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DS-17-1377Permit NO. DS-5-17-1377 Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address ■ Permit Type: Driveways/Sidewalks/Stabs e' Work Classification: AdditioniAlteration Permit Status: APPROVED Parcel Number Issue Date. 5/26/2017 Expiration: 11/22/2017 Applicant 690 NE 93 Street Miami Shores, FL 1132060141490 Block: Lot: HUGO MIRABAL CLAUDIA GRAI Owner Information Address Phone Cell HUGO MIRABAL CLAUDIA GRANDAS 690 NE 93 Street MIAMI SHORES FL 33138-2907 690 NE 93 Street MIAMI SHORES FL 33138-2907 Contractor(s) MATSA CONSTRUCTION CO INC Phone (305)525-1975 Cell Phone Valuation: Total Sq Feet: $ 455.00 3250 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Work: PAVER DRIVEWAY AND WALKWAY Bond Return : Scanning: 3 Additional Info: PAVER DRIVEWAY AND WALKWAY Classification: Residential Fees Due Bond Type - Owners Bond CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $500.00 $0.60 $3.75 $3.75 $0.20 $250.00 $9.00 $0.80 $768.10 Pay Date Pay Type Invoice # DS-5-17-64076 05/26/2017 Credit Card 05/22/2017 Credit Card 05/26/2017 Check #: 161 Bond #: 3412 Amt Paid Amt Due $ 218.10 $ 550.00 $ 50.00 $ 500.00 $ 500.00 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Planning Review Building 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 rl -ccurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -name. L'>rh actor to do the work stated. May 26, 2017 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy May 26, 2017 1 BUILDING PERMIT APPLICATION BUILDING ['PLUMBING JOB ADDRESS: Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Chores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ❑ ELECTRIC ❑ ROOFING ❑ MECHANICAL ❑PUBLIC WORKS 00 Pi FBC OIL Master Permit No. DS 1 g a.R • Sub Permit No. ❑ REVISION EXTENSION ❑RENEWAL ❑ CHANGE OF El CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: Follo/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: Load: pp /�Construction Type: Flood Zone: f OWNER: Name (Fee Simple Titleholder : /"T� 4 14( p e#?; 7d 6'S 3-1/71,3 Address: GO � NO BFE: FFE: City: M(Ct m 1 State: Zip: -',/30 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: /aj �,eua/ �',, l Phone#: 3tir 52r 7r Address: /y� 7 f 6 //93 Cr: City: di State: /i"� zip:35 ' ' Qualifier Name: a ,‘fr4Jejltel Phone#: ,'sr- szS"-- / 5- State Certification or Registration #: C'C 67.2- 767 Certificate of Competency #: - DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Tr` Value of Work for this PeImit: $ SZS 0 Square/Linear Footage of Work: 7-✓-•5 / Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace vev -Dfuv -4- -�K- Description of Work: ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ 2 _ CCF $ 0 •6 d CO/CC $ Scanning Fee $ 1 ' C)) Radon Fee $ 2 -� DBPR $ -3'.S Notary $ Technology Fee $ CS. • 490 Training/Education Fee $ (' 2-0 Double Fee $ Structural Reviews $ Bond $ -0(3 • C) (Revised02/24/2014) TOTAL FEE NOW DUE$ ate ` 10 ��e � 10 I ' 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 /%b Signature OWNER or AGENT The foregoing instrument was acknowledged before me this /9 day of , 20 /7 , by I--euO/o ►�c rzt.( who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUB Sign: Print: Seal: / ,'�,Y PUB FOPV ° ;Ps.' Bonded through National Notary Man, ZOE SALGUEIRO Public - State of Flotida Commission # F n 30 2010 The foregoing instrument was acknowledged before me this ,h day of ,20 (7 .by Mlf�eo/G[�'l�Z , who is personally known to P Y me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: ��,� Print: z/c Seal: as j �µl", „,, p,je ,--- ZOE SALGUEIRO I1 `1,= Notary Public - State of Florida )• Commission # FF 245464 t`O My Comm. Expires .Iun 30, 2019 Bonded through National Notary Assn. ****************************** * *********************************************************************** APPROVED BY Plans Examiner J 2 3/0 Zoning Structural Review (Revised02/24/2014) Clerk RICK SCOTT, GOVERNOR STATE OF FLORIDA KEN LAWSON. SECRETARY DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 ES. Expiration date AUG 31. 2018 SANCHEZ, MATEO MATSA CONSTRUCTION CO IN 14167 SW 143 COURT t`V`, MIAMI; FL 33186 ISSUED' 06/15/2016 DISPLAY AS REQUIRED BY LAW SEC) # L1606150001338 Local Business Tax Receipt Miami -Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY 1915140 BUSINESS NAME/LOCATION RECEIPT NO. MATSA CONSTRUCTION COMPANY INC RENEWAL 14167SW 143CT 1915140 MIAMI FL 33186 LBT \ EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS MATSA CONSTRUCTION COMPANY INC 196 GENERAL BUILDING CONTRACTOR CGC032784 Worker(s) 1 PAYMENT RECEIVED BY TAX COLLECTOR S75.00 07/21/2016 CIiECK21-16-098721 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license. perms, 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.miamidddg,gov 0.kfs!:1_6V9f JEFF ATWATER CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 3/22/2017 PERSON: SANCHEZ FEIN: 650050046 BUSINESS NAME AND ADDRESS: MATSA CONSTRUCTION COMPANY, INC. 14167 SW 143 CT M IAM I FL 33186 SCOPE OF BUSINESS OR TRADE: Licensed General Contractor EXPIRATION DATE: 3/22/2019 MATEO IMPORTANT: 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 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 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 'ACQ. RDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/21/2017 PRODUCER A&D ALL -LINES INS ASSOC INC 5600 SW 135 Ave Ste 106 Miami, FL 33183 (305) 463-6781 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. INSURERSAFFORDING COVERAGE NAIC# INSURED MATSA CONSTRUCTION CO . , INC. 14167 S.W. 143 COURT, MIAMI , FL 33186 CIO 5-525-1975 INSURER A WESTERN WORLD INS CO INSURER @ INSURERC: INSURER D: INSURER E THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NOTWITHSTANDING MAY BE ISSUED OR OF SUCH IKifK LTR quart. NERD TYPF(1F INRIIRANCF POLICY NUMBER POLICY EFFECTIVE rIATF(MM/L][1/YYl POLICY EXPIRATION ❑ATF(MM/lfNYI LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL UABIUTY NPP8320769 02/18/17 02/18/18 EACH OCCURRENCE $ 1.000.000 PREMISES Eaooccutiencel $ 100 .000 CLAIMS MADE fl OCCUR MED EXP (Any one person) $ 5.000 PERSONAL & ADV INJURY $ 1.000.000 _ GENERAL AGGREGATE $ 2,000.000 $ 2.000.000 _ GEN'LAGGREGATEUMITAPPUESPER: PRODUCTS - COMP/OP AGG DPOLICY n PIF , LOC AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS COMBINED SINGLE UMIT (Ea accident) $ BODILY INJURY (Per person) $ _ BODILY INJURY (Peraccident)$ PROPERTY DAMAGE (Peraccident) $ GARAGE UABIUTY ANYAUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTOONLY: AGG $ EXCESS/UMBRELLALIABIUTY EACH OCCURRENCE $ DIOCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERSCOMPENSATIONAND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Ifyyeeas,,desalbeunder SPF"JAI PROVISIONS below TH- ITARYIWITSI IGFR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY UMIT $ OTHER • DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAL PROVISIONS GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 FAX: 305-245-6341 1 ACORD 25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DATE THEREOF, THE ISSUING INSURER WILL ENS NOTICE TO THE CERTIFICATE HOLDER NAMED T IMPOSE NO OBLIGATION OR UAB REPRESENTATIVES. AUTHORIZED REPRESENTATIVE BE CANCELLED BEFOR THE EXPIRATION DAYS WRITTEN ETODOSOSHALL ER, ITS AGENTS OR ©AC 1 CORPORATION 1988 MATSA® CONSTRUCTION CO., INC GENERAL CONTRACTOR CGC 032784 To: Miami Shores Village Building Department 10050 N.E. 2nd Avenue Miami Shores, FL 33138 I , Mateo Sanchez as qualifier of Matsa Construction Company, Inc authorize Saul Gavidia to be the only person working on the project located at 690 N.E. 93 ST, Miami Shores FL 33138. IN WITNESS WHEREOF, I have set my hand and seal unto this instrument this day of 20 % 7 . COMPANY: Matsa Construction Company Inc. BY: TITLE: President STATE OF , COUNTY OF The foregoing instrument was acknowledged before me this day of , 20f % by Sac)/ 60.4. ,"/S/ of a Corporation, on behalf of the Corporation. He/She is personally known to me or who has produced , as identification and did take an oath. My Commission Expires Notary Public Serial Number, IF any Print 14167 SW 143 COURT, MIAMI, FLORIDA 33186 PHONE: 305 235 5390 FAX: 305 235 5391 CELL; 305 5251975 EMAIL: mateo@matsaco.com www.matsaconstruction.com Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this —2 1 day of By /`(/'r P 12, / who is personally known to me or has produced ,20>7. as ide „UN L1[ •-,1,n,,� �y � SAY 1 rr Notary PrbOe . sate al Fledda b Coarairs1Oa a FF 246484 ` My Convn. Exal as Jan 20, 2019 rig„ eagdmincomiscramirgyw«.