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CC-18-797Miami Shores Village 10050 N.E: 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit NO. CC-3-18-797 Permit Type: Commercial Construction Work Classification: Alteration Pennit Status: APPROVED Issue Date: 412612018 Expiration: 10/23/2018 Parcel Number Applicant 1700 NE 105 Street Number: 512 Miami Shores, FL 1122300500880 Block: Lot: JORGE RODRIGUEZ Owner Information Address Phone Cell JORGE RODRIGUEZ 1700 NE 105 Street MIAMI SHORES FL 33138- 1700 NE 105 Street MIAMI SHORES FL 33138- Contractor(s) Phone B ESCOBAR PAITING SERVICES INC (786)333-2124 Cell Phone Valuation: Total Sq Feet: $ 700.00 9 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: REPAIR AND PAINT CEILING DAME Stories: Front Setback: Left Setback: Plans Submitted: Certification Date: Bond Return : Scanning: 3 Occupancy Load: Exterior: Rear Setback: Right Setback: Certification Status: Additional Info: REPAIR AND PAINT CEILING DAMA Classification: Commercial Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $9.00 $0.80 $114.60 Pay Date Pay Type Amt Paid Amt Due Invoice # CC-3-18-66945 03/28/2018 Check #: 1286 $ 50.00 $ 64.60 04/26/2018 Check #: 1304 $ 64.60 $ 0.00 Available Inspections: Inspection Type: Window Door Attachment Tie Beam Slab Termite Letter Framing Store Front Attachment Insulation Drywall Screw Final PE Certification Window and Door Buck Ceiling Grid Fill Cells Columns Review Building Review Planning Review Electrical Review Plumbing Review Structural Review Mechanical 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 a• • that all work il be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor o d. t e wor s Authorized Signature: Owner / Applicant / Contractor April 26, 2018 Date Building Department Copy April 26, 2018 1 , JOB ADDRESS: City: Folio/Parcel#: Occupancy Type: 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 MAR; 2 72018 FBC 2OP Master Permit No.Ct Sub Permit No. ❑ REVISION ❑ EXTENSION PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS ❑ CHANGE OF 0 CANCELLATION CONTRACTOR i1b (U.c— Jv� �,+ �►AMt s 4 D C Miami Shores Load: County: Miami Dade Zip: Is the Building Historically Designated: Yes Consthuction Type: 122.4'1\4(t.. Flood Zone: BFE: ❑RENEWAL SHOP DRAWINGS.. NO FFE: OWNER: Name (Fee Simple Titleholder): G£02 � Li (2-(_ - -� Z Phone#: Address: 1 )dO M.E. 1 CAS kAnu I i 5k City: hvl ( 4-VkLl State: �� Zip: —3 I Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name S G� �!� 2�q.i J l NG Address: ; CQ k> I,O . (i' 1 Phone#:X(7$6 —333 -a4G 4 City: rirA L--L2C K-4 (f State: �" . - Zip: 3 P S .S Qualifier Name:13 (2-1't'� -1 i ' S- A-2. Phone#: State Certification or Registration #: Certificate of Competency #: kp FJ G O O 1-3 L-/ DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ '1 DO , DO Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Description of Work: Repair/Replace n Demolition C d l aid of fC� + Specify colorotcolor ttvic' Submittal Fee $5�.� (���°;} Scanning Fee $ t ii the:: 4 . taA;,•,QO YM Permit Fe $t 1 w • ..... ;2$4UT A At3!', 'r u i{ •t p CCF $ i : "nr :, r •..,.s r <i 13CO/CC $ ems.. DBPR'$'"r--------------Notary $_.... Technology Fee $ Training/Education Fee $ J Double Fee $ Bond $ � /� TOTAL FEE NOW DUE$ 67 60 "'"""Radon Fee $ Structural Reviews $ ' (Revised02/24/2014) • i • 1 5 Bonding Compny'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. 77 f/72 V '% S e.nvo 41,r/ r ) X/ C _ Signature CONTRACTOR The foregoing instrument was acknowledged before me this /6 day of //jaltr/�.. ,20�d , by /J (L(34.A_ S S(1Mi1'\ 4)S. who is personally known to (a% , who is personally known to The foregoing instrument was acknowledged before me this ' day of 22l'Lr✓fl , 20 /( , by me as me ielentifieatisaa-aad who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: 'MY'" Gi A LI = Stubbs ********* APPROVED BY PATRICIA A. STUBBS I {'= MY COMMISSION # GG075388 i ***i)PfRE6�Mehd#*18�203********************'** NOTARY PUBLIC: who did take an oath. Sign: -P Vl' Print: Pit 7-4ot) A. S1 fjM5 Seal: Plans Examiner . ; PATRICIA A. STUBS '`: MY COMMISSION # GG07538: $ Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application - Miami -Dade County Page 1 of 2 Summary Report Property Information Folio: 11-2230-050-0880 Property Address: 1 1700-NE 15 ST UNIT: 5121 -----.1-- ' Miami'Shores, FL 33138-2145 Owner 'c oRGEM RODRIGUEZ, Mailing Address 1700 NE 105 ST #512 MIAMI SHORES, FL 33138-2142 PA Primary Zone 4900•MUbTI-FAMILY•- �--- CONDOMINUM ^'.-1 Primary Land Use 0407 RESIDENTIAL - TOTAL VALUE : CONDOMINIUM - RESIDENTIAL Beds / Baths / Half 2/2/0 Floors 0 Living Units 0 Actual Area Sq.Ft Living Area 1,154 Sq.Ft Adjusted Area 1,154 Sq.Ft Lot Size 0 Sq.Ft Year Built 1965 Assessment Information Year 2017 2016 2015 Land Value $0 $0 $0 Building Value $0 $0 $0 XF Value $0 $0 $0 Market Value $180,448 $138,806 $127,345 Assessed Value $70,782 $69,327 $68,846 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction $109,666 $69,479 $58,499 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $20,782 $19,327 $18,846 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description THE SHORES CONDOMINIUM APT 512 FIFTH FLOOR UNDIV .0110% INT IN COMMON ELEMENTS CLERKS FILES 64R-124472 Generated On : 3/27/2018 WEt»►.Qili'AY,'5A: .c Taxable Value Information 2017 1 2016 2015 County Exemption Value $45,782 $44,327 , $43,846 Taxable Value $25,000 $25,000 $25,000 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $45,782 $44,327 $43,846 City Exemption Value $45,782 ' $44,327 $43,846 Taxable Value $25,000 $25,000 $25,000 Regional Exemption Value $45,782 ' $44,327 $43,846 Taxable Value $25,000 1 $25,000 $25,000 Sales Information Previous Sale Price OR Book -Page Qualification Description 10/01/2001 $86,500 19959-1673 Sales which are qualified 03/01/1988 $87,000 13627-2428 Sales which are qualified 09/01/1983 $85,000 11898-2409 Sales which are qualified 05/01/1980 $72,000 10737-1647 Sales which are qualified The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability. see full disclaimer and User Agreement at htto://www.miamidade.aov/info/disclaimer.aso http://www.miamidade.gov/propertysearch/ 3/27/2018 2047 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT DOCUMENT# 707621 Entity Name: THE SHORES CONDOMINIUM, INC. Current Principal Place of Business: 1700 NORTHEAST 105TH STREET MIAMI, FL 33138 Current Mailing Address: 11700 NORTHEAST 105TH STREET MIAMI, FL 33138 FEI Number: 59-1095398 Name and Address of Current Registered Agent: JARA & ASSOCIATES, PA 19 WEST FLAGLER STREET SUITE 504 MIAMI, FL 33130 US FILED Jan 24, 2017 Secretary of'State CC6479283647 Certificate of Status Desired:, No ,The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida. SIGNATURE: FRANKLIN ANTONIO JARA 01/24/2017 Electronic Signature of Registered Agent Officer/Director Detail : Title Name Address City -State -Zip: Title Name Address City -State -Zip: Title Name Address City -State -Zip: TREASURER STUBBS, PATRICIA 1700 NE 105 ST #211 MIAMI SHORES FL 33138 SECRETARY GRABLE, JANE 1700 NE 105 ST #117 MIAMI FL 33138 VP BENAVIDES, JORGE 1700 N.E.105 ST #409 MIAMI SHORES FL 33138 Title Name Address P CSAMMONS, CHARLESJ 1700 NORTHEAST 105TH STREET #301 City -State -Zip: MIAMI FL 33138 Title Name Address City -State -Zip: VP RAJO, PEDRO 1700 NE 105 ST #111 MIAMI FL 33138 Date I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears above, or on an attachment with all other like empowered. SIGNATURE: CHARLES SAMMONS PRES 01/24/2017 Electronic Signature of Signing Officer/Director Detail Date Owner's Name C A AP/\RTM1MENTs WORK REQUEST APPLICATION• Unit 57 cR I hereby request approval from the Board of Directors for the following modification or alteration to my unit that will be performed by a licensed contractor. Electrical work Carpet installation Tile installation Plumbing work **Windows Other work 5ehc�e 4- • Description of the work 19-1L.1,4.19 Before you decide to upgrade your apartmen (other than pal t or carpet) you must obtain permission from the Board of Directors and/or Miami Shores Village. A copy "of the plans, specifications and permits, and a description of the licensed work to 'be performed must be submitted for consideration and approval by the Miami Shores Village Building Department (305-795-2204)., It is the owner's responsibility to ensure that the contractor removes all excess construction material or building debris. It cannot be placed in the dumpsters. **Window frames must be gray in color to look like aluminum. Windows must be Two (2) panels over Two (2) panels. Glass must be clear color. I, as the unit owner acknowledge responsibility for any damage to the building or personal injuries that may occur during the project. The Shores Condominium Inc. its officers and employees are in no way responsible for damage or theft to my apartment or my belongings. (A $200.00 deposit is required and will be refunded if no damage to the property is reported.) I fully understand and agree to the statements made above. 3a//� Datd CTSB Construction Trades ualifying Board BUSINESS CERTIFICATE OF COMPETENCY 16BS00134 B.ESCOBAR PAINTING SERVICES INC D.B.A.: COBAR BRYAN VLADIMIR Is certified under the provisions of Chapter 10 of Miami-Dade,County ONUNIVd (Malys]. orsudrivno 8L00 001337 Local Business Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY 7235778 BUSINESS NAME/LOCATION AJS LANDSCAPING & TREE TRIMMING OPERATING IN DADE COUNTY MIAMI FL 00000 RECEIPT NO. RENEWAL 7521733 OWNER SEC. TYPE OF BUSINESS /A15 LANDSCAPING & TREE TRIMMING 213 SERVICE BUSINESS C/O B. ESCOBAR PAINTING SERVICES-INC Employee(s) 1 LBT i EXPIRES SEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $75:00.0.1/07/20'T8''• CREDITCARD-18-022214 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 AAccm J► CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/24/2018 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 have ADDITIONAL INSURED provisions or 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 Annette Willis Insurance 18401 N.W. 27 Ave Miami, FL 33056 Phone (305) 625-2403 Fax (305) 625-6472 CONTACT Jeff Willis NAME: PHONEtExt)• (305) 625-2403 FAX No): (305) 625-6472 ADDRESS Jeff.Willisr�annettewillisinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : AM Trust Morth America INSURED B. Escobar Painting Services Inc. 3820 NW 171 St Miami Gardens FL 33055 INSURER B : INSURER C : INSURER D : INSURER E : INSURER 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 TYPE OF INSURANCE NSR�WVD UBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A V COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE d OCCUR ❑ Y Y WPP1620429-00 03/23/2018 03/23/2019 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO PREMISES EaENTEoccu ence) $ 100,000.00 MED EXP (Any one person) $ 5,000.00 ❑ PERSONAL & ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: V POLICY ❑ JECT ❑ LOC GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 ❑ OTHER $ AUTOMOBILE LIABILITY ❑ ANY AUTO OWNED ❑ SCHEDULED ❑ AUTOS ONLY AUTOS HIRED ❑ NON -OWNED ❑ AUTOS ONLY AUTOS ONLY ❑ ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIV N / A ❑ STATUTEPER ❑ ERH E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Painting - Interior & Exterior CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2 Ave Miami Shores Village, FL 33138 ACORD 25 (2016/03) QF 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 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 12/08/2017 EXPIRATION DATE: PERSON: BRYAN ESCOBAR FEIN: 472496238 BUSINESS NAME AND ADDRESS: B. ESCOBAR PAINTING SERVICES, INC 3820 NW 171 ST OVA LOCKA, FL 33055 SCOPE OF BUSINESS OR TRADE: 1 - Painting: Melal Structures Ove 12/08/2019 F IMPORTANT • O Pursuant to Chapter 440.05(14), F.S., an officer "of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. H 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 E the notice of election to be exempt.' R E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or Ithe 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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on 'the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 B. Escobar Painting Services Inc. 3820 NW 171 St Miami Gardens, Fl 33055 Date: vx%- 7b, �o/g State of /74. o e-i BA Country of /4 $ A Before me this day personally appeared 8t AW o ho, being duly sworn deposes and says: That he or she will be the only person working on the project located at: / 700 ,r..f. e . is 5 u A)/ ! /V / Air), S NoRC ,c 3 / 3 V Contra.c or Signature Swo -n to (or affirmed) and subscribed before me this . day of 9. l(, 201.. by.. OP,./AA/ e5 cp / R, ii'' PATRICIA A. STUBBS MY COMMISSION # GG075388 4!.,. EXPIRES March 18, 2021 Personally know ✓ OR Produced Identification Type of Identification Produced PedA),-v:14) 4rO-1.4) nf+-rrzr ci/ A 665 Print, Type or Stamp Name of Notary 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 officerof 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: i State of Florida County of Miami -Dade �� ,,� The foregoing was acknowledge before me this �-(// o42 day of G'li - , 201L. By C/}APie S4 oNS who is personally known to me weed as-iidentiieation. Notary: SVaiti-4) fPA772fGA A - �TU�BS SEAL: PATRICIA A. STUBBS I MY COMMISSION # GG015388 EXPIRES March 18, 2021 PAT #: la _191 - Miami Shoree; Village APPROVED 70NING DEFT bEPT BY DATE • - • 4 v.; - , • • • • • • • -Florida Department of Environmehtar Protection Division of Air Resource Management NOTICE OF DEMOLITION OR ASBESTOS RENOVATION • TYPE OF NOTICE (CHECK ONE ONLY): `gORIGINAL TYPE OF PROJECT (CHECK ONE ONLY): - ❑ DEMOLITION IF DEMOLITION, IS IT AN ORDERED DEMOLITION? IF RENOVATION: ti IS IT AN EMERGENCY RENOVATION OPERATION? ❑ YES, IS IT A PLANNED RENOVATION OPERATION? • ❑ YES I. Facility Name j\a 0 a 1. j Qpr l\ --' N I Address 1 `7QO 1`/• E / 0 5 r C1C: i-T 51 City '/141 A t 1 State County • Site ❑REVISED ❑ RENOVATION . '❑ YES ❑ CANCELLATION ❑ ROOFING •❑ NO ❑ NO, ❑ NO Consultant Inspecting Site Building Size • (Square Feet) # of Floors Building Age in Years ' y Pnor Use:`% ❑School/College/University] ❑Residence - • ❑Small Business Other yt ' 5 Present Usse:4 . .❑School/College/University• '❑ Residence _ ❑ Small Business Other ••••fe ll �.Facihty=Owner v o l� ' E. E r� t-,1Z 61 C:J rr. Phone - a ( ) File # Process # Regulatory and Economic Resources Air Quality Management Division 701 N.W. 1st Court, 2nd Floor Miami, Florida 33136 VIVED MAR 3 0 2018 Air Quality Management Division Imo, -AKA N Address S A tiA- is ' • ` Citjit 473 State Zip < III Contractor's Name 1 1`'t z S C Cx ( �z qr.,-4 . r•Li k.: •City C) i�u L �7L1<.r� f .State f Is the contractor exempt from licensure under section 469.002(4) F.S.? "•* ❑ YES ❑ NO T IV Scheduled Dates: -(Notice must be postmarked 10 working days before the project start date) _ a { ' � -Asbestos Removal (mm/dd/yy)-Start Finish: a f + e� ' t Demo/Renovation (mm/dd/yy) Start: -). )D Finish: k'1 3 x SV ' Description of planned demolition or renovation`work to be performed and methods to be employed, including demolition or renovation techniques to • be used and description of affected facility components. C `.1 L I It) C ..3 t FAO— of' i•r . Cc- 17 411Wt ACo L L= S S: 1-1 A r) I'C.O -).• i-:. Address �'1 I ,/mot 0 • 7 Phone S ; `7115 - Procedures •to`be Used (Check All That. Apply):.... ❑ .Strip and Removal ` ❑ Glove Bag ❑ "Bulldozer • . ❑ Wrecking Ball 'Wet Method _ - Dry Method ;�.•. - - Explode ,...- ❑ Burn Down OTHER: : r ' t ... . VI. Procedures for Unexpected RACM: VII. Asbestos Waste Transporter: Name T 6', Addresst 12, Phone ( .vlll tWasteiDisposal Site: °✓-Address' Name 1, I. r State Zip s Gty . State Zip •SIX " RACM or ACM: Procedure, including analytical methods, employed to detect the presence of RACM and Category rand II nonfriable ACM. • w Mount of RACM or ACM* t. square feet surfacing material linearfeet pipe'e'=:.44-, r u cubic feet of RACM off facility components• square feet cementitious material -msquar'efeet resilient flooring square -feet asphalt roofing *Identify and describe surfacing material and other materials as applicable: • This is to certify that the required notification(s) regarding asbestos have been submitted in compliance with. applicable regulations., -4. A k 11•'Ah• RER:Official Sigbataie Date ' • I certify that the above information is correct and that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on - site during the demolition or renovation and evidence that the required training has been accomplished by this person will be available for inspection during normal business hours.') have read and understood the additional information provided on the back of this form. (Print Name of Owner/Operator) _- - (Signature of Owner/Operator) -. • (Date) (Contact phone #) RER USE ONLY Postmark/Date Received ID # 161_01-158 8/14 DISTRIBUTION: White-RER Yellow -Applicant Pink -Reserve 11111•1111111111111•111111011111PIMMIT--...--- DISCLAIMER This "NOTICE OF DEMOLITION OR ASBESTOS RENOVATION" is required pursuant to the provisions of 40 CFR 61 Subpart M and Rule 62-257.301, F.A.C. and must be submitted prior to any demolition or regulated asbestos abatement activity. This document is an Asbestos Notification only and is not a permit. This NOTICE OF DEMOLITION OR ASBESTOS RENOVATION does not constitute a waiver of or approval for any federal, state, county, or local permits that may be required for this facility. RER/DERM PLAN REVIEW FINAL APPROVAL REVIEWER: SIGNATURE: DATE: THIS APPROVAL IS FOR ASBESTOS ROOFING OR DEMOLITION REVIEW ONLY