REV-17-138 1
Miami Shores Villa e
� g N1g2017
Building Department
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Q 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 $"y
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No. 4I-Z"�-� `S
PERMIT APPLICATION Sub Permit No., � 1,:a- �
QBUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zia: /
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: &5, Load: Construction Type: Flood Zone: BFE: FFE: W
OWNER:Name(Fee Simple Titleholder): a Phone#: V,6j- —,WA-'p4-
Address: APSE /p 6 ST'
City: /e;�IAOWI S�fO.�/�s State: �-G Zip:
33l3�
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name://� �0�� / �� "/OVL!,/l Phone#:(��h
Address: 17D92
City: State: Zip: �g3,/��57
Qualifier Name: �lSTO ��LL /LJ Phone#:�78�/5 t�- Al Ar
State Certification'or Registration#: �G'I fZpg Certificate of Competency#:
DESIGNER:Architect/Engineer: Iff Phone#:
Address: I City: State: Zip:
Value of Work for this Permit:$ Square/Linear Foota a of Work:.
Type of Work: F-1Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
1
Description of Work: !X/4a 1,
wAT&- ?- 1443A-7292,—
Specify
4L3A-7292 —Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ksb CCF$ CO/CC$
Scanning Fee$ Radon Fee$ 2 DBPR$ Notary$ S
Technology Fee$ ` Y Training/Education Fee$ LAO Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Rev1sed02/24/2014)
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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 Signature nature _o!M � .
OWN or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
f day of .20 by /3 day of 120 ,/ 7 by
(-1Q52Jlam_,who is personally known tom O �f�i ho is personally known to
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me or who has produced -�'ZJ�J ZC1C7-�;-Z-(400as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign: 1
Print: MAHARAI K.GONZALEZ Print: C�T/�� `' �&WIA ACOSTA
COMMISSIUN 9 UU U44buz
2U20MY COMMISSION N 000060'l3
Seal: :,•= EXPIRES:November Seal: '; EXPIRE July 2
Bonded Thtu Notary Public UnderwliterS •, 0-
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S u 4,20,20
(407) P0rkW40ary39r ia.cw
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
! 005276—
local
05276—=Local Business Tax Receipt
. P
. Miami-Dade County;State of Florida
` —THIS IS NOT A,BILL—DO NOT PAY
4649423 [LBT
g BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
MARINO.CONSTRUCTION ENGINEERING INC RENEWAL: SEPTEMBER 30, 2017
7575 W FLAGLER ST 208 4854452 Must be displayed at place of business
MIAMI FL 33144 Pursuant to County Code 1
4 Chapter 8A-Art9&10
OWNER. is —w SEC.TYPE OF BUSINESS
MARINO CONSTRUCTION ENGINEERING 196 GENERAL BUILDING CONTRACTOR BY TAX dT COLLECTOR'RECEIVED
BY TAX COLLECTOR'
I - CGCA58750
Worker(s) t $75.00 07/09/2016 i
ECHECK-16-169394
This Local Business Tax Receipt only confnnms pay lent of the Local Business Tax.The Receipt is not a license, r
i 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 N0.above must be displayed on all commercial vehicles=Miami4ade Code See Ra-276.
For more information,visit W&W miamidade nov/tamcollector
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STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING:BOARD (850) 487-1395
'r HOT 1940 NORTH.MONROE STREET
TALLAHASSEE FL 32399-0783
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t GUERRERO, FAUSTO E'SR
MARINO CONSTRUCTION ENGINEERING, INC.
17082 SW 91 AVE
PALMETTO BAY FL 33157
{
Congratulations! With this license you become one of the neady
one million Floridians licensed by the Department of Business and
Professional Regulation. Our professionals and businesses range STATE OF FLORIDA
from architects to yacht brokers,from boxers to barbeque _ DEPARTMENT OF BUSINESS AND
restaurants,and they keep Florida's economy strong.-, --PROFESSIONAL-:REGULATION
Every day we work to improve the way'we do business in order ISSUED - 06/14/2016
to serve you better. For information about our services.please Ir' A.. '
log onto www.myfloridalicense.com. There you can find more ' CERTIFIED.PLUMBING CONTRACTOR I
information about our divisions and the regulations that impact 1 _,� . GUERRERO;FAUSTO E SR..;' a' ✓"" fi
you,subscribe to department newsletters and learn more about 1 MARINO CONSTRUCTION ENGINEERING i"''^�
the Department's initiatives.
Ou`r mission at the Department is: License Efficiently,Regulate
Fairly.We constantly strive to serve you better so that you can ' q .a t
serve your customers. Thank you for doing business in Florida, I Ir ,_ '. RTIFIED under th_ :11 p o provisions I of Ch.489 FS. +- f
>- Expuat,on date AUG 3,.za1a _ L1GWAW01061
and congratulations on your new iicensel _
i
DETACH HERE
'RICK SCOTT, GOVERNOR KEN LAWSON."SECRETARY "
OF FLORIDA .
3 r _ y ; " DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
`- CONSTRUCTION INDUSTRY.LICENSING BOARD;-..
° ,'CFC1429169
{ Named:beloWIS CERTIFIED
6-70nder"the provisions"of.Chapter 489 FS '
Expirationdate: AUG.,31;g2018
a'`w ..},.'� +-"' ,. - T •tet _ y.., * � "".' -�. a,... -: .+
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'r ' ..GUERRERO, FAUSTO,E SR
MARINO CONSTRUCTION,ENsGINEERING, INC
`r``17082 SW 91 AVE
K� PALMETTO BAY- -.FL S3,157-_A _ :
.� s�x ,,. ._,t� .� „°.7 "` ...tis. -• i�. +4� •.� t." '"'-"_ y�,
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g . ... • S xYs L, n `ce.2
't IssuEo:. osi1412o16 .�„ `DISPLAY'AS`REQUIRED-13Y LAW sEn# 1:1sosla ooiosl
wivlalul,4 ter vvvnr%cna %.VMrcmQAiium
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS,, COMPENSATION ,LAW
C00STRUCTION,INDUSTRY :EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 07/30/2016 ,EXPIRATION DATE: 07/30/2018
PERSON: GUERRERO FAUSTO E
IFEIN: 650989438
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BUSINESS NAME AND ADDRESS:
iMARINO CONSTRUCTION ENGINEERING, INC.
17082 SW 91 AVE
tPALMETTO BAY FL 33157
I .
SCOPES OF BUSINESS OR TRADE:
f1--CONCRETE OR CEMENT WORK - FL00 2- LICENSED GENERAL CONTRACTOR .
IMPORTANT: Pursuant to Chapter 440 . 05114►, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this
'section may.not recover benefits or compensation under this chapter. Pursuant to Chapter-440.05(12), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of election to be exempt. Pursuant-to Chapter 440.0503►, 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 issuince 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 certificate at any time for failure of the person
:named on the certificate to meet the requirements of this section. (IUESTIONS? (850) 413-1609
'DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
........... - -..._ -
i -
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I
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE "REFERENCE
tSTATE OF FLORIDA_ IMPORTANT
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who
CONSTRUCTION INDUSTRY 0 elects exemption from this chapter by filing a certificate of election
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this
WORKERS'COMPENSATION LAW D chapter.
L.
EFFECTIVE: 07/30/2016 EXPIRATION ,DATE: 07/30/2018 Pursuant to Chapter 440.05(12), F.S., Certificates "of election to be
PERSON: FAUSTO E-GUERRERO H exempt:. apply only within the scope of the business or trade listed on
,FEIN: 650989438 E`the notice of election to be exempt
R
BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
MARINO CONSTRUCTION ENGINEERING, INC. and certificates of election to'be exempt shall be subject to: revocation
11682 sw 91 AVE if, at any time after the filing of the notice or the issuance of the
!•- PALMETTO BAY, FL 33157 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 certificate at any time.for failure of the,
` SCOPE'OF BUSINESS OR TRADE: person named on the' certificate to meet the requirements of this
1- CONCRETE OR CEMENT h)ORK - FLOO 2- LICENSED,GENERAL CONTRACTOR Section.
QUESTIONS? (850) 413-1609
CUT HERE
Carry bottom portion on the job, keep upper portion for your records.,
DWC-252 CERTIFICATE-OF ELECTION TO BE EXEMPT REVISED 01-11
I
Miami shores Village
Building Department
LORA 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.
Signatur
Owner
State of lorida
County of Miami-Dade
The foregoing was acknowledge before me this Ll day of �Q r ,20
Byy f 1aQn('�1�1 who is personally known to me or has produced
C�2 _ZOO_�2— �� as identification.
No ....... mAHARAi K.GONZALEZ
,st` r"BSt' MY COMMISSION#GG 044602
SEAL: EXPIRES:November 2,2020
Bonded TWU Notary PublicUndenwrltere
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Marino Construction Engineering, Inc.
DBA Marino Plumbing Solutions
License #CFC7429169
17082 SW 91 Avenue, Palmetto Bay FL. 33757*PHONES.,(786)4431685 *FAX.,(305)9710240
GENERAL CONSTRUCTION
Date:
State of Florida
County of Miami Dade
To whom it may concern:
Before me this day personally appeared X,?� who being
duly sworn, disposes and says:
That he will be the only person working on the project located at
Y
OSS �� 4� � �T �i��� o s G 3 g •
Sworn to—Or affirmed) and subscribed before me this __—3day of� _____- 20_�Z,
by ---X5" 0-- __ GiP�rPr�-----
a '
Personally Known to me______________
OR Produced Identification----_✓_____ ,
Type of Identification Produced
Type, Print or Stamp Name of Notary
PATRICIA ACOSTA
MY COMMISSION#GdOW73
EXPIRES JUIX 224,2020
1
(407 396 Q/53 Fj1W1d8Nots Smv�ae.com
TE
ACC CERTIFICATE OF LIABILITY INSURANCE DADD/YYYY)
2//1312013/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). CONTACT
PRODUCER ME:
NAME: Yemi Diaz
Sun Insurance LLC Py"�"N Ext: (305)224-1268 a/c No): (786)623-0837
2525 Ponce De Leon Blvd,Suite 300 ADDRESS: yemi@sun-insurance.com
INSURER(S)AFFORDING COVERAGE NAIC#
Coral Gables FL 33134 INSURERA: UNITED SPECIALTY INSURANCE COMPANY
INSURED INSURER B:
MARINO CONSTRUCTION ENGINEERING INC INSURER C:
DBA MARINO PLUMBING SOLUTIONS INSURER D:
17082 SW 91 ST INSURER E:
MIAMI,FLORIDA 33157 INSURER F: F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE• $ 1,000,000
DAMAGE TO RENT
CLAIMS-MADE F]OCCUR PREMISES Ea occurrence $ 1,000,000
MED EXP(Any one person) $ 5,000
A SI11037A13931 05/15/2016 05/15/2017 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
FJPOLICY —,PROJECT ❑LOC PRODUCTS-COMP/OP AGG s 2,000,000
OTHER'
AUTOMOBILE LIABILITY _ Ea(Eaaccident)
LIMIT $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAR HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
ANY PROPRIETOR/PARTNERIEXECUTIVE Y❑ N/A E.L.EACH ACCIDENT I $
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
1 If Yes describe under E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
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DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
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Florida State Certified Plumbing Contractor
License#CFC1429169
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2nd Avenue
Miami Shores Florida 33138 8R4&FM SE�N}TATIVE I
EC72ED37CSDOC44F...
@ 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD