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PW-18-2162Location Address Permit NO.: PW-8-18-2162 Permit IVR Number: 631550 DMiami Shores Village r -� ,. L Permit Type: Public Works 10050 NE 2 Ave Miami Shores FL 33138 work Classification: Public Works 305-795-2204 Permit Status: Applied Issue Date-10/03/2018 Expiration: 03/18/2019 Parcel Number Project 123 NW 109 ST, Miami Shores, FL 33168-4316 1121360030220 <NONE> Contacts MARIE BOBO Owner MARIE BOBO Applicant 123 NE 109 ST, MIAMI SHORES, FL 33138 123 NE 109 ST, MIAMI SHORES, FL 33138 ACA CONSTRUCTION INC Contractor ANDRES LEMUS 10725 SW 55 TER, MIAMI, FL 33165 Business: 3057888914 Description: BRICK REPLACEMENT ON SWALE AREA Valuation: $ 11,000.00 f�5-162-4949 Inspection Requests: Total Scl Feet: 1,700.00 Fees Amount Education Surcharge $0.20 Permit Fee $100.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $104.00 Building Department Copy Payments Amt Paid Total Fees $104.00 Credit Card $104.00 Amount Due: $0.00 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. OWNER FIDAVIT: erti that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regal# nstruct�ion z i uthermore, I authorize the above named contractor to do the work stated. / Applicant / Contractor / Agent Date 09, 2018 Page 2 of 4 1+ Miami Shores Village ` Public Works Department (305)795-2210 Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL PUBLIC WORKS PERMIT APPLICATION Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property Permit#: uS(G 236 Name of Applicant (if utility see below): �//G� I'R�q/s Owner off the following described property: Legal Description: Lot Block Subdivision Folio #; — bix o C`D Address: f�fet %0 9 �a _ f, 1000yw" �r/i�. ��.�/�F UTILITY NAME: Qualifier/Authorized Agent: Address: City: Telephone: State Certification or Registration #: CONTRACTOR NAME: Email: State: ZIP: Certificate of Competency # Qualifier/Authorized Agent: Address: _f_ A, — City: State: ZIP: Telephone:00.f-Email: Gyorn State Certification or Registration # C'�r�/�///� Certificate of Competency #: l' Type of Work: Zr Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation ❑ Landscape ❑ Antenna ❑ Other: DESIGNER: Architect/Engineer: Address: City: State: Telephone: __ Email: Registration #: ZIP: Value of Work for this Permit: $ Square/Lineal Footage of Work: 17dO *****Fees***** Permit Fee $ 100.00 Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ Bond $ (if required) Total Fee Now Due e Bonding Company's Name (if applicable): Bonding Company's Address: City: State: ZIP: Application is -hereby made to obtain a public works permit to do the work in the right of way and installatiogs 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, regulation construction in this jurisdiction. I understand that separate permits must be secured for APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with applicable laws regulating construction and specifically construction in the right-of-way. "WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value exceeding $2,500, 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 the 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 public works permit is issued. In the absence of such posted notice, the inspection will not be approved an¢,�inspection will f q charged. Signature J� ✓�" rlA."I,� 4�� Applicant or Authorized Agent The forego' g instrument was acknowledged before me this day of 20 by !" ..�-C �`��or*-_ a-Z3-a I who is personally known to me or who has produced UGE0.15t-, as identification. NOTARY PUBLIC: Sign: i_% SEAL: r0 P. Notary Public State of Florida Sindia Alvarez oa MY Commission FF 156750 APPROVED BY: Signature mpanyf Utility ent The foregoing instent was ackn wledged before me this day of 20� by e A.who is pe me or who has produced as identification. NOT P I . ;• G��' HENRY ALBERTO JR U '_�•� Notary Public - State of Florida Sign: Commission GG 182842 oa Fv; Y Expires Feb 5, 2022 Bonded through National Notary Assn. ********************* Public Works Director, or Designee 2017-04-15 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fn,.• iinAl 79a 007') CFN 21 ISR0495689 OR BY. 311rI1 Ps 4844 t11"30 RECORDED US 15f2ii18 12:21:1-6 HARVEY RUVIHr CLERK OF COURT MIAMI-DARE COUNTYr FLORIDA IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above -mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said items within public right of way including restoration of street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from' any and all liability, which may rise by virtue of permitting the installation of these items within the public right of way. 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village (or his fully authorized representative). �� ` SATE OF FLORI E1NTY OF DADE a. cue. Signature �� in an+e g r a . Owner or Agent HAWY R! IN, C4%k of C ris State of Florida County of Miami Dade JESSIE MERRITTi#310229 The foregoing instrument was acknowledged before me this 3Q) day of �U� , 20 ( emu°, by who is personally known to me or who has produced as identification. NOTAR UBLIC: Sign: , Print: �( SEAL: oot PY,, Notary Public State of Florid@ ? z•india Alvw'07 `. commission PF 1547>U �...,.o�' Exoires06/831i01p '�; ii1 r A Airport Brick ACA Contractor 4385 N W 7 Street Miami, FL 33122 305-871-6050 305-796-4545 BILL TO: MARIE BOBO 123 NW 109 Street Miami Shores, FL 33168 COMMENTS OR SPECIAL INSTRUCTIONS: Quantity DESCRIPTION Complete driveway with concrete 4x8 pavers from Gem Pavers, color to be determined by customer. Job consists of: 1 excavation and preparation of existing driveway, compacted lime rock with compact screening sand. Installation of all pavers, cement borders, all deliveries and total cleanup of project. THANK YOU. Date: August 20, 2018 Invoice: 20021 Rate TOTAL $11,000.00 SUBTOTAL $11,000.00 SALES TAX 7.00% TOTAL DUE $11,000.00 RICK SCOTT, GOVERNOR L� KEN LAWSON, SECRETARY STATE OF FLORIDA ' DEPARTMENT OF BUSINESS:AND PROFESSIONAL REGULATION CONSTRUCTION- INDUSTRY LICENSING BOARD CGC1511172 The GENERAL CONTRACTOR Named below IS CERTIFIED - Under the provisions of Chapter 489 FS. Expiration date: AUG'31, 2018 LEMUS, ANDRES` . r ACA-CONSTRUCTION 10725 SW 55-TER MIAMI ISSUED: 07n4/2016 DISPLAY AS REQUIRED BY LAW Local Business Tax Receipt Miami —Dade County, State of Florida THIS IS NOT BILL —DO NOT PAY 5811083 BUSINESS NAME/LOCATION ACA CONSTRUCTION INC 10725 SW 55 TERR MIAMI, FL 33165 ■ SEQ # L1607240002050 RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2018 �- 6059026 Must be displayed at place of business Pursuant to County Code Chapter SA — Art 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEMEQ ACA CONSTRUCTION INC 196 GENERAL BUILDING BY TAX CauEOTOR _ CONTRACTOR 75.00 0=7=7 Worker(s) 1 CGCISII172 CREDITCARD-17-054336 Tbb I scei Bmbass%x Haosipt oey firms pgatsrdof tiro Lacer B TazT6a Receipt is nag ticeem permit oracarlillcaCwnofthalmidefsquallfiaadombtodoImimms.Holdwmtntcomptywdha 19mgameatal on ongorarnmentel regobtmy taws and regniremeefswbieh applytotbebsineas. The HEIZIFrN0.o4Avemotbedisplayeianall coatmer I Vehicles— Miami-Daiecode Secrla-m ® )X For mars informadon. visitwMunlowdedlegildwawleft AC RD CERTIFICATE OF LIABILITY INSURANCE DATEINl=D)YYYY) 08/0612018 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 poficy(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 endorseme s . PRODUCER DELTA INSURANCE UNDERWRITERS, INC. 777 N.W. 72nd AVENUE, SUITE 3133 MIAMI, FLORIDA 33126 CONTACT LUIS DE LA LLERA NAME: A)CNo EI<t : 305 269 1107 . 305 269-1108 t-tw �: DELTAINSUND@AOL.COM ADDRINSURERS) AFFORDING COVERAGE NAIL tt INSURER A. ARCH SPECIALTY INSURANCE COMPANY 21199 INSURED ACA CONSTRUCTION, INC. dba ACA PLUMBING 10725 SW 55 TERRACEINSURER MIAMI, FLORIDA 33165 ��� B: INSURER C: D. INSURER E INSURER F: CuviEk; Eto CFRTIFIrATF NI IMRCR• ocana,r�u v.mer,n_ 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 OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. im TYPEOFINSURANCE INSR WVD POLICY NUMBER MWW MMfD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0007 COMMERCIAL GENERAL LIABILITY CLAIMS-m-DE © OCCUR ENTE PREMISES occurrence) $ 100,000. MED D (P (Ary one person) $ 10,000. PERSONA 1,000,000.8 A 0/05/2019 GENERALAGGREGATE S 2.000,000. GENLAGGREGATE LIMIT APPLIES PER:. POLICY ECT LOC PRODUCTS -COMP/OPAGG S 1,000,000. Deductible per Claimant s 2,500. AUTOMOBILE LIABILITY COMBINED SINGLE (Ea accident) S A WN ALLL OWNED SCHEDULED AUTOS AUTOS HIREDAUT`OS NON -OWNED AUTOS BODILY INJURY (Per person) S BODILY INJURY (Per acciderd) S PROPERTY DAMAGE (Peraccident) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE S 1— DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS' LIA SIry Y / N TORY UM TS R ANY PROPRIETOR/PARTNER/EXECUTNE .[—] OFFICER/MEMBER EXCLUDED? NIA _ E-.. EACH ACCIDENT S F-LDISEASE -EA EMPLOYEE S (Mandatory in NH) If yes, describe under EL DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule. N more space is required) GENERAL CONTRACTOR LICENSE NUMBER: CGC1511172. PLUMBING CONTRACTOR LICENCE NUMBER: CFC1427635. ROOFING CONTRACTOR LICENSE NUMBER: CCC1328217. MIAMI SHORES VILLAGE / BUILDING DEP T. 10050 NE 2nd AVENUE MIAMI SHORES. FL 33138 PH 305 795 2204 FAX 305 7568972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORMED REPRESENTATIVE LUIS DE LA LLERA B 1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD JIMMY PATRONIS CHIEF FINANICAL OFFICER .y •AWE WE 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: 621nm PERSON: ANDRES LEMUS FEIN: 204524410 BUSINESS NAME AND ADDRESS: EXPIRATION DATE: 6/202020 EMAIL: ANDRES.LEMUS@YMAILCOM ACA CONSTRUCTION INC ACA CONSTRUCTION INC DBA ACA PLUMBING 10725 SW 55 TER ,MIAMI, FL 33165 SCOPE OF BUSINESS OR TRADE: Lt-sod 0—rsl Contractor I.imrwd Roorag Contacllor IMPORTANT: Purouart to Chapter 440.05(14), F.S., an of5oer of a corporation who eke hs ser~on may not recover bene% or apmpens tinder this dtapter. Pursuant to Ch Ption from this d1apter by filing a certificate of election under only vvitirn the scope d the business Or asdo rued on the native of election to be 440.1kS(12). F.S.. Certificates of election be exempt.. apply exempt and motes of election to be exempt shah be RM91nt to Chalft 440.05(13), F.S.. Notices of election to be person named on the notice Or oortifi� no longer meets to n ff °t any torte after the filing of the notice or the issuance of Lhe certificate. the cert.'icata at sty time for Burs of tho regtireme is of this section for ism of a txrtifiW& The department shall revoke a person named an the certificate b meet the requirements of this section. DFS-F2-OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Scanned with CamScanner TV\,) 1 �5 - 2162--1 `D� 1`3 - 23\D ACA Construction Company Date: State of: County of: �a /1� Before me, this day personally, ClC.1 �ry�j who being dully sworn deposes and says: That he or she will be the only person working on this project located at: 123 NW 109 Street /� Miami Shores, FL 33168 Contractor signature Sworn to (or affirme ) and subscribed before me this day of A Yv )— 20 % 2S by Personally know v Or Produced Type of Print, Type or Stamp Name of Notary A. Gkm `= ComJose mission t FF990930 Expires: Sept. 3, 2020 Bonded thru Aaron 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 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. A _ Signature",. State of Fli County of Miami -Dade The foregoing was acknowledge before me this k 9- day of AQ GU S-7 , 20 I u . By MACE &9T 1 -. t�C�Z3c� who is personally known to me or has produced ��Z -tom 1-� l.LS hJsL-as identification. Notary: SEAL: }v*�: `;r��,�ti'�+'kiSfif,fit►" f� o1P�� Notary Public State of Florida r} ^. Sindia Alvarez Expires 09/03/2018 J4 i RG RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY UP Wa� STATE OF FLORIDA ; DEPARTMENT OF BUSINESS,,A -PROFESSIONAL REGULATION CONSTRUCTI 1 ISIOU V-211 NSING BOARD THE GENERAL CQ ei&OWHEREFAMUNDER THE PROVISlI5 0►FHAITlrR¢489 FLORISTATUTES it �' •yrrtr ACA cDRkt GMST CTION, - -� '140 5R+ _ Lt NSE°NUIWI��'t°-�'S1,1�7'2 EXPIRATONy©T A11Gt _ 31, 2020 Always verify licenses online at MyFloridaUcense.com S Do not alter this document in any form. f o This is your license. It is unlawful for anyone other than the licensee to use this document. 4 's