DS-18-3048Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Permit No.: DS -10-1
M
Permit Type: Driveways/Sidewalks/Slabs
jl Work Classiffcatfon: Addition/Alteration
Permit Status: Approved
issue Date: 11/06/2018 1 Expiration: 04/01/2019
Location Address Parcel Number
670 NE 97TH ST, Miami Shores, FL 33138 1132060171630
Contacts
JOHN BARBICK Owner CHAMPION CONCRETE Contractor
670 97 ST, MIAMI SHORES, FL 331382471 JAIME BASILIO
Other: 3057546966 10280 NW 63 TER 105, DORAL, FL 33178
Business: 3052528055
Other: 7864024802
ns e
Description: DIAMOND BRITE POOL DECK PAVERS TO REPLACE Valuation: $ 8,400.00
Iction Requests:
305-X62-49DS18-332
Total Sq Feet: 900.00
Need to provide engineer certification for the pool and
ool a ui ment electrical groundingandbonclin .
Fees Amount
Application Fee - Other 50.00
CCF 5.40
Concrete/asphalt/pavers, slabs, dways, 75.00
swalks
DBPR Fee 2.00
DCA Fee 2.00
Education Surcharge 1.80
Planning and Zoning Review Fee 35.00
Scanning Fee 3.00
Technology Fee 3.13
Total: 177.33
Payments Date Paid Amt Paid
Total Fees 177.33
Check # 2997 11/06/2018 $177.33
Amount Due: 0.00
Building Department Copy
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 construction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Owner / Applicant / Contractor / Agent Date
November 06, 2018 Page 2 of 2
Miami Shores Village RECEIVED
Building Department O(:T 08 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 cvTel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 C
FBC 20 Iq
BUILDING Master Permit No. DS 1 _ 30145
PERMIT APPLICATION Sub Permit No.
BUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: C70 /115 ZZ : t
77
City: Miami Shores County: Miami Dade Zio:.73,jf
Folio/Parcel#: t'F 3 196 0%2- s.3 n Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): .)L Q=J A I,jr- 616, Phone#:
Address: (r, -71D NE (TJ sT
City: Ni ms State:
Tenant/Lessee Name:
Email
ne#:
3313 x'
CONTRACTOR: Company Name: L twifty (26`n --e Phone#: 'qq Z Ld:!
1 t_"N
F-1517, 11ll.(0MILIF AMMMI ria
City: V) Q
Qualifier Name
State Certification or Registration #:
Phone#:
Certificate of Competency #: &,!'S Wr,'
DESIGNER: Architect/Engineer: Phone#:
Address:'' City: State:_ Zip:
1ValueofWorkforthisPermit: $ is 00 Square/Linear Footage of Work: 41 (9 0
Type of Work: Addition Alteration New(
D
Repair/Replace Demolition
1DescriptionofWork: , O ' w VS A0 i
Specify color of.itbld thcdlile: f; n
Submittal Fee $' _
r
Permit Fee $.` .1 CCF
i;
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
I v
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 $250F, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be livered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencementmus a posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In th bsence f uch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
4Signature Signatu
OWNER or AGENT CONTRACTOR
The fo going instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
9 ` day of 0l+Db1P- (- 20 19 by V darty ofd ""(
Q (- 20 19 by
1 (%rq F -'W b VIS, who is personally known to mP, A • 15(i
cc .
who is personally known to
Rmeorwhohasproducedb(\iers SCO ( as
y
me or who has produced R. br4peS i --z cnl-'as
identification and who did take an oath. %%
Lel
GG%5e"n identification and who did take an oath.
N TARY PUBLIC: Oi ` / `'S Y6 NOTARY PUBLIC:
Sign:_
Print:Print:
Uk
Seal:
MARVAL WILLIAM8
Seal:
My MARVA M. VNLLUMS
EXPIRE
520 92 3 + W COMWSSKMV f FF 203592
q 90 dW m'T 'sA € EXPIRES: Febnaary 25. 2019
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
Revised02/24/2014)
JAMIE BASILIO CORP/ CHAMPION CONCRETE
Date: 1\ 1Ayc 1 I g o 19
State of: i Lori
County of Miami -)&4
Before me this day personally appeared \(A-Imlp- A.&S-
14
0
1 10 who, being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
S} - N
Contractor Signiture
Sworn to (or affirmed) and subscribed before me this Igo
day of I" orck 2019
By Uic A GSiI i 0
Personally know /
OR produced identification- dentification V
Type of identification Produced f)I ClQ,4'iS cQ
I V\'o n
1
CHAMPIONr'6y YANADYPRIEO
r •:
MY cOMMISSION # FF 214031CONCRETE
EXPIRES: March 25, 2019
H'.•
DF NRP•• Bonded Thru Notary Public Underwriters
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.
v
Signature:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this // day of il r
y OGi' 20
By who is personally known to me or has produced
as identification.
Notary:!-—
SEAL: —
MAGALY LLAPUR
EXPIRES: March 25, 2023
ACCORU CERTIFICATE OF LIABILITY INSURANCE DATE01/29/18
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 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
CONTACT
NAME: Lucia Estrella
PH
Et• (305)226-8727 aC No: (305)226-8767Accurate
aoDR1E S: accurate. certificates@gmaii.com8300WestFlaglerSuite114
INSURERS AFFORDING COVERAGE NAIC pMiami, FL 33144
INSURER A: Covington Specialty Insurance CompanyPhone (305) 226-8727 Fax (305) 226-8767
INSURED INSURER B: SUA
INSURER C: Jamie Basilio Corp dba Champion Concrete
INSURER D: 10280 NW 63 St Suite 105
INSURER E:
Doral, FL33178- (305) 252-8055
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.
ILTR TYPE OF INSURANCE INS SSR
POLICY NUMBER MM/DIDY POLICY EXP
LIMITS
A
GENERAL LIABILITY
a COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE d OCCUR VBA593994-00 01 /28/2018 01 /28!2019
EACH OCCURRENCE $ 1,000,000.00
DAMEAPREMISESS Ea occurrence
MAGE ( RENTED $
100,000.00
MED EXP (Any one person) $ 5,000.00
PERSONAL &ADV INJURY $ 1,000,000.00
GENERAL AGGREGATE $ 2,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER:
W POLICY PRO
LOC
PRODUCTS - COMP/OP AGG $ 2,000,000.00
AUTOMOBILE LIABILITY
ANY AUTO
F]
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
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 $
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTNE
OFFICER/MEMBER EXCLUDED?
Mandatory in NH) FE
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WC1278487
03/10/2017 03/10/2018
T STLIM T ORH
E.L. EACH ACCIDENT $ 100,000.00
E.L. DISEASE - EA EMPLOYE $ 100,000.00
E.L. DISEASE - POLICY LIMIT 1 $ 500,000.00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
License CC05BS00815
CERTIFICATE HOLDER CANCELLATION
Miami Shores Village
10050 NE 2nd Ave
Miami Shores, FL 33138
305-756-8972
ACORD 25 (2010/05) OF
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORIAANCEAVITH THE POLICY PROVISIONS.
Lucia
1988-2010 ACORD CORPORATION. All rights reserved.
ae ACORD name and logo are registered marks of ACORD
Miami s Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Date: 02-12-2018
Permit Number: 18-332
Rejection Comments:
1. Provide details and specifications for the required pool barrier.
2. Provide note to read. "must pass pool barrier inspection prior to adding water to the pool'
I Provide details and specifications for the pool bonding and grounding.
4. Provide details and specifications for the pool light.
Ismael Naranjo, BO
Building Director
Email: bo@msvfl.gov
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