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RC-14-1410l`+ Miami Shores Villages=`�' I� Building Department JUL 01 2014 ti g p 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 FBC 20 BUILDING Permit No. PERMIT APPLICATION Master Permit No..p C I" Permit Type: BUILDING ROOFING JOB ADDRESS: 2 S / /0 , E • I ©q ST City: Miami Shores County: Miami Dade Zip: �? i 13J8 Folio/Parcel#: Is the Building Historically Designated: Yes NO ✓ Flood Zone: OWNER: Name (Fee Simple Titleholder): l O Glk /1 fi -U-I S i �()rn L- -C Phone#: Address: g /li l: • O `I' S T- City: MA4A41 S1462ES State: L- Zip: Tenant/Lessee Name: Phone#: '7ZO 4 978 Email: CONTRACTOR: Company Name: c r"6d:A 6 G 0111-f I�.G((�l f (1 C O&Q Phone#: 91Y- Z 4% -LS 9 3 Address: _r 21 f .S Tt (W M (r- PC) #10 �O City: t A Al A 4 AG14 State: rz-- Zip: 3 -X49 9L Qualifier Name: M 10a 141A M S Phone#: ZY/ State Certification or Registration #//: C CT G / 5-1 94`7A- Certificate of Competency #: Contact Phone#: EAPq(� !4M 6 UET Email Address: q.AE (&6 UET-m00% CQrs7 DESIGNER: Architect/Engineer: Phone#: �3 Q Value of Work for this Permit: $ f' ftfl 0 V Square/Linear Footage of Work: Type of Work: DAddition DAlteration ❑New Gdirepair/Replace DDemolition Description of Work: iftiedw D lei fC^en Color thru tile: :�Permit Submittal Fee $ Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ S� kI Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 ection fee will be charged. � Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this day of�, 20) ; by ��' yf g who is personally known to me or who has produced 0-0 & OlZalL As identification and who did take an oath. NOTARY PUBLIC: Sign: My 0�1 • ion{lic State of Florida , Joanna M Feliciano My commission FF 082753 awr Expires 01 /1212018 APPROVED BY 0, -1A The foregoin instrument was acknowle ed before me this day of , 20 &by e✓h, who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: e—' `/ Arm eJ My Commission Expires: ��1►R,Y?GB�� Melanie James ;',;MISSION#EE144681 e4'EXP!RcS: NOV. *ak18 2015 �nun� Plans Examiner Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) JAN-27-2016 WED 11:13 AM CAROLINA INSURANCE FAX No. 305 227 6287 P-001 ,qCQ D,r CERTIFICATE OF LIABILITY INSURANCE avi7iio e PRODUCER 305-227-0082 CAROLINA INSURANCE CONSULTANTS 8250 W FLAGLER 57 #198 MIAMI, FL 33144 THIS CERTIFICATE 18 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. INSURERS AFFORDING COVERAGE INSURED UBALDO BLANCO GC, INC 437 GOLDEN ISLES DR # 8F HALLANDALE BEACH, FL 33009 INSURER A: INTERNATIONAL INSURANCE CO. OF HONNOVER SE INSURER B: INSURER C: INSURER D: INSURER E: vv. 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 13 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMIYS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. . LTR TYPE OF INSURANCE POLICYNUMBER POLICY EFFE I RATION LIMITS' . A GENERAL LABILITY X COMMERCIALOENERAL LIABILITY CLAIMS MADE MX OCCUR G06AO03067-02 03/1012015 03110/2016 EACH OOCURRENCE $ 1,000,000 FIRE DAMAGE (Any enb fire) $ 100,000 MEO EXP (Any are person) $ 5.000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; X POLICY PRO Loc PRODUCTS- COMPIOP AGG $ 2,000,000 !� AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS COMBINED SINGLE LIMIT (E■ ■cadenQ $ 130DILY INJURY (Per person) $ BODILY INJURY (Perioddent) , $ PROPERTY DAMAGE (Per acGAent) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - CA ACCIDENT S OTHER THAN EAACC AUTO ONLY: AGG $ $ EXCESS LIABILITY OCCUR CLAIMS MADE DEOUC7IBL$. RETENTION $ .. EACH OCCURRENCE S AOOREOATH $ $ >; � WORKERS COMPENSATION AND EMPLOYPRV LIABILITY .. STATU DTH- TORY LIMBS ER E.L. EACH ACCIDENT $ IS.L,OISEASE - EA EMPLOYE9 $ El, DISEASE - POLICY LIMIT $ 'OTHER DE$CRIFTIONOFOPERATIONSILOCATTONSIVEHICLESIEXCLUSIONSADoEb13YENDORSEMENTISPECIALPROVWION9' C00047289- LICENSED GENERAL CONTRACTOR X I ADDITIONAL INSUREb: INSURER LETTER: CITY OF MIAMI SHORES BUILDING & ZONING 1005D NE 2N11 AVE MIAMI SHORES, FL 33136 I , ACORD 26-S (7197) CANCELLATION .,., I ".: SHOULD ANY OP THE ABOVE DESCRIBED FOLICIS$ BB CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENO FAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDE9 NAM M TO THE LEFT, BUT FAILURE TO DO $0 $HALL IMPOSE NO 013MOAT10N OR LIMUTY OF ANY KIND UPON ^ INSURER, ITS AGENTS OR REPRESENTATNES.._- AUTHORIZED ROPARSENTATNE RD CORPORATION 1988 DI 04RA L ►J CONSTRUCTION CORP. RENSS0 LOPEAESSINA PRESIDENT I CIVIL ENGINEER 4 , � +1796-3557999 rensso@diobra.com L- -- I lift .ate VIS JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 9/12/2014 EXPIRATION DATE: 9/11/2016 PERSON: BLANCO UBALDO FEIN: 651096775 BUSINESS NAME AND ADDRESS: UBALDO BLANCO G C INC 437 GOLDEN ISLES DR. # 8 FiALLANDALE BEACH FL 33009 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL LICENSED ROOFING CONTRACTOR CONTRACTOR 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 ofthe 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 UBALDO BLANCO GENERAL CONTRACTOR INC. 437 Golden Isles Dr. Apt 8-F Hallandale, FL. 33009-7557 License No. CGC047289 May 1, 2014, 2014 To: Miami Shore village 10050 NE 2"" Avenue Miami Shores, FI 33138 To whom it May Concern This letter shall serve to substantiate that UBALDO BLANCO INC. IS THE ASSIGNED CONTRACTOR to performed all windows and Doors labor for the property located at 289 NE 104t" Street. Miami Shores, FI 33138: Any additional questions or concerns regarding this matter, please do not hesitate to contact me at (305) 888-9946. Respecfully, (j i" W Ubaldo Blanco. (Licensed General Contractor)