NES5 R RECORD CR RADIUS
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RAD. RAp1AL RW
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BR*C'/1L'E 0.?..52. :0IANEN7 REFERENCE YWa.'MENT -r FIRE N19RAXT EOM. WOE OF WATER
P.C.C. 00917 OF CCSIPIMINO CURVATURE V WL MAN HOLE L. EJ�..P. EOEE OF PAVEMENT
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OWL OVERHEAD LMS C.V.C. COI VALLEY 021 1ON
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COKOQR SLAB
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GENERAL NOTES:
go,
T4
�-Ftorlda Land
t1) LEGAL DESCRIPTION PROVIDED BYOTHERS.
2) 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 OP.
p9p9p9 OTHER RECORDED ENCUMBERANCES NOT SHOWN ON THE PLAT.
4) THE PURPOSE OF 751IS SURVEY IS FOR USE IN OBTAINING TITLE INSURANCE
AND FINANCING AND SHOULD NOTRE USED FOR CONSTRUCTION, PERMITTING
DESIGAL OR ANYOTHER PURPOSE WITHOUT THE WRIT 12N CONSENT OF
ONLINE LAND SURVEYORS INC.
.5) UNDERGROUND PORTIONS OF FOOTING* FOUNDATIONS OR OTHER
IMPROVEMENTS WERE NOT LOCATED.
6) ONLY VISIBLE AND ABOVE GROUND ENCROACHMENTS LOCATL:D.
7) FENCE OWNERSHIP NOTDE7ERMINED.
8) WALL TIES ARE TO THE FACE OF THE WALL
9) BEARINGS ARE BASE ON AN ASSUMED MERIDIAN.
10) BOUNDARY SURVE �MEAMS A DRAWING ANDiDR GRAPHIC REPRESENTATION
OF THE SURVEY WORX PERFORMED IN THE F4P..D, COULD BE DP.AWN ATA
SHOWN SCALE ANDIOR NOT TO SCALE
11) NO IDENTIFICATION FOUND ON PROPERTY CORNERS UNLESS NOTED.
12) NOT VALID UNLESS SEALED: W)TH THE SIGNING SURVEYORS EMBOSSED OR
ELECTONIC SEAL.
13) DIMENSIONS SHOWN ARE PLAT AND MEASURED UNLESS OTHERWISE SHOWN.
14) ELEVATIONS IF SHOWN ARE EASED UPON NG.V.D. 1929 UNLESS OTHERWISE
NOTED.
15) THIS ISA BOUNDARY SURVEY UNt=SS OTHERWISE NOTED.
16) THIS SOUNDARY SURVEY HAS SEEN PREPARED FOR THE EXCLUSIVE USE OF
3 THE ENTITIES NAMED HEREON, THE CER77FICAT7ONS DO NOT EXTEND TO ANY
UNNAMED PARTIES
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URVEY CODE:
0-28105 i 04 i
6 t 15271 NW 60 AVE, Suite 206 i
�/ U _ V. _ a y� Miami Lakes, FL 33014 ;
r' �, JJ . a a lit �W1a B ® Phone: (305) 910 0123 i
- _ SUR:5E `ORG,INC. Fax (305) 675 0899
ws�A i.OntineLandSurveyora.Com
Survey Date:8/16/2016
Survey Code:O-28105
Page 2 of 2 Not valid without all pages.
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