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RC-16-2605
"t'�\i7r'Of w+t :•'t )ti ratPlirr Certificate of Completion Miami Shores Village 10050 NE 2 Ave, Miami Shores FL, 33138 Tel: 305-795-2204 Fax: 305-756-8972 Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: Date Issued Occupancy Load Occupancy Type • INSPECTION 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 -9-16-2605 Permit Type: Residential Construction Work Classification: Addition/Alteration Issue Date: 1/26/2017 Expires: 07/25/2017 7 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 #:1132060130600 Owner's Name: Job Address: 90 NE 96 Street Miami Shores. FL 33138 - Bond Number: BE ON Contractor(s) Phone TOTAL QUALITY RESTORATION IN' (305)669-0353 primary -Contractor Yes Owner's Phone: (305)902-4660 -) Total Square Feet: 3000 Total Job Valuation: $ 45,000.00 K 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. ized e‹,,t, .6 Ai fr . A j..4.0, ILO CA.641..15 (ik), cfri, 47, A/9,p_, oit/ INSPECTION RECORD INSPECTION Foundation STRUCTURAL DATE INSP Stemwall Slab Columns (1st Lift) Columns (2nd Lift) Tie Beam Truss/Rafters Roof Sheathing Bucks Windows/Doors Interior Framing Insulation Ceiling Grid Drywall Firewall 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 Zoning Final ZONING COMMENTS /7 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 Telepho "' oug Telephone Final TV Rough TV Final Cable Rough Cable Final tintercorn Rough DOCUMEN Soil Bearing Cert Soil Treatment Cert Floor Elevation Survey Reinf Unit Mas Cert Insulation Certificate Spot Survey Final Survey Truss Certification Intercom Final Alarm Rough Alarm Final Fire Alarm Rough Fire Alarm Final Of Service Work With FINAL ELECTRICAL COMMENTS STRUCTURAL COMMENTS INSPECTION FIRE DATE INSP Final Sprinkler Final Alarm FINAL PLUMBING INSPECTION DATE INSP Rough (y>-k,d &h Water Service 2nd Rough la/C" '� R Top Out 11"24P ri 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 t, - ._ 0 PLUMBING COM ENTS -+x e �,r---1, ' LM0+re.S,PL7 p CI 2124 L I� / 7 3' 3O I �1` I �tl6�s )-Y- 17 1 ' U- f iru- D l 1,91317 ,5-4 III -AV DATE , fINSPECTION INSP. Underground Pipe i' �' Rough 5 ems- ; I t r Ventilation Rough Hood Rough Pressure Test Final Hood Final Ventilation Final Pool Heater Final Vacuum ' Ilt t5 FINAL MECHANICAL COMM NTS Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. RC -9-16-2605 Permit Type: Residential Construction Work Classification: Addition/Alteration Pennit Status: APPROVED Issue Date: 1/26/2017 Expiration: 07/25/2017 Parcel Number Applicant 90 NE 96 Street Miami Shores, FL 33138- 1132060130600 Block: Lot: VERO HOMES LLC Owner Information Address Phone Cell VERO HOMES LLC 701 BRIECKELL AVE MIAMI FL 33131- (305)902-4660 701 BRIECKELL AVE MIAMI FL 33131- Contractor(s) Phone Cell Phone TOTAL QUALITY RESTORATION INC (305)669-0353 Valuation: Total Sq Feet: $ 45,000.00 3000 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: REMODEL Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: Bond Return : KITCHEN , ADD ONE BA Occupancy: Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: REMODEL Classification: Residential KITCHEN , ADD ONE BA Fees Due CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Preliminary Plan Review Preliminary Plan Review Scanning Fee Technology Fee Total: Amount $27.00 $50.00 $20.25 $20.25 $9.00 $1,350.00 $200.00 $200.00 $15.00 $36.00 $1,927.50 construction an i Fu he ore, Authorized Signature: Owner / Building Department Pay Date Invoice # 10/07/2016 01/26/2017 09/21/2016 Pay Type RC -9-16-61419 Credit Card Check #: 2221 Credit Card Amt Paid Amt Due $ 200.00 $ 1,727.50 $ 1,527.50 $ 200.00 $ 200.00 $ 0.00 bove-named contractor to do the work stated. pplicant / Contractor / Agent opy Available Inspections: , Inspection Type: Final PE Certification Drywall Miscellaneous Window Door Attachment Tie Beam Final Framing Insulation Truss Insp Columns Foundation Window and Door Buck Fill Cells Columns Wire Lathe Review Electrical Review Electrical Review Electrical Review Building Review Building Review Building Review Plumbing Review Plumbing Review Plumbing F. Termite Letter F. Elevation Certificate Review Planning Review Mechanical Review Mechanical Review Mechanical Declaration of Use Review Structural January 26, 2017 Date January 26, 2017 2 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. RC -9-16-2605 Permit Type: Residential Construction Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 1/2612017 Expiration: 07/25/2017 Parcel Number Applicant 90 NE 96 Street Miami Shores, FL 33138- 1132060130600 Block: Lot: VERO HOMES LLC Owner Information Address Phone Cell VERO HOMES LLC 701 BRIECKELL AVE MIAMI FL 33131- (305)902-4660 701 BRIECKELL AVE MIAMI FL 33131- Contractor(s) Phone CeII Phone TOTAL QUALITY RESTORATION INC (305)669-0353 Valuation: Total Sq Feet: $ 45,000.00 3000 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: REMODEL KITCHEN , ADD ONE BA Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: Bond Return : Occupancy: Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: REMODEL KITCHEN , ADD ONE BA Classification: Residential Fees Due CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Preliminary Plan Review Preliminary Plan Review Scanning Fee Technology Fee Total: Amount $27.00 $50.00 $20.25 $20.25 $9.00 $1,350.00 $200.00 $200.00 $15.00 $36.00 $1,927.50 Pay Date Pay Type Invoice # RC -9-16-61419 10/07/2016 Credit Card 01/26/2017 Check #: 2221 09/21/2016 Credit Card Amt Paid Amt Due $ 200.00 $ 1,727.50 $ 1,527.50 $ 200.00 $ 200.00 $ 0.00 Available Inspections: Inspection Type: Final PE Certification Drywall Miscellaneous Window Door Attachment Tie Beam Final Framing Insulation Truss lnsp Columns Foundation Window and Door Buck Fill Cells Columns Wire Lathe Review Electrical Review Electrical Review Electrical Review Building Review Building Review Building Review Plumbing Review Plumbing Review Plumbing F. Termite Letter F. Elevation Certificate Review Planning Review Mechanical Review Mechanical Review Mechanical Declaration of Use Review Structural 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 January 26, 2017 1 a Miami Shores Village 12,o\\�r Building Department C ` 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 � Tel: (305) 795-2204 Fe3c (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION R�n -- DEC 0 YI 2016 FBC 20N Master Permit No.e2N C L - Sub Permit No. pE BUILDING ❑ ELECTRIC ❑ ROOFING E] REVISION ❑ EXTENSION DRENEWAL PLUMBING E] MECHANICAL []PUBLIC WORKS ❑ CHANGE OF EJ CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Foilo/Parcel#: 09 Ai C sr Miami Shores County: Miami Dade it: 3 3I.? Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Ve 20 1 -4 -OM eT5 t -u-` Phone#: Address: 70) Bnck•e.t AV(. $c -,«a (SSc� City: i a•-' ' State: % - Zip: 3 3 1 3 / Tenant/Lessee Name: 01 p. Phone#: S 8- 7 Z z- f 3 k -s Email: 1.1 -e -d--+-02 54 lc C12 1%.-D 1-4004-(C$ I( C - � #''( CONTRACTOR: Company Name: -roT#Iv L Qva1-ir1 ..S`c'rAil011 Phone#: 301 C., 6F—&?S3' Address: 1 Zz' $ Sc_' 1'7_$ S`t St.,:i14 Ztk City: 1 c ..- 1 State: r=4- zip: 33t trio Qualifier Name: _.'4 u m.7)c COt vC2-• Phone#: 3as-- t 3 71 3 Y - State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: _2.- _ 1 rz L -G 4o 17. 4 . ASSec t/ 5 Phone#: Address: 10 ' S 0 N "1--) 13 2-r- yCity: ata k h g f) id State--- Zip: 73 0 /k Value of Work for this Permit: $ At v W -- Square/Linear Footage of Work: 3 o0O Type of Work: ❑ Addition ❑ Alteration oo ❑ New ❑ Repair/Replace ❑ Demolition/� Description of Work: V e ti &i R 4WV`f oo� s � i N•�t Be foo H) Li tk i fez 'pi o AtI i ji‘ S 6•- t eL4 0 it . ) C PG is -e 4t.os2. L'iv c( QooM , t)7)54cLe ul:Nbo s_ rt ✓a4 ()li.S.S? . Specify color of color thru tile: .l. iii --r 4 s -e-1 • ,/� Submittal Fee $ 50 PArt D Permit Fee $ 1 S .O ccF $ 2.1 - c0/CC $ 5l J Scanning Fee $ Radon Fee $ to , ZS DBPR $ ZC). ZS Notary $ Technology Fee $ (.0 Training/Education Fee $ Cls Double Fee $ Structural Reviews $ W 0 Z00 Bond $ TOTAL FEE NOW DUE $ 12-4 SO (Revlsed02/24/2014) , Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage tender'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 OWNER or AGENT The foregoing Instru nt was acknowledged before me this day of , who 0 personally known to j\.,' /t- . 20 _11"2_,_, by me or who has produced Identification and who did take an oath. NOTARY PUBLIC: Sign: Vnu4.Prrk Seal: Veronica Ptneda NOTARY PUBLIC STATE OF FLORIDA Signature ge-4<0.-t-.1-0 CONTRACTOR The foregoing instrument was acknowledged before me this day of C , 20 , Mo , by is personally known to I gi 1441 A�e2 t � as me or who has produced identification and who did take an oath. ****•*••s NOTARY PUBLIC Sign:_i Print: a fir \-e S C� Seal: *t **••*******••s• APPROVED BY ,.w f Roulwrfl9 /7d/7n1 a1 Plans Examiner Structural Review .17w%* Gari Wtary Arc. Site of Fluids C.(A11fni7Con No. FP 238 Zoning Clerk Prepared by Global Title Alliance, LLC and return to: ATTN: Bruna Corso 700 NE 90th Street Miami, FL33138 Phone: 786-762-2716 Property Appraisers Parcel Identification (Folio) Number(s): 11-3206-013-0600 WARRANTY DEED This Indenture, made this 15th day of September, 2016, between Ari Lynn Turner, joined by her spouse, Marc Thomas Henderson,whose post office address is 90 NE 96th St., Miami, FL 33138, hereinafter called the Grantor of the first part, and Vero Homes, LLC, a Nevada limited liability company, whose post office address is 701 Brickell Ave.,Suite 1550, Miami, FL 33131, hereinafter called the Grantee of the second part, (Wherever used herein the terms "Grantor" and "Grantee" shall include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations.) Witnesseth, that said Grantor, for and in consideration of the sum of Ten Dollars ($10.00) and other good and valuable considerations to said Grantor in hand paid by said Grantee, the receipt whereof is hereby acknowledged, has granted, bargained and sold to the said Grantee, and Grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida, to wit: Lot 1 And 2 Block 5, AN AMENDED PLAT OF MIAMI SHORES SECTION NO. 1, According To The Plat Thereof Recorded In Plat Book 10, Page 70 Public Records Miami Dade County, Florida. Parcel Identification Number. 11-3206-013-0600 Subject to all reservations, covenants, conditions, restrictions and easements of record and to all applicable zoning ordinances and/or restrictions imposed by governmental authorities, if any. Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever And the said Grantor, does hereby fully warrant the title to said land, and will defend the same against the Iawftd claims of all persons whomsoever; and that the land is free of all encumbrances, except taxes accruing subsequent to December 31, 2015 and restrictions, covenants, and easements of record. In Witness Whereof, Grantor has caused these presents to be duly executed the day and year first above written. Signed, sealed and delivered in our presence: ,v,6 Print Witness Name: Witness clu Print Wi /5'1/q) z>li C f$z jz • Print Witness Names witnessr34JJ__9 //`` iO Print Witness Name: State/Commonwealth of 4------Q-101,00. O.— Marc Thomas Henderson State/Commonwealth of i ,earlA Q ra._ County of -e The foregoing instrument was acknowledged before me this 15th day of September, 2016 by Ari Lynn Turner and Marc Thomas, Hende on, husband and wife, who are personally known to me or have produced d44.VIA ,f 'C2 'z' f as identification, and who did (did not) take an oath. In witness whereof, hereunto set my hand and official seaL BRU ACORSO MY COMMISSION #010007111 81142020 Bonded mcelgh 1st Statelnsuranq Notaty Public My commission expires: (y 9 - 2i� A. Settlement Statement U.S. Department of Housing and Urban Development OMB No. 2502-0265 B. Type of Loan 1. ❑ FHA 2. 0 FmHA 3. 0 Conv Units 8. Mortgage Ins Case Number 6. File Number 658-000681 7. Loan Number 4. 0 VA 5. ❑ Conv Ins. 6. 0 Seller Finance C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlemen agent are shown. Items marked "(p.o.e.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower Vero Homes, LLC, a Nevada limited liability company 701 Brickell Ave.,Saite 1550 Mind, FL 33131 G. Property Location 90 NE 96th St. , Miami , FL, 33138 90 NE 96th St. Miami ,FL 33138 E. Name & Address of Seller Ari Lynn Turner 90 NE 96th St. Miami , FL 33138 F. Name & Address of Lender Grand Coast Capital Fund 1, LLC 350 Lincoln Str, Suite 2503 Hingham, MA 02043 H. Settlement Agent Name Global Tide Alliance, LLC 700 NE 90th Street Miami, FL 33138 Tax 1D: 47-3713076 Underwritten By: Flrst American Tide- National Accounts Place of Settlement Global Title Alliance, LLC 700 NE 90th Street Miami, FL 33138 1 Settlement Date 9/15/2016 Fund: J. Summary of Borrower's Transaction 100. Gross Amount Due from Borrower K. Summary of Seller's Transaction 101. Contract Sales Price 5582,000.00 v .......• 401. Contract Sales Price 102. Personal Property5582,000.00 402. Personal Property 103. Settlement Charges to borrower 522,060.28 403. 104. Construction Holdback 5194,000.00 404. - 105. 405. Adjustments for items paid by seller In advance Adjustments for items paid by seller in advance 106. City property taxes 406. City property taxes 107. County property taxes 407. County property taxes 108. Assessment Taxes 09/16/16 thru 09/30/16 5122.37 408. Assessment Taxes 09/16/16 then 09/30/16 512237 109. School property taxes 409. School property taxes 110. HOA Dues 410. HOA Dues 111. Other taxes 411. Other taxes 112. 412. 113. 413. 114. 414. 115: 415. 116. 416. -Millig.11.1,181RIFT1811M111111.5582 122.37 120. Gross Amount Due From Borrower 200. Amounts Paid By Or in Behalf Of Borrower 500. Reductions in Amount Due to Seller 201. Deposit or earnest money 530,000.00 501. Excess Deposit 202. Principal amount of new loan(s) $621000.00 ' 502. Settlement SttlChines to Seller (line 1400) 538,453.20 203. Existing loan(s) taken subject to 503. Existing Loan(s) Taken Subject to 204. Loan Amount 2nd Lam 504. Payoff of first mortgage to loan 205. 505. Payoff of second mortgage loan to 206. - 506. Chase 5228,103.97 207. 507. 208. 508. 209. 509. Adjustments for items lama by seller Adjustments for items unpaid by seller 210. City property taxes 510. City property taxes 211. County property taxes 01/01/16 then 09/15/16 $4,12435 511. County property taxes 01/01/16 thin 09/15/16 54,124.35 212. Assessment Taxes 512. Assessment Taxes 213. School property taxes 513. School property taxes 214. HOA Dues 514. HOA Dues 215. Other taxes 515. Other taxes 216. 516. 217. 517. 218. 518. 219. 519. 220. Total Paid B /For Borrower 5655 124.35 520. Total Reduction Amount Due Seller 5270 681.52 300. Cash At Settlement From/To Borrower 600. Cash At Settlement To/From Seller 301. Gross Amount due from borrower (line 120) 5798,182.65 601. Gross Amount due to seller (line 420) 9582,122.37 302. Less amounts paid by/for borrower (line 220) 5655,124.35 602. Less reductions in amt. due seller (line 520) 5270,68132 303. Cash From Borrower Section 5 f rbc Real Fs 5143,058.30 603. Cash To Seller 5311,440.85 o tate Settlement Procedures Act RFSPA) requires the following: • HUD mast develop a Special Information Booklet to help persons borrowing money to finance the purchase of residential real estate to better understand the nature and costs of real estate settlement services; • Each lender must provide the booklet to all applicants from when it receives or for whom it prepares a s.sitten application to borrow money to finance the purchase of residential real estate; • Lenders must prepare and distribute with the Booklet a Good Faith Estimate of the aettkmeat costs that the borrower is likely to incur in connection with the settlement. These disclosures aro mandatory. Previous Editions are Obsolete Page 1 Section 4(a) of RFSPA mandates that HUD develop and prescribe this standard form to be used at the time of loan settlement to provide full disclosure of all charges imposed upon the borrower and seller. These are third party disclosures that are designed to prom the borrower with pertinent information during the settlement process in order to be a better shopper. The Public Reporting Borden for this collection of information is estimated to average one how per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required lo complete this form, unless it displays a currently valid OMB control number. The information requested does not lend itself to confidentiality. fonn HUD -1 (3/86) Handbook 4305.2 File No. 658-000681 L. Settlement Charges rue. a out satewaroner's conn ssion based on price 5582,000.00 @2 % = S11,640.00 Paid From Paid From Sellers Funds at Settlement Division of Commission (line 700) as follows: Borrower's 701. 511,640.00 to Keller Williams Eagle Realty Funds at 702. to Settlement 703. Commission Paid at Settlanent 50.00 511,640.00 800. Items Payable in Connection with Loan 801. Loan Origination Fee % to 802. Loan Discount % to 803. Appraisal Fee to 804. Credit Report to 805. Loin Commitment Fee to Grand Coast Capital Fund 1, LLC 515,525.00 806. Mortgage Insurance Application to 807. Assumption Fee to 900. Items Repaired by Lender To Be Paid In Advance 901. Interest from to @ 50 /day 902. Mortgage Insurance Premium for months to 903. Hazard Insurance Premium for years to 1000. Reserves Deposited With Lender 1001. Hazard insurance months @ per month 50.00 1002. Homeowner's insurance months @ per month 50.00 1003. City property taxes months @ per month 50.00 1004. County property taxes months C per month 50.00 1005. Assessment Taxes months @ per month 50.00 1006. School property taxes months @ per month 50.00 1007. HOA Dues months f6? per month 50.00 (008. Othertaxes months @ per month 50.00 1011. Aggregate Adjustment 1100. Tide Charges 1101. Settlement or closing fee to Global Title Alliance, LLC 5850.00 5495.00 1102. Abstract or title search to Global Title Alliance, LLC 5200.00 1103. Title examination to Global Title Alliance, LLC 1104. Title insurance binder to Global Title Alliance, LLC 1105. Calvary Judgement Payoff 10 Andreo, Palma Lavin &Solis PLLC Trust Acct. 519,139.20 1106. Wire Fees to Global Title Alliance, LLC 520.00 540.00 1107. Digital Docs to Global Title Alliance, LLC 520.00 (includes above items numhas: .__._ ..R,.,,.y�,,,_� 1108. Title insurance to Global Title Alliance, LLC Y' 75',�ii.y+t 53,075.00 (includes above items numbers: ) q.W.". . 4 7w' .r, 1109. Lenders coverage 5621,000.00/5565.50 . 4 .,. 1110. Owners coverage $582,000.00/$2,985.00 E ;_ [Ir°.'_.. arra✓;_`T 1111. Statutory Surcharge to First American Title Insurance 53.28 1112. Type of Insurance Rate to Global Title Alliance, LLC 1113. FL Form 9 to Global Title Alliance, LLC 5320.50 1114. FL 8.1 Environ Pmt to Global Tltie Alliance, LLC 525.00 1200. Government Recording and Transfer Charges 1201. Recording Fees Deed 5111.50 ; Mortgage 5112.00 ; Rel to 5130.50 1202. City/county tax/stamps Deed ; Mortgage $1,242.00 to 51,242.00 1203. State tax/stampsDeed $3,492.00 ; Mortgage $217330 to Stnptillte 'Recording 52,173.50 53,492.00 1204. Tax certificates to 1205. Courier/Messenger Fee to 1300. Additional Settlement Charges 1301. Legal Fees and expenses to Pierce Atwood, LLP 51,275.00 1302. Lien Search Fee to Property Debt Research 5172.00 1303. Final Water Bill Escrow to Global Tide Alliance, LLC 5200.00 1400. Total Settlement Charges (enter on lines 103, Section .1 and 502, Section K) 522,060.28 838,453.20 I have carefully reviewed the HUD -I Settlanent Statement and to the best of my knowledge and belief, it is a true and accurate statement of all recants and Statement e on my account or by me is this transaction. 1 further certify that I have received a completed copy of pages 1, 2 and 3 of this HUD -1 Settlement File No. 658-000681 Vero Homes, LLC a Nevada limited I =tfilifycompany By: Prl pNName: Hector De L e: Manager Y: tint Name: nal, Sr SEITI.MENT AGENT CERTIFICATION The HUD -1 Settlemen Statement which I have prepared is a true end accurate account of this transaction.�I t?htav/e�cauused the funds to be disbursed in ac with this state. / . i Settlement Ant - Bate Warning: It is a crime to knowingly make false statements to the United States on this or any other similar form Penalties upon conviction can include a fine and imprisonment For details see: Title 18 U.S. Code Section 1001 and Section 1010. Previous Editions are Obsolete q JA L,t� Ari Lynn Tura(aP Page 3 form HUD -1 (3/86) Handbook 4305.2 Prepared by Global Title Alliance, LLC and return to: 700 NE 90th Street, Miami, FL 33138 Phone: 786-762-2716 SELLER'S AFFIDAVIT BEFORE ME, the undersigned authority, personally appeared Ari Lynn Turner, a married person, who being duly sworn, deposes and says: 1. That they are/he is/she is the sole owner(s) in fee simple and in possession of the following described property, to wit; Lot 1 And 2 Block 5, AN AMENDED PLAT OF MIAMI SHORES SECTION NO. 1, According To The Plat Thereof Recorded In Plat Book 10, Page 70 Public Records Miami Dade County, Florida. also known as 90 NE 96th SL, Miami, FL 33138 and all amendments thereto, together with its undivided share in the common elements. 2. That affiants possession has been peaceful and undisturbed; and that affiant's title therefore has never been disputed, questioned or rejected. 3. That the above described property is free and clear of all liens, taxes, encumbrances and claims of every kind, nature and description whatsoever, except for mortgage or mortgages, if any, described in the deed given between the parties named herein, and except for real estate and personal property taxes for the current year that are a lien against said property but not payable. 4. That there are no mechanic's materialman's or laborer's liens against said property and/or unit and that there are no unpaid bills or claims outstanding for labor or material incident to the constructions, repairs, renovation, or improvement to the building and/or common areas and Improvements located upon said property Including materials furnished or labor performed within the last 90 days thereof. 5. That the personal property contained in the building on said property or on the said premises, and which, if any, is being sold to the purchaser(s) mentioned below, is also free and clear of all liens, encumbrances, claims and demands whatsoever and seller has not recorded and bas no knowledge of any documents recorded after the effective date of December 19, 2014 that would adversely affect title. 6. That affiant(s) know of no violation of Municipal Ordinances pertaining to the above described property. 7. That no judgment or decree has been entered in any court of this state or the United States against said affiant(s), and which remains unsatisfied; that no proceeding in bankruptcy has ever been instituted by or against deponent(s) in any court, or before any officer of any State. 8. That he/she/they are not aware of any unrecorded easements or claims of easements affecting the property. 9. That this Affidavit is made for the purpose of inducing Vero Homes, LLC, a Nevada limited liability company and to purchase said property from affiant(s) and Global Title Alliance, LLC and First American Title Insurance Company to issue Its owners policy and/or mortgagee title insurance policies on this transaction. 10. Affiant(s) further state that they are each familiar with the nature of an oath; and with the penalties as provided by the law of the State aforesaid for falsely swearing to statements in an instrument of this nature. Affiant(s) further certify that they have read or have heard read to them, the full facts of this Affidavit, and understands its contents. Global Title Alliance, LLC 786-762-2716 taFLSellerA,(fldavit File No. 658-000681 Page 1 of 2 STATE OF - {h7-t,ti c'U COUNTY OF /"' moi. Ct�(.2A - - oL„ Sworn to (or affirmed) and subscribed before me this day of 20 , by TARY SEAL Signature of Notaryiublic-State of Florida J Name of Notary Typed, Printed, or Stamped Personally Known _ OR Produced Identification Type of Identification Produced Global Title Alliance, LLC 786-762-2716 taFLSellerAfidavit File No. 658-000681 Page 2of 2 TAX PRORATION AGREEMENT Property: 90 NE 96th St., Miami, FL 33138 The undersigned sellers and purchasers of the above described property hereby acknowledge that the tax prorations on the closing statement were based on last years tax amount provided to us by the most recent search report as of this closing date, and that the taxes present on the property are payable (prorata) by the buyer (s) and the seller(s). Should there be a difference between last years tax amount and this years tax amount, or a misstatement or error by the county or miscalculation of this tax by any party, it is between the purchaser(s)and the sellers to re -prorate this amount between them and in NO event is Global Title Alliance, LLC responsible for the payment of this tax. SELLER(S): BUYER(S): Vero Homes, LLC a Nevada limited liabil By: Print Name: Title: M By: P. for De . Canal Name: Hector De r Global Title Alliance, LLC 786-762-2716 taFLTaxProration File No. 658-000681 Page 1 of 1 Florida Insurance Premium Disclosure & Settlement Agent Certification Federal law requires the costs of the policies to be calculated using the full premium for the lender's policy. Florida law recognizes the owner's policy as being primary because it protects the interests of Florida consumers. Florida law allows the premium for the lender's policy to be calculated using a lower rate when purchased along with an owner's policy. If both an owner's policy and a lender's policy are being purchased, the title insurance premiums on this form might be different than the premiums on the Closing Disclosure. The owner's polity premium listed on the Closing Disclosure will probably be lower than on this form, and the lender's policy premium will probably be higher. The chart below lists the amounts disclosed by the lender and the premium for the policies being purchased: The total for the policies as disclosed on the form should be equal to the total premium calculated using the Florida Insurance Code. The Florida Premium amounts listed above will be used to disburse the funds being held In escrow to (Insurer) and its agents. The undersigned hereby certifies that they have carefully reviewed the Closing Disclosure or other settlement statement form and they approve and agree to the payment of all fees, costs, expenses and disbursement as reflected on the Closing Disclosure or other settlement statement form to be paid on their behalf. We further certify that we have received a copy of the Closing Disclosure or other settlement statement. 01/4Ait Vero Ho =« LLC a Neva . li ited liability company Ari Lynn Tull) r AntName: H Title: Manager ey: Date nt Nal e: H Slgn Seller Printed Name Date Signed Seller Printed Name La Canal De La Canal. Sr Buyer/Borrower.PriMed Name Buyer/Borrower Printed Name Date Signed Date Signed Settlement Agent Certification I have reviewed the Closing Disclosure form or other settlement statement prepared for this transaction and I agree to disburse the escrow funds in accordance with the Closing Disclosure or other settlement statement, as modified above. Settlement Agent/Attorney Signature Date Signed FL form 4DFS-H1-2146 (Effective 08/01/2015) 698-186.008, F.A.C. Disclosure Amount Florida Premium Buyer Seiler Buyer Seller Lender's policy i 15.50 17, 075.0`-' Owner's policy ' Total $000 $0 00 The total for the policies as disclosed on the form should be equal to the total premium calculated using the Florida Insurance Code. The Florida Premium amounts listed above will be used to disburse the funds being held In escrow to (Insurer) and its agents. The undersigned hereby certifies that they have carefully reviewed the Closing Disclosure or other settlement statement form and they approve and agree to the payment of all fees, costs, expenses and disbursement as reflected on the Closing Disclosure or other settlement statement form to be paid on their behalf. We further certify that we have received a copy of the Closing Disclosure or other settlement statement. 01/4Ait Vero Ho =« LLC a Neva . li ited liability company Ari Lynn Tull) r AntName: H Title: Manager ey: Date nt Nal e: H Slgn Seller Printed Name Date Signed Seller Printed Name La Canal De La Canal. Sr Buyer/Borrower.PriMed Name Buyer/Borrower Printed Name Date Signed Date Signed Settlement Agent Certification I have reviewed the Closing Disclosure form or other settlement statement prepared for this transaction and I agree to disburse the escrow funds in accordance with the Closing Disclosure or other settlement statement, as modified above. Settlement Agent/Attorney Signature Date Signed FL form 4DFS-H1-2146 (Effective 08/01/2015) 698-186.008, F.A.C. Prepared by Global Title Alliance, LLC and return to: 700 NE 90th Street, Miami, FL 33138 Phone: 786-762-2716 Property Appraisers Parcel Identification (Folio) Number(s): 11-3206-013-0600 BILL OF SALE, ABSOLUTE KNOW ALL MEN BY THESE PRESENTS: That Ari Lynn Turner a married person, whose address is 90 NE 96th Street, Miami, FL 33138, Grantor of the first part, for and in consideration of the sum of Ten Dollars (810.00), lawful money of the United States, to be paid by Vero Homes, LLC, a Nevada limited liability company, whose post office address is 701 Brickell Ave.,Sulte 1550, Miami, FL 33131, Grantee of the second part the receipt whereof is hereby acknowledged, has granted, bargained, sold, transferred and delivered, and by these presents does grant, bargain, sell, transfer and deliver unto the parties of the Grantee, their heirs, successors and assigns, the following good and chattels located at: Lot 1 And 2 Block 5, AN AMENDED PLAT OF MIAMI SHORES SECTION NO. 1, According To The Plat Thereof Recorded In Plat Book 10, Page 70 Public Records Miami Dade County, Florida. To Have and to Hold the same unto the said parties of the second part, their heirs, successors and assigns forever. And they do for themselves and their heirs, successors and assigns, covenant to and with the parties of the second part, their heirs, successors and assigns, that they are the lawful owners of the said goods and chattels; that they are free from all encumbrances; that they have good right to sell the same aforesaid, and that they will warrant and defend the sale of the said property, goods and chattels hereby made, unto the said parties of the second part, their heirs, successors and assigns, against the lawful claims and demands of all persons whomsoever. In Witness whereof, the parties of the first part have hereunto set their hands and seals this 15th day of September, 2016. Signed, sealed and delivered in the presence of us: W itnesss ,p L -!Jr r ,p rat_ of Print Witness Name: State/Commonwealth of reCtin. County of On this 15th day of September, 2016, before me, the undersigned officer, personally appeared Ari Lynn Turner a married person, known to me (or satisfactorily proven) to be the person(s) whose mune(s) is/are subscribed to the within instrument and acknowledged that he/she "they executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. File No. 658-000681 ri/yeu2/1, Notary Public MAP OF BOUNDARY SURVEY NORTH ICAO 1..30 1 - r I §I LOT• KO= / Lm91 B1OCM T r a -r 1 M's10T.151'�9 nAOs.Wr __E_, ._Ilj NE 95th STREET LOTS MOOS] (VHORELAMJ BOULEVAR4)(P) 0.IM'MLI:r1.4MM ;.4e JO I LW 21' 8.9.12'4 ILMISSVISSOIS 1 4.5Tl• 40.1 LEGEND SWINGS Fl =aw12 •02•5anLCa ems ElswalieSSANTONSESSYCISIS RasnitOq M maama▪ l'�R aWaF mg awls,. ..11••••2•112.......„ es▪ . DE rwoormalema maTormomalako moo A MAKS :oSWIM f• u▪ rr ;Gam 801E O3R Lea .la4,5.54545.5650G.mm� �.M1911 RPI.aa00SLa1RT41¢ .ALm...aA insIME • a. a MM2. .0007b1._095RR 593 SURFACES: 1-7 )L'SfACY ]�RrtIPA4Da1FlEZ 9RO20 S4,w1.4 4Udl1142 Yur40030ylnp 6 mannInc. Inc. 13100 8W 13111 9140.7. Sults 20, 21.1)1, Florida 13190 Tel: 306.696.1110 0.0: 306.593.1986 www..uaraz.urva yloO.Com PEAT IMAGE: NOT TO :CNE P'ROPERTYADORES. 20 SY 1.111 . a'4I .1001; R 031]1 LEGAL 0E11OR4T0: LOT I .1I. D.= 4 0r WWI 0001 2c NO. 1, ]OCl120C To Si 1101 W K.la-rmix mom 5, AS 160100 POUT Baa[ IC PAM R O K W H.aROOMS&DODD:WeEFOIWAT/03 1110 oN 1ns 71.000 MYNA. kW YM a E04A. 31405000 ▪ .001611 MOM RISF.m914 00,11/04 00/11704 1 40004LLPI T CCI9D 0.16MC19) 0104. ON OW 1A. a 511.10 ]S[ S 344 Oa. 0.044 M BV 000101) 0413 A 1106801Wa RUC .>s•+ 1W A Pon .•®r 1i� YEnR L SURVEYOR"NOM:sysl ROM 10 le. 4.4110.44.]IX • 'SOB 60010.0 044 .RYI: 11C :01[14. 1i4 404 2 440 lu1.S uw MA, O 40 / NolED. fm ]1a1]a11Yli OI Mo.Yaos MOM 81:4021 P. 1,2Rlmo.`M ramlals�0013 Cr 50 a1 .Taa,,STD .ATs Pms M rat W cameo 334 AM 115 5 rto ¢or i1.01)5�m11u� 01000 4 M� :,; 53 3 W'11EA-2211[ 10TH *401045 x0004050 A01 Nol ALImwOor ATON as 110 4w.0 019 05 7A 01)03Tama ▪ MS Mx Ma RUT. 091ST CONSTRUCTOR FPuRrsExAIaMWYRo. D1 011t90. SURWT1OPS 1O M Roca, BY 01100 10CuT pm. Waal a LRE MamaS. s 15 5001oR [7 sr ROOM. mono _NF SIM ID AM.. Y TYPE Cr 99 ,1. 4.ML 4o.:FLF ) ] 10 fM an 1 _ .▪ .1000 „RM SASSY ST FO FOOT413 ALL1WIOMT 0.41:99N t NaGWSAsuivo IF SE O 111,10 4 iuReam am a1A oRED m 115 NEAREST 9/0aou1 of LEGAL OM.1^TOY FIOIaM 1, Wars 9477.1017 1A C41 on RS SaKY 1A4D 92 4)0 41 3(OWo O 0 StowT rat A„uaa 1.1ar 1)0 a 10525 a 04) :190142Yo6S0 0 2AMG Cr CERT/Aa „Amami SE10 HOTEL LLO 408/0 IRS NORMS. LLC AIEROM! nu 8 YIAPVETdPH C6t7R1C47C: 1317 MAT 106 310105 IS TTM 109 WIRECT M TE x51 Or 9T 300009➢¢ AND 11011- iS 10030100 SMIEIID AMO CRAM MOM 4/150/04 .45 90019 114 092119 0[049[10 STANDARDS SET 0010 Sr ➢E 009051 STATE BONA Cr SaE(07475 4O 11,591 S CHAFER 61-11 FLOW, 104901)411: CODS 1094.10110 RL105 412021 4/.904 STARE ISSYSEIGIC CORER OMNI re Juan A. ,I: ; Juan A..:w cwomALIIIONATIIIISMO 444•444FRr0. 40.54440540.15 - MIND WLOP TI. ATIFAT1tl0900191.. sIM1t1.RAra Suarez :', Stgagt4P�„1 DATE OF SLWIEY: 01/22/20/6 P 440723727 nE r C-tI PGC0401:1416 AM1M 2016 1-40t* 0000 k'WES 9WEI1 OF I Detail by Entity Name FLORIDA DEPARTMENT OF STATE DIVISION_ OF CORPORATIONS Page 1 of 2 Detail by Entity Name Foreign Limited Liability VERO HOMES, LLC Filing Information Document Number FEI/EIN Number Date Filed State Status Principal Address 701 BRICKELL AVE., SUITE 1550 MIAMI, FL 33131 Mailing Address 701 BRICKELL AVE., SUITE 1550 MIAMI, FL 33131 Registered Agent Name & Address DE LA CANAL, HECTOR S 701 BRICKELL AVE., SUITE 1550 MIAMI, FL 33131 Authorized Person(s) Detail Name & Address Company M16000001730 NONE 02/29/2016 NV ACTIVE Title MGR DE LA CANAL, HECTOR S 701 BRICKELL AVE., SUITE 1550 MIAMI, FL 33131 Annual Reports No Annual Reports Filed Document Images 02/29/2016 -- Foreign Limited View image in PDF format http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 9/21 /2016 ACORL7® �-�. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/05/2017 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 Merchant Insurance Solutions 12326 Isabella Drive Bonita Springs FL 34135 CONTACT NAME: Staci Merchant PHO ((Nc No. EMI: (239) 823-4382 FAX No): (866) 406-4983 ADDDREADRE SS: smerchant@merchantinsurancesolutions.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: FLORIDA CITRUS BUSINESS & INDUSTRIES FUN COMMERCIAL GENERAL LIABILITY INSURED Total Quality Restoration, Inc 12235 SW 128th Street Suite 211 Miami FL 33186 INSURER B INSURER C : INSURER D: $ INSURER E : INSURERF: 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 LTRINSD TYPE OF INSURANCE ADDL SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS UAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N/A 10653816 01/15/2017 01/15/2018 X PER PEATUTE OTH ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 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 - ` " " '� ` h" ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABLITY INSURANCE POLICY WC 00 00 01 A INFORMATION PAGE Insurer: Florida Citrus, Business & Industries Fund Carrier Code: 31259 1. INSURED: TOTAL QUALITY RESTORATION, INC Mailing address: 12235 SW 128TH ST UNIT 211 MIAMI, FL 33186 Policy No.: Individual 10653816 Partnership Or Li Corporation Insured's I.D.No(s) 453480373 093076117 FEIN NCCI Risk ID 2. POLICY PERIOD: The 1olioat the01 A.M. Standard Time, policy period is from 01/05/16 to 01/05/17 at the insured's mailing address 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Florida B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 Each Accident Bodily Injury by Disease $ 500,000 Policy Limit Bodily Injury by Disease $ 500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: WC 00 00 01 A, WC 89 04 15, WC 00 03 08 4. PREMIUM: The Premium for this policy will be determined by our manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code No. Premium basis Total Estimated Annual Remuneration Rate per $100 of Estimated Remuneration Premium See Extension Schedule Premium for Increased Subject Premium Experience Modification Standard Premium Limits Part Two 0.91 Modified Premium Expense Constant Terrorism Risk Insurance Premium Total Estimated Premium 75 2,980 2,712 2,712 200 7 2,919 Minimum Premium 1,003 Deposit Premium Name of Producer: MRH: Merchant Insurance Group, Inc. dba Merchant 12326 Isabella Dr Bonita Springs,FL 34135 Servicing Office: FUBA WORKERS' COMP PO Box 1303 Tallahassee, FL 32302 Countersigned by Telephone No.: (888) 262-4483 (239) 823-4382 ?-10€1-) 10/26/16 Authorize° Reeresertatwe Date Florida Citrus, Business & Industries Fund WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Policy No.. 10653816 TOTAL QUALITY RESTORATION, INC EXTENSION SCHEDULE CLASSIFICATIONS CODE NO. PREMIUM BASIS TOTAL ESTIMATED ANNUAL REMUNERATION RATE PER $100 OF REMUNERATION ESTIMATEC PREMIUM CARPENTRY -INSTALL OF CABINET W (1.000) 5437 32, 500.00 8.92 2,89: CLERICAL OFFICE EMPLOYEES NOC. (1.000) 8810 2,600.00 0,23 1 Premium for Increased Limits Part Two 7 Subject Premium 2,98 Experience Modification 0.91 Modified Premium 2,71 Standard Premium 2,71 Expense Constant 20 Terrorism Risk Insurance Premium Total Estimated Premium 2,91! Policy Effective 01/05/16 Endorsement Effective 01/05/16 Policy Expiration 01/05/17 Policy Number 10653816 Insured TOTAL QUALITY RESTORATION. INC Carrier Code 31259 Endorsement No. 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Partners Officers Others EDUARDO RODRIGUEZ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 01/05/16 Policy Number 10653816 Endorsement No. 4 Insured TOTAL QUALITY RESTORATION, INC Insurance Company Florida Citrus, Business & Industries Fund, NCCI Carrier Code 31259 WC 00 03 08 (Ed. 4-84) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT The following item(s) ❑ Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address (WC 89 06 05) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change in Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3.A. States (WC 89 06 11) is changed to read: CHANGE IN CLASS CODE/PAYROLL (WC 89 04 15 ) See Extention Schedule for changes in Payroll/Class Codes. *Item 4. See Extension Schedule Attached ❑ Item 3.B. Limits (WC 89 06 12) 0 Item 3.C. States (WC 89 06 13) ❑ Item 3.D. Endorsement Numbers (WC 89 06 14) IN Item 4." Class, Rate, Other (WC 89 04 15) D Interim Adjustment of Premium (WC 89 04 16) O Carrier Servicing Office (WC 89 06 17) ❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) ❑ Carrier Number (WC 89 06 19) O Issuing Agency/Producer Office Address (WC 89 06 25) Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate per $100 of Remuneration Estimated Annual Premium See Extension Schedule Total Estimated Annual Premium $ Minimum Premium $ Deposit Premium $ All other terms and conditions of this policy remain unchanged This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Effective 01/05/16 Policy Expiration Endorsement Effective 01/05/16 Policy Number Insured TOTAL QUALITY RESTORATION, INC WC 89 06 00 B (Ed. 7-01) © 2001 National Council on Compensation Insurance, Inc. 01/05/17 10653816 Carrier Code 31259 Endorsement No. 4 WORKERS COMPENSATION AND EMPLOYERS LIABLITY INSURANCE POLICY WC 00 00 01 A INFORMATION PAGE Insurer: Florida Citrus, Business & Industries Fund Carrier Code: 31259 1. INSURED: TOTAL QUALITY RESTORATION, INC Mailing address: 12235 SW 128TH ST UNIT 211 MIAMI, FL 33186 Policy No.: Individual 10653816 E Partnership or Li Corporation Insured's I.D. 453480373 093076117 No(s) FEIN NCCI Risk ID 2. POLICY PERIOD: The policy period is from 01/05/16 to 01105/17 at'tthe A.M.sStandard Time, the 7270f mailing address 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Florida B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 Each Accident Bodily Injury by Disease $ 500,000 Policy Limit Bodily Injury by Disease $ 500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: WC 00 00 01 A, WC 89 04 15, WC 00 03 08 4. PREMIUM: The Premium for this policy will be determined by our manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code No. Premium basis Total Estimated Annual Remuneration Rate per $100 of Estimated Remuneration Premium See Extension Schedule Premium for Increased Subject Premium Experience Modification Standard Premium Limits Part Two 0.91 Modified Premium Expense Constant Terrorism Risk Insurance Premium Total Estimated Premium 75 2,980 2,712 2,712 200 7 2,919 Minimum Premium 1,003 Deposit Premium Name of Producer: MRH: Merchant Insurance Group, Inc. dba Merchant 12326 Isabella Dr Bonita Springs,FL 34135 Servicing Office: FUBA WORKERS' COMP PO Box 1303 Tallahassee, FL 32302 Countersigned by Telephone No.: (888) 262-4483 (239) 823-4382 10/26/16 AJthonzeo Recresemat a Dale Florida Citrus, Business & Industries Fund WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Policy No.: 10653816 TOTAL QUALITY RESTORATION, INC EXTENSION SCHEDULE CLASSIFICATIONS CODE NO. PREMIUM BASIS TOTAL ESTIMATED ANNUAL REMUNERATION RATE PER $100 OF REMUNERATION ESTIMATES PREMIUM CARPENTRY -INSTALL OF CABINET W (1.000) 5437 32, 500.00 8.92 2, 89: CLERICAL OFFICE EMPLOYEES NOC. (1.000) 8810 2,600.00 0.23 1 Premium for Increased Limits Part Two 7 Subject Premium 2,98 Experience Modification 0.91 Modified Premium 2,71 Standard Premium 2,71 Expense Constant 20 Terrorism Risk Insurance Premium Total Estimated Premium 2,91! Policy Effective 01/05/16 Endorsement Effective 01/05/16 Policy Expiration 01/05/17 Policy Number 10653816 Insured TOTAL QUALITY RESTORATION. INC Carrier Code 31259 Endorsement No. 4 ' WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Partners Officers Others EDUARDO RODRIGUEZ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 01/05/16 Policy Number 10653816 Endorsement No. 4 Insured TOTAL QUALITY RESTORATION, INC Insurance Company Florida Citrus, Business & Industries Fund, NCCI Carrier Code 31259 WC 00 03 08 (Ed 4-84) io Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKER$ COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT The following item(s) ❑ Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address (WC 89 06 05) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change in Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3.A. States (WC 89 06 11) is changed to read: CHANGE IN CLASS CODE/PAYROLL (WC 89 04 /5) See Extention Schedule for changes in Payroll/Class Codes. *Item 4. See Extension Schedule Attached 0000❑®❑❑❑ Item 3.B. Limits (WC 89 06 12) Item 3.C. States (WC 89 06 13) Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15) Interim Adjustment of Premium (WC 89 04 16) Carrier Servicing Office (WC 89 06 17) Interstate/Intrastate Risk ID Number (WC 89 06 18) Carrier Number (WC 89 06 19) Issuing Agency/Producer Office Address (WC 89 06 25) Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate per $100 of Remuneration Estimated Annual Premium See Extension Schedule Minimum Premium $ Total Estimated Annual Premium $ Deposit Premium $ All other terms and conditions of this policy remain unchanged This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Effective 01/05/16 Policy Expiration Endorsement Effective 01/05/16 Policy Number Insured TOTAL QUALITY RESTORATION, INC WC 89 06 00 B (Ed. 7-01) © 2001 National Council on Compensation Insurance. Inc. 01/05/17 10653816 Carrier Code 31259 Endorsement No. 4 rzrva— RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CGC1520357 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 RODRIGUEZ, EDUARtiO TOTAL QUALITY RESTORATIvN INC 12235 SW 128 ST. #211 • MIAMI F L 3-3-186 At. h N‘T. ISSUED: 09)04/2016 DISPLAY AS REQUIRED BY LAW SEQ # L1609040002399 007703 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7158973 BUSINESS NAME/LOCATION TOTAL QUALITY RESTORATION INC OPERATING IN [ADE COUNTY OWNER TOTAL QUALITY RESTORATION INC C/O LISETTE GONZALEZ PRES Employee(s) 6 RECEIPT NO. RENEWAL 7436195 SEC. TYPE OF BUSINESS 213 SERVICE BUSINESS EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 09/19/2016 ECH ECK-16-177855 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visit www.miamidade.gov/taxcollector 1 •DATE(MM/DD/YY) ACORD CERTIFICATE OF LIABILITY INSURANCE OCT25,2016 PRODUCER Florida Insurance Agency of Miami P.O. Box 441340 Miami, FI. 33144 P; 305-445-9100 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. INSURER AFFORDING COVERAGE NAICS # INSURED Total Quality Restoration Inc 12235 sw 128 st #211 Miami FI 33186 INSURER A: Admiral Ins Co 12537 INSURER 8: INSURER C: INSURER D: INSURER E: INSURER F: coverages THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT- WITHSTANDING ANY REQUIREMENT,TERM,OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADDL INSR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE (MM/DD/YY) EXPIRATION (MM/DD/YY) LIMITS A GENERAL LIABILITY GOMMEf1CIAL GENERAL LIABILITY OCCUR PER: LOU FEIC2200600-01 9/25/2016 9/25/2017 EACH OCCURRENCE 51,000,000 x DAMAGE 10 REN I ED PREMISES(Ea occurrence) 5100,000 CLAIMS MADE x MED EXP (any one person) 55,000 PERSONAL & ADV INJURY 51,000,000 GENERAL AGGREGATE 52,000,000 GENL AGGREGATE LIMIT APPLIES PRODUCTS-COMP/OP AGG 52,000,000 x POLICY PR0JEC1 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) 5 L30UILY INJURY (Per Person) 5 BODILY INJURY (Per Accident) -PROPER i Y UAMAC,E (Per Accident) GARAGE LIABILI I Y ANY AUTO ALL OWNED AUTOS AU 10 UNLY-EA Aet;IUkN I o I titK I I -IAN LA AUL $ AUTO ONLY AGG 5 , EXCESS UMBRIA.); LIABILITY CLAIMS MADE ANL) EACH OCCURRENCE OCURR AGGREGATE DEDUCTIBLE RETENSION $ COMPENSA I ION LIABILITY EXCLUDED? under below WUSIAIU- ITORY LIMITSI 0114 ER WORKERS EMPLOYERS ANY PROPIERTOR/PARTNER/EXECUTIVE OFFICER/MEMBER if yes describe SPECIAL PROVISIONS EL EAUH AUUIL)N 1 EL UISEASE-EA EMPLOYEE EL DISEASE-POL1CY LIMI 1 Ui HER DESCRIPTION OF OPERATIONS / LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS: Cgc 1520357 x CERTIFICATE HOLDER ADM. INSURED Miami chores Village Bldg Dept 10050 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3.2 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURED. ITS AGENT OR AUTHORIZED REPRESENTATI p• Tony Zoghbi i 7—, .., ACORD 25 (2001/08) ACCORD CORPORATION 1988 FLOR10 A PRovsoiNC SOLUTIONS TO TM TEC Lab Report No. 127342 C.A. # 30448 Lab Certificate # 13-0507.02 INSPECTION DATE: June 1,2017 PERMIT No : RC16-2605 CLIENT NAME: Total Quality Restoration HOME OWNER: Hector de Canales PROJECT ADDRESS: 90 NE 96th St., Miami Shores REPRESENTATIVE: Andres Alvarez AS BUILT CERTIFICATE Our office inspected approximately 102 Wf of concrete slab pouring at the above referenced slab. The slab was exposed to verify proper installation. During this inspection the following components were verified: El Wire Mesh Concrete Pour Wire Mesh: 6" Wire Mesh Concrete Pour. 2500 PSI To the best of my knowledge, belief and professional opinion, the above concrete pouring complies with the minimum requirements as set fotth by the Florida Building Code and the approved documents This report is not to be construed as a warranty of the slab, only the representation of the actual conditions at time of inspection in the areas inspected. Do not hesitate to call my office with any questions. a - San zalez, 41 . 10735 SW 216th St. Unit 416 Miami FL 33170 Page 1 of 1 www.FloridaTEC.net Tel 305-256-4550 Fax: 305-256-6833 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 BUILDING PERMIT APPLICATION jXBUILDING ❑ ELECTRIC ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: 9 1 V G 1(j City: Miami Shores County: Master Permit No Sub Permit No. ❑ EXTENSION ❑ REVISION RECEIVED SEPI 2016 BY: Fsc 2011 ath c)>c, q- l6 -26U5 ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Dade Zip: 33/38 Folio/Parcel#: "-3 206, _013 -0600 Is the Building Historically Designated: Yes NO Occupancy Type: 5F H Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): �f e ro ccH©1 5/ LL Address: 701 O(1c ( aVe• x 117e /55C� City: / "/ ICe,l % State: (- L— Phone#: 305 -go Z- `I6 60 Tenant/Lessee Name: ` } Email: i -FF V ia'ro \ 0 WICj JI c o c c m Zip: 33131 Phone#: 305 -90z - L/660 CONTRACTOR: Company Name: ` Phone#: Address: City: Qualifier Name: State Certification or Registration #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ ' - J 000 Square/Linear Footage of Work: eo p ) ificate of Competency #: Type of Work: ❑ AdditionAlteration Description�-�of Work: /?'moa'//fa-Chef? jL ❑ New [ Repair/Replace Demolition Acta 1 hthr©om ar�d mac/'J Specify color of color thru tile: Submittal Fee $ J. O Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ Rpvi dr17/74/7x1141 CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 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. _! y "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. 4,00111117 Signature ....001 Sig natu . e OWNER or AGENT if, f' CONTRACTOR The foregoing instrument was acknowledged before me this �, eo going instrument as acknowledged before me this .6 tl• A Z 1 day of 5e/9/ . , 20 1 ,,pi, dayy�of , 20 by who is personally known to �¢� , who is personally known to me or who has produced V C" iV`eV t a C'K.Y6 t as me or who has produced as identifica d who did NOTAR Sign: Print: Seal: *************** APPROVED BY tnovicaanl Nn Nni nt /WY. YANADY PRIETO u� MY COMMISSION # FF 214031 EXPIRES: March 25, 2019 Bonded Thar Notary Public Underwriters identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: *********************************************************** Plans Examiner Zoning Structural Review Clerk 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 BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ▪ PLUMBING MECHANICAL PUBLICS JOB ADDRESS: 610 NE 16 '* RE,CEI\TED MAY 2 6 2017 FBC 201h-‘ ��,�,,O//�� Master Permit No. 12 -C -12-C-(, ' Z S Sub Permit No. I U 2 ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF 0 CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: OWNER: Name (Fee Sim le Titleholder): Vero {p✓he5, ?Li lr 9 (- z& eII ewe 5ut/e /2Zo Address: City: /''(. j State: FL, Tenant/Lessee Name: Email: BFE: 33l3 a NO FFE: Phone#: 10.5 ?oe— V6L0 id @ veraIxisesllc Phone#: Zip: 3-3/-3/ CONTRACTOR: Company Name: Address: City: Qualifier Name: -TV 0 -EoSe SOi4n41241 d ret, Phone#: State Certification or Registration #: CMC 12. N O SL / Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ TOO Square/Linear Footage of Work: SH Tl1-tee con Su t kilj La, Z7t (A) sq st. Alm tea State: F Phone#: Zip: 3 30 / Z Type of Work: ❑ Addition I 1 Alteration/ / Description of Work: t� � ,Ih/ .5 ,-0/ a ei ,41c - New — New ❑ Repair/Replace n Demolition Specify Submittal Fe Scanning Fee Technology Fee $ Structural Reviews $ q of gior a UI �j• `', ; St, tee -H rcitaimno3 CCF $ (Revised02/24/2014) DBPR $ Training/Education Fee $ Notary $ Double Fee $ Bond $g_i9 C TOTAL FEE NOW DUE$ 8 7 . I3 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 OWNER or AGENT The foregoing'instrument was acknowledged before me this 2.31"4 day of M, 20 11 , by 1AC.0-0 .(CICO,GA , who is personally known to me or who has produced r1 V . L CellS1 identification and who did to NOTARY PU Sign: Print: Seal: Signature CONTRACTOR 4 , The foregoing instrument was acknowledged before me this day of ' r , 20 11 , by who ipersonal) knoZOto as me or who has produced as Y v PRIETO s MY COMMI ON # FF 214031 EXPIRES: March 25, 2019 , ' Bonded Thru Notary Public Underwriters ********************** APPROVED BY (Rev:sed02/24/2014) *********** identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: (YiiCtnirt) ******************* 4 MICHEU.E PINEDA Notary PubNe - State of Fioride Commission I FF 991421 *4/pCemr fapiN ssMayif4i #N!! Plans Examiner Zoning Structural Review Clerk