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PT-15-3000Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 3313 8 DEC 0 1Z015 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949=_ FBC 2014 PAINT Master Permit No.P TI S 300C) PERMIT APPLICATION Sub Permit No. JOB ADDRESS: 1 032-) Z 'AV City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: �.1 / Is the Building Historically Designated: Yes NO �1 OWNER: Name (Fee Simple Titleholder): ' 1 -S v Phone#: � -752r �f � O T Address: City: State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Address: City: Qualifier Name: C. LeabiI2 Phone#: State: p ��[\ Zip: State Certification or Registration #: Phone#: Certificate of Competency #: Value of Work for this Permit: $ c& Square/Linear Footage of Work: Description of Work: PA (\CT 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 ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC "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 an inspection fee will be charged. Permit Fee $ CCF Fee $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ TOTAL FEE NOW DUE $ PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate t DIRECTIONS: Please circle corresponding number to appropriat Walls: ,( 1 Fascia: 1 Drip edge: 1 Soffit: 1 Flower Bins: 1 Shutters: 1 Awnings: 1 Chimney: 1 Doors & Jambs: 1 Garage Doors: 1 Railings: 1 Fences: 1 All Brick: 1 Stucco Bands: 1 Ot 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 �Yvvv 1 2 ®3 4 •Aecessory-BMgi© 2 3 4. Attal 4 number Sw (tSs -TTi a3 — 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 regulati nstruction and zoning. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this Ise day of -rook Pivitx\ Signature CONTRACTOR The foregoing instrument was acknowledged before me this by day of , 20 , by , who •ersonally know to _ , 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: Sign: Print: Seal: Zaiho Marbae), EF ee APPROVED BY: �Nl 41! BARBARA A. ESTEP MY COMMISSION # FF 073975 EXPIRES: March 29, 2018 ®Ond�d rim Notary public Underwriters NOTARY PUBLIC: Sign: Print: Seal: Code Official Historic Preservation Board ,1341,f -, • PAINT PERMIT APPLICATION JOB ADDRESS: CDS:. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 762-4949 1 0 RFr - IVFD NOV 262015 F BC 20 I LI Master Permit No. r*p1 i - 8- 1 j Sub Permit No. City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes f �J r�NO OWNER: Name (FeenSimple Titleholder):�j�lp.r QIYC k l -� _ -,Phone#: `2 1 - 6f) i� 9 Address: Cool ( G () (l City: S State: (-- Zip: P'1 r. Tenant/Lessee Name: Phone#: CONTRAGTOR: Company Name: 1 "Nr,^ \ �Q. Phone#: -CD fox bN J Email: Address: Qualifier Name: State Certification or RegistrAion #: _ .,.. Value•of Work for this•Permitr$ l l titik‘44‘ Square/Linear Footage of Work: , , [—Description`of Work: � � !- p')C `SCA t k kQ_ \N6-4-,), 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 ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC State: Zip's" J L Pht ne#:S--33( 137)-) cate of Competency #: 1 1. as DOW - "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 an inspection fee will be charged. Permit Fee $ CCF Fee $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ TOTAL FEE NOW DUE $ 6DE3 1 PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be painted DIRECTIONS: Please circle corresponding number to appropriate color sample. Walls: 1 Fascia: 1 Drip edge: 1 Soffit: 1 Flower Bins: 1 Shutters: 1 Awnings: 1 Chimney: 1 Doors & Jambs: 1 Garage Doors: 1 Railings: 1 Fences: 1 All Brick: 1 Stucco Bands: 1 Other Stucco Feature: Accessory Bldg: 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 3 4 �2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 1 2 3 4 1 2 3 4 OWNER'S AFFIDAVIT: I certify that all the applicable laws regula ' g constructs n and j// Signature 6 OWNER or AGENT Attach color sample with name and number foregoing information is accurate and The foregoing instrument was acknowledged before me this U1 day of NO .m c. .2 , 20 , by CP v T r r .;T) tJ ; w�fio is personally known to me or who has produced NEW `-r'C) K- mak`— as identification and who did take an oath. NOTARY PUBLIC,' Sign: Print: -t NJt A. ALA/ Seal: APPROVED BY: Ow 000e Notary Notary Public State of Florida Sindia Alvare.z dos 10 Ay Commission FF 1503750 0 o Expires 0910302018 Signature The foregoing instrument was acknowledged before me this /9 day of No vac/au , 20 l5 , by Jesus V e2ez- that all work will be done in compliance with all CONTRACTOR , who is peronl) kn wn to me or who has produced A.)7/1— identification .l fyidentification and who did take an oath. NOTARY PUBL C: Si Prin Seal: as J' i!80,7o DOS` ELAINE DO R. RUBIANOGR007 �s_ Notary Public - State of Florida •_ My Comm. Expires Jun 21, 2017 ?o� Commission * FF YY0P Bonded Through National Notary Assn. de Official i o c e ation Board CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 11 BS00457 JP PAINTING N MORE CO D.B.A._ EREZ JESUS ANTONIO Is certified under the provisions of Chapter 10 of Miami -Dade Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL -DO NOT PAY 7194445 BUSINESS NAME/LOCATION JP PAINTING N MORE CO 18840 NW 57 AVE #206 MIAMI, FL 33015 OWNER JP PAINTING N MORE CO Worker(s) 1 RECEIPT NO. NEW BUSINESS 7476539 LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SPECIALTY BUILDING CONTRACTOR 11BS00457 PAYMENT RECEIVED BY TAX COLLECTOR 75.00 11/24/2015 0200-16-000057 This Loral Business Tex Receipt oily confirms parmeet of the Local Business Tax. The Ibceipt is nota license. permit or certification of the holder's quali Icatioxs, to do business. Holder mast comply will. any governmeebl or songoverememal regulatory laws and reguiremenb wbicb apply to the business. The RECEIPT NO. above must be displayed on ell commercial vehicles - Miami -Dade Code Sec $a-276. For more ialonnatiea, visit ACORL) CERTIFICATE OF LIABILITY IN URANCE DATE (MMIDOITYYY) 11/23/2015 PRODUCER f"' 305-418-8413 P"Aus 305-418-8411 Westward Insurance Services, Inc 2500 NW 79th Avenue Suite 203 Doral, FL 33122 SUED Fais/ JP Painting N More Co 18840 NW 57 Ave # 206 Hialeah, FL 33015 Phoned THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, INSURERS AFFORDING COVERAGE NSURER A Granada Insurance Company I INSURER B Progressive American Insurance Co INSURER C; NsuRER E i rINSURER D; COVERAGES iNSR:liD01.7 JJR THE POLICIES OF INSuRANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD iNDICATED NOTWITHSTANDING ANY REOUiREMENT, 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, AGGREGATE LIAM'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' I POLICY EFFECTIVE fRoLICY ExRIRAT1ON INSRD TYPE IN5URACE I POUCY NUMBER I DATE (HIII)0rYYYY1 DATE (NM/OD/WW € LIMTS A , GE AL IJA DUTY € 1 i - 1 COMMERCIAL GENERAL LIABILITY 1 / I CLAIMS MADE 1 OCCUR I B10 240 1 10 12015 , 10/06/2016 I , ,• ' I EACH OCCuRREMCE 51 ,000, 000 . -rixi(A-65T"Evrtu- ' 100,000 (Ea OCCutspead 5 ,,...ERE5A/SES I MED EXP (Antnrat ;teflon! ; S 5,000 I PERSONAL & ADV INAJRY $ 1 ,000, 000 . * . I GENII AGGREGATE UM( T APPL(ES P, ERI — , . , ROUCYL OC I JECT • 1 GENERAL AGGREGATE I S 2,000,000 I PROouCTS - COMP/OP AGG 1 S 2,000,000 ; ! ; AUTOMOBILE UABILITY 1 ANY AUTO 1 € ALL OWNED AUTOS ; • 8048889-4 ! 08/24/2015 I 1 * SCHEDUI.E0 AUTOS / / nIRED AUTOS 4500ILY I , I , I NON”OWNEO AUT S ' ; ,• / I 02/24/2016 t I, I , , • • 1 COMBaJED $iNGLE LIMIT ; s 50,000 (Ea amdenD I 80C4LY INJURY / 5 (Per (roam) f 1 (NARY I 1 „ (Per acaciec) (.- I PROPERTY DAMAGE 1 (Per acradono >5 ; I GARAGE LIABILITY 1! ,.._.. . ANY AUTO „ AUTO ONLY - EA ACCIDENT I 3 :t.. - , E OTHER THAN EAACC $ AUTO ONLY AGG ! 5 I EXCESS .1 UMBRELLA LIABILITY OCCUR CLAIMS MADE ' , / DEDUCTIBLE I- 1 / ; RETENTtON5 I ( 1 EACH OcCuRRENCE i I AGGREGATE .3 5 , 1 5 , WORKERS COMPENSATION , AND EMPLOYERS" UABILITY - Y N 11 A N y PROPRIETOXOPARTNERIEAECuT/ OEFICER,VEMEIER EXCLUDED'? WC STATU € :Orr(/' i I E L. EACH ACCIDENT I$ t (Mandatory in NH) 1 d xis dratumv undo( 1 5rEDIAL PROVISIONS € , EL. DISEASE - EA EMPLOYEE $ EL : EASE / POLICYPOtJCY UMT 1 5 '0ThEl I I E TION OF OPERA 0 S i LGT10JS (VEHICLES EXCLUSIONStADOED BY ENDORSEMENT SPECIAL PRO Certificate Holder listed as Additional Insured: license # 11BS00457 .. _. 0 Fax one CANCELLATION Miami Shores Village 10050 NE 2nd Ave tvliarni Shores, FL 33138 Gemaya ail.com ACORD 25 (2009/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 0050 SHALL IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON THE IN 115 AGENTS OR REPRESENTATIVES/ AUTHORIZED REPRESENTATIVE Maylin Perez @1988-2009 ACORD CORPRAT #N1,hts reserved. The ACORD name and logo are registered marks of ACORD 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 * * NON -CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 9/14/2015 EXPIRATION DATE: 9/13/2017 PERSON: PEREZ JESUS A FEIN: 452991223 BUSINESS NAME AND ADDRESS: JP PAINTING N MORE CO 18840 NW 57TH AVE APT 206 MIAMI FL 33015 SCOPES OF BUSINESS OR TRADE: PAINT MFG. PAINTING: SHIP HULLS I?ursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by fiing 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 fisted on the notice of election to be exempt Pursuant lo 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 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, 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 09 day of NOV N CL , 20 1 S . By- k ' %�� ( (� Notary: SEAL: who is personally known to me or has produced as identification. Notary Public State of Florida Slndla Alvarez My Cumthhsio , rr 15G750 Expires 09103/2018 JP Painting N More Co PO Box 680411 Miami FL, 33168 11/19/15 State of Florida County of Dade Before me this day personally appeared Jesus Antonio Perez from JP Painting N More Co who being duly sworn, deposes and says That he will be the only person working on the project located at 69 NE 98 st Miami Shores 33138 Sworn to and subscribed before me this 19 day of November. 2015 by Perso Or Produced Identification Type of identification Produced i / I ,OSpRYPVA, ,- ELAINE DO R. RUBIANOGROOT � Notary Public - State of Florida • ° My Comm. Expires Jun 21, 2017 °;' Commission # FF 2202 �o,„oa: Bonded Through National Notary Assn.