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RC-19-1214 (2)Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Bate: Location Address Parcel Number 9330 NE 12TH AVE, Miami Shores, FL 33138 1132050070160 Contacts Permit ► o.: RC-05-10-1214 Permit Type: Building (Residential) Work Classif tcation: Alteration Expiration: 12/11/2019 WEI CHEN Owner 9330 NE 12 AVE, MIAMI SHORES, FL 33138 ELITE AMERICAN INC Contractor CAROLINE SHEMTOV 9740 SEA TURTLE DR, PLANTATION, FL 33324 Business: 9548126907 Inspection Requests: Description: INTERIOR RENOVATION OF KITCHEN, DINING, Valuation: $ 20,000.00 305 *2-4949 ^^^ FOYER AND LIVING ROOM. Total Sq Feet: 380.00 mj Fees Amount Application Fee - Other $200.00 CCF $12.00 Certificte of Completion for Single Fam $50.00 and Duplex Change of Contractor $110.00 DBPR Fee $9.00 DCA Fee $6.00 Education Surcharge $4.00 Permit Fee $400.00 Scanning Fee $30.00 Technology Fee $15.00 Total $836.00 Payments Date Paid Amt Paid Total Fees $836.00 Cash 08/12/2019 $110.00 Credit Card 05/28/2019 $200.00 Credit Card 06/14/2019 $526.00 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, 1 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 co ion and zoning. Futhermore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date August 12, 2019 Page 2 of 2 Miami Shores Village RECEIVED BUILDING PERMIT APPLICATION Building Department A G 07 20i9 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: INSPECTION LINE PHONE NUMBER: (305) 762-4949 Y� FBC 201_ Master Permit NO.RC -I;-m 1114 Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS 1� CHANGE OF ❑ CANCELLATION ❑ SHOP (� A' I f_ CONTRACTOR DRAWINGS JOB ADDRESS: 153 D NE 12 % ttyM 4& City: MiamiShoresCounty: Miami Dade Zip: VJ�70 Folio/ParcelM I In9 7 0 I bl U 0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): VVyl l/1( I eh Phone#: city: 11 111A1111. V r l Tenant/LessseeNaame: Email: \46eI 12 0� 1. State: . Zip: 3 31s b Phone#Aus. 4-7 • w gv U -;k -`-�4 `-�Lu6� - �/o� z CONTRACTOR: Company Name: p r% Phone#: zv/_�l2—h 90 Address: / 711d ��ey la,— e City: plel i1-&C / d / �^ State:. L` Zip: l� Qualifier Name: � r& �l 2f =j.� �/C 7 Phone#: _9Sy_J1P1z4 W % State Certification or Registration #: 4r-6CZ_'20S7 ( Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Ad City: State: Zip: Value of Work for this Permit: $COI Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ ,N,eew��/� ❑ Repair/Replace ❑ Demolition Description of Work: r`r�-�� 6 n02A U �^ Specify color of color thru the: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) 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 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. t—�fSignature Signature OWNER or AGENT The foregoing instrument was acknowledged before me this ZZ dial y, of v I/I N 20 ( c by C1Q /i�� InCL II , who is personally known to me or who has produced fL`>� C 50 p ey 1 tt8 60 as identification and who did take an oath. NOTARY PUBLIC: CONTRACTOR The foregoing instrument was acknowledged before me this Z U day/VL('�'yloff J� u ki 20 U-f by Nrol i :h,V , who is personally known to me or who has produced FLA-+!+ 43( ( 00 7ggtI D as identification and who did take an oath. NOTARY PUBLIC: Print: TI I I r ,a " �" - TOAKEEN PENA I Print: Seal: MY COMMISSION # GG054738 Seal: MY COMMISSION # GG054738 ?•o,�d?' EXPIRES December 13, 2020 EXPIRES December 13, 2020 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. % - d 5' / f " 12 ` Owner's Name (Fee Si Owner's Address: City: Job Address (Of where work is being done): 4-1,,� b City: Miami Shores Contractor's Corr Address:�Z City: "A Qualifier's Name: State: —Florida Zip Code: Name: IN\ 0S &C&truct" Phone #: .L r Architect/ Engineer of Record Name: Address: City: Describe Work - State: EL Zip Code: Lic. Number: State: Phone #: Zip Code: I I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. 1 hold the Building Official and the J�Iiami,,Shores harmless of all legal involvement. Signature &ZaY - L //� Signature Owner or Agent Contractor or Architect The foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me this zkday of , 1,�,�1 2017,by i9kjj&r this 1� day of �u�, 207by Co i I laWho is personally known to me or who has produced who is personally known to(m�e or who has produced urT flfri �� Y ii�l/�I J as indentification. NotaryIPublic: f /) Notary-,Bublit: A /] A Sign: V Sign:{ Seal: :+` CAYTEN CLARK Seal: �•5 MY COMMISSION # GG0e9356 EXPIRES February 03, 2021 1" CAYTEN CLARK "'- MY COMMISSION # GG069356 EXPIRES February 03, 2021 Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. / COPY OF QUALIFIER'S STATE LICENCES OB COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. �_ COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. .................. ........................................................................ BUSINESS NAME: I I Ameh(An 1 n C- BUSINESS ADDRESS: 11 ` ) \RQGI CITY Uh STATE_ ZIP33!i2� BUSINESS PHONE: 1 5+ ) 12- - MCI FAX NUMBER ( ) CELL PHONE ( ) QUALIFIER'S NAME: Oct[ DI in e 6C 1('fl IUV QUALIFIER'S LIC NUMBER: C GC I SID S1 I RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY b a dpr STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE GENERAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORID/ SHEMTOV, CAROM ELITE AMERICAN INC !If - WET E 9740 SEA TURTLE DR PLANTATION " FL 33324 ML STATUTES LICENSE NUMBER: CGC1510571 EXPIRATION DATE: AUGUST 31, 2020 Always verify licenses online at MyFloridaLice nse.com Do not alter this document in any form. This is your license. It is unlawful for anyone other than the licensee to use this document. BROW RD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, FL Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2018 THROUGH SEPTEMBER 30, 2019 DBA: Business Name: ELITE AMERICAN INC Receipt #:180-7GENERL7coNrRACTOR (GGl Business Type: CONTRACTOR) Owner Name: cARoc,>:Nc sHer�-lnv Business Location: 9740 SEA TURTLE DR Business Opened:09/06/2006 PLANTATION State/County/Cert/Reg:CGC 15I 0 5 71 Business Phone: 954-236-3530 Exemption Code: Rooms Boats Employees Machines 1 Professionals For vondtng ausln@96 Only Number of Machin STaxmount Transfer Fq�n. Vending Type: Penalty Prior Years27. 00 0 00 Collecllon Cost Total Paid 0.00 0.00 0.00 27'00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-reWHEN VALIDATED and zoning requirements. This Businin nature, You must ess Tax Receall ipt most be t ansfety rred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that t is in compliance with State or local laws and regulations. Mailing Address: CAROLINE SHEMTOV 9740 SEA TURTLE DR Receipt #OIA-17-00006890 PLANTATION, PL 3332.4 Paid 08/16/2018 27.00 R]C3P@If1PA ®t'1 !�0'111R1`b'V 9 ^el A r MI snonfr--,e% AC'OR" CERTIFICATE OF LIABILITY INSURANCE `.� DATE(MM/DDIYYYY) 07/23/2019 YHIS 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: Steve Greep PHONE (954) 561-9496 ac No): (954) 561-1350 Alexander, Greep, & Tate Insurance 2727 E Oakland Park Boulevard #200 E-MAIL h marsa aexander ree ADDRESS: G g p•Com INSURER(S) AFFORDING COVERAGE NAIL# Fort Lauderdale, FL 33306 INSURER A : Cypress Property and Casualty INSURED INSURER 8 INSURER C : Elite American Inc. INSURER D : 9740 Sea Turtle Dr. INSURER E : INSURER F : Plantation, FL 33324 954 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. NL�ITSRR TYPE OF INSURANCEMEMO POLICY NUMBER POLICY EFF MM/D POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FKil OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 A N N SGL00052050281 10/12/2018 10/12/2019 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 17 POLICY r PRO LOC $ AUTOMOBILE LIABILITY Ea BIKED SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per acddent $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA WC STATU- OTH- T Y TI ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) N yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT — $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) License #CGC 151-0571 CERTIFICATE HOLDER CANCFI I ATInN Miami Shores Village Building Department 10050 NE 2 Ave Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tI V 1VUB-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v. JIMMY PATRONIS 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: 8/19/2018 PERSON: CAROLINE SHEMTOV FEIN: 223860860 BUSINESS NAME AND ADDRESS: ELITE AMERICAN INC 9740 SEA TURTLE DR FORT LAUDERDALE, FL 33324 SCOPE OF BUSINESS OR TRADE: Licensed General Contractor EXPIRATION DATE: 8/18/2020 EMAIL: ELITEAMERICAN@YAHOO.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 Elite American, Inc. 9740 Sea Turtle Drive Plantation, FL 33324 P: 954-812-6907 July 22, 2019 State of 1;"lari ')Cl County of tl n 2l Before me this day personally appeared 6ii re, %ty L Wm;GV who, being duly sworn deposes and says: That he or she will be the only person working on the project located at: 1330 1,1E 12-th Avl✓. Mim 4'h9w Fi— 3313% Contractor Signature Sworn to (or affirmed) and subscribed before me this 22 day of 201 ' By�e +cN Personally know Or Produced Identification Type of Identification R- bL-4 , qq M - ( Q%.1q. �01 • l) A-�• I een n�t.A- p6il-11 Print, Type or Stamp Name of Notary AILEEN PENA n MY COMMISSION* GG054738 ',,� EXPIRES December 13, 2020 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: I _ 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 Y ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: I &—i , Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 2-3 day of .20( By who is personally wn to me or has produced i- DL C��A as identification. Notary: SEAL: MY COMMISSION 8 GG054738 EXPIRES December 13, 2020