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WS-18-2053�, gxoees °�i Fa am�� yoo � F�OR'l�A Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit No. wS-8-18-2053 Permit Type: WindowsiShufters Pen Ol ork Classification: Window/Door Replacem Permit Status: APPROVED Issue Data: 8/16/2018 1 Expiration: 02/12/2019 Project Address Parcel Number Applicant 289 NE 104 Street 1121360130610 Miami Shores, FL 33138- Block: Lot: GOODNIGHT MIAMI LLC Owner Information Address Phone Cell ROC ACQUISITIONS LLC 289 NE 104 Street MIAMI SHORES FL 33138- 289 NE 104 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone UBALDO BLANCO (305)219-5717 (305)885-8083 ie of Work: WINDOW & DOOR of Openings: 25 iitional Info: OPENING MODIF & IMPACT INSTALLATION ssification: Residential canning: 6 Fees Due Amount CCF $0.00 DBPR Fee $0.00 DCA Fee $0.00 Education Surcharge $0.00 Notary Fee $5.00 Permit Fee $350.00 Scanning Fee $0.00 Technology Fee $0.00 Total: $355.00 Valuation: $ 14,800.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # WS-8-18-68404 08/01/2018 Check #: 1199 $ 50.00 $ 305.00 08/16/2018 Check #: 1203 $ 305.00 $ 0.00 Available Inspections: Inspection Type: Window Door Attachment Final 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 is accurate and that all work will be done in compliance with all applicable laws regulating constructio a g. Futhermore, I authorize the above -named contractor to do the work stated. Q ' August 16, 2018 Owner / Applicant / Contractor / Agent Building Department Copy 6, 2018 1 BUILDING PERMIT APPLICATION Miami Shores Village Building Department JAU012018 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY Tel: (305) 795-2204 Fax: (305) 756-8972 �� INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 Master Permit No. W� 100 —2DS3 Sub Permit No F-IBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION [—]SHOP CONTRACTOR DRAWINGS JOB ADDRESS: `i v� - - J Folio/Parcel#: Occupancy Type: Load OWNER: Name ( ee Simple Titleholder): Address: ('4 iC City: Tenant/Lessee Name: Email: Is the Building Historically Designated: Yes NO Construction Type: Flood Zone: BFE: FFE: Phone#: State: CONTRACTOR: Company Name: ` "q Rc4wcz) (:�t a Phor Address: c�lXJi`i � ceE� r- City: State: FL e#: Qualifier Name: M ' 7 Phone#: State Certification or Re istration #: CC-rC I Z Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: Address: p City: Stat Value of Work for this Permit: $ U tDSquare/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Description of Work: Nmm Doo +-0 %t is S l p: Zip: ❑ Demolition Specify color of color thru tile: Submittal Fee $ SO f ct-4 I Permit Fee $ 96 (T 00 CCF $ CO/CC $• Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ ��5' 00 (Revised02/24/2014) f , 1,—, 1 1?4"1 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 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 OWNER or AGENT Signature C Lop ' VK ays CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrum nt was acknowledged before me this 6 t day of U S: r 20 119 by daof 0 5�-- 20 r S by '�Te1GiP l '�P who is known to l`1CJ�l� �aYl V . who is personally known to me or who has produced �� a me or who has produced r;\Ay j MAST as identification and who did take an oath. NOTARY PUBLIC: identificatidn and who NOTARY PUBLIC: Sign: r Sign: Print: WPrint: Seal: Notary PubliCState ofFlorida Seal: Sindia Alvarez tea` My Commission FF 156750 ortid� Expires09/03/2018 APPROVED BY Plans Examiner Structural Review oath. MY COMMISSION # FF 214031 EXPIRES: March 25, 2019 *********** Zoning Clerk (Revised02/24/2014) Notice to Owner — Workers' Corn Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 nsation 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this b J day of AUc.,v!::-, ,201(: o. f By :aT'i-ACM. - �A l 1� who is personally known tome or has produced L- —t> V—' l L--C-4Z� r, S:�as identification. Notary: SEAL: Jo r Notary Public State of Florida r, Sindia Alvarez { AAW s Aa,, rn Missinn FF 156750 11. Expires 09103/2018 AAJIJIA A PlA A. Jk A STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION i ONSTRU TION INDUSTRY LICC€NSING 8040D 2601 BLAlk'STONF ROAD TALLAHASSFF Fl. 0`2399=0785 i850l4A i L, ;Isratulzitiens! With this license you becofine o(e of the nearly one trillion Floridians 11wsod by the `)epartmclit of Business an,d Profesylonal kegulatlon: Our and buslnedses range from ari_hitet, to �� ht brokers, from boxers to barbepue resta grants, grid they keep Florida's ecomorny Wong— f cW cl,,y we work to improve the way we do business in order to s€rve you better: For information about eur. ta1ea5t lob onto www,myfloridallcense,com, There you can find more Information about OUr diVi>iens 'Im! the regulations that impact you, subscribe to department newsletters and learn more about the iJcsFiartriir sit 5 initlatives: Our riiist;iorl at the Department is; License Efficiently, Regulate Fairly, We constantly Strive to serve YOU Lettc: Aso that you can serve your CLIStorners. Think you for doing blisineSs in Florida, and congratulations oil Vour t evv lic��rise! :? STA`Tt•:®F FL0i bXrDkPARTNI"-N r d u0 -18USNE E$S N0F A0 PP--SS10N. I, REr,QJAGf N€RAL CONTRACTOR L,MALDO DLANd.. ti � INS `' •.. s t 1 , y CL AM 7 LICENSECIUNDER CbA0TEt2 , 1lik1�A tiTA1217E_ LXPIAMIQN DATEt`l�l UST M;,, 2020` ACOPQ. CERTIFICATE OF LIABILITY_INSURANCE °08/01/2018 PRODUCER 305-227-0082 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CAROLINA INSURANCE CONSULTANTS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SUITE 116 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 8250 W FLAGLER STREET MIAMI, FL 33144 INSURED UBALDO BLANCO GC, INC 437 GOLDEN ISLES DR # 8F HALLANDALE BEACH, FL 33009 L:V V LKAULb INSURERS AFFORDING COVERAGE INSURER A: WESTERN WORLD INSURANCE COMPANY INSURER B: INSURER C: INSURER D: INSURER E: 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 '1-0 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMEYS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE F_x_l OCCUR NPP8508583 03/10/2018 03/10/2019 EACH OCCURRENCE S 1,000,000 _ FIRE DAMAGE (Any one fire) $ 100,000 MEO EXP (Any one person) S 5,000 PERSONAL A ADV INJURY .__...__ ... ....- - $ 1 000 000 $ 2,000,000 GENERALAGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT . (Ea accident) $ ALL OWNED AUTOS SCHEOULEDAUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ _ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S S AUTO ONLY: AGG EXCESS LIABILITY OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE S $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND - EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT b E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATION SILOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS GENERAL CONTRACTOR LICENSE # CGC047289 CRRTIGICATc unt nco ---�----. _---' _ _ -- -._ %lAIVLCLLA I IVIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN MIAMI SHORES VILLAGE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 10050 NE 2ND AVE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSUR ITS AGENTS OR MIAMI SHORES, FL 33138 REPRESENTATIVES. FAX: 305-756-8972 AUTHORIZED REPRESENTATIVE ACORD 25-S (7/97) O RPORATION 1988 V V • a �W wig JIMMY PATRONIS CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERSCOMPENSATION * * CERTii SCATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENS aTiON L:,�d' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 9/11/2018 PERSON: UBALDO, BLANCO FEIN: _ 651096775 BUSINESS NAME AND ADDRESS: UBALDO BLANCO G C INC 437 GOLDEN ISLES DR #8F HALLANDALE, FL 33009 SCOPE OF BUSINESS OR TRADE: Licensed General Contractor Licensed Roofing Contractor EXPIRATION DATE: 9/10/2020 EMAIL: CF3612@GMAIL.COM 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