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RC-19-169961IM119 <39 a Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address i U . Issue Date:10/02/2019 Parcel Number 128 NE 99TH ST, Miami Shores, FL 33138 1132060132270 Contacts Permit O.: RC-07-19-1699 Permit Type: Building (Residential) Work Classification: Alteration Permit Staters: Approved Expiration: 01/20/2020 JUAN CARLOS ACOSTA Owner 128 NE 99 ST, MIAMI SHORES, FL 33138 WILLIAM SEAY INC Contractor WILLIAM SEAY 2020 TAYLOR ST 2-C, HOLLYWOOD, FL 33020 Business: 9549230999 Mobile: 9543948895 Description: NEW CONCRETE STEPS AND LANDINGS Valuation: $ 13,100.00 Inspection Requests: 305-A2400 Total Sq Feet: 750.00 Fees Amount 50% Renewal Fee $100.00 Application Fee - Other $50.00 Total: $150.00 Payments Date Paid Amt Paid Total Fees $150.00 Credit Card 07/24/2019 $50.00 Check # 1199 10/02/2019 $100.00 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 for . information is accurate and that all work will be done in compliance with all applicable laws regula ' constr t*WandM-rTtrtg—. uthe :I 1uthorize the above named contractor to do the work stated. L utho ' ed Sign e: Owner / Applicant / Contractor / Agent Date October 02, 2019 Page 2 of 2 Miami Shores Village Building Department artment 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 JUL- 2 4 zoos Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 �. FBC 20��1-1 BUILDING Master Permit No. f C— PERMIT APPLICATION Sub Permit No. 9BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: tlg ME 55 -Str-eft' City: Miami Shores County: Miami Dade Zip: 331,319 Folio/Parcel#: 111=4O 13 2-17O Is the Building Historically Designated: Yes NO Occupancy Type: & fAMLoad: Construction Type: GbS Flood Zone: BFE: FFE: OWNER: Name ((Fee Simples Titleholder): Address: 12.g /�l p 1'1 * S+f Phone#: 796-326— 83+2_ City: State: Pt— Zip: 3-313 0 Tenant/Lessee Name: Email CONTRACTOR: Company Name: hone#: Phone#: q 5+—g23—ojj9 Address: 7.020 ThVIOE J I I'Q, ,� 2— MCity: /WDA State: FL Zip: 3.302.0 Qualifier Name: JAZIWIAM Se�1Y Phone#: q'%-3ff'! ggJ�' State Certification or Registration #: DESIGNER: Architect/Engineer: Certificate of Competency #: hone#: Address: City: State: Zip: Value of Work for this Permit: $ 1 3/ 100 . 00 Square/Linear Footage of Work: _ , T e of Work: X Addition lde yp ❑ Alteration ❑New ❑Repair/Replace Demolition Description of Work: Specify color of color thru tile: Submittal Fee $.5c) Permit Fee $ 1 Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary $ Double Fee $ Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ ( 00 ` Bonding Company's Name (if applicable) Bonding Company's Address City I--- 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 w construction in this jurisdiction. I understand that a separate FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC.. ork will be performed to meet the standards of all laws regulating permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, 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. ® �f Signat OWNER or AGENT The foregoing instrument was acknowledged before me this day of 20 by -51A,vc,4 s _ L1 who is personally known to me or Who has produced as identification and who did take an oath.- 'ARY PUBLIC: t0.YP(.�C' JOSEPH FILS DQLGER �o d� MY COfv1MISSION t# GG064164 EXPIRES March 26, 2021 l.n C ; /� ... .0 Signature mL�� 22.0� CONTRACTOR The foregoing instrument was acknowledged before me this ('g day of f 20 K,9� by Sc&r4 who is personally known to me or o a roduez - � e �--a- as identification and who did take an oath. {{Y. NOTARY PUBLIC: JCSIIEPH FII_j�DA .OER :�"' `°iF;-: MY COMMISSION # GG064164 EXPIRES March 26 202 P r i 4 Seal: Seal: 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 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. Sign ure: Owner State of Florida County of Miami -Dade G� The foregoing was acknowledge before me this / % day of l 20 By / ®-S who is personally known to me or has uce as identification. :4: JOSEPH F, S C►AL€ ER Notary: MY COMMISSION # GG064164 ,Y SEAL: EXPIRES March 26 2021 2020 TAYLOR STREET, 2C HOLLYWOOD, FL 33020 954-923-0999 off. 954-923-3681fax Date, WI�LLiAM S+EAY, 1lNC. State of ...�.r County ..� STATE CERTIFIED GENERAL CONTRACTOR LICENSE No. CGCO09728 bilccccc@bellsouth.net Before me this day personally appeared W! I�lM..SP u who, duly sworn,. " deposes and says; �..r . That heor she will b the only person worktw.m, U re:MiALL 40t *od at: 12.$j& qgSf l S 33 -4 Contractor Signature Sworn to (ar affirmadi and sub ►ci nro is If day of 2o1z' by r,&I Personally know, 6R Produced Identification 1 .Type of tdetti#ification Produced or Stamp Name of Notary ,30uEPH FILE DALG R MY COMuss"ON # GG064164 EXPIRES March 26, 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 B. ✓ 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: W * 11 Se6Xj--NG BUSINESS ADDRESS: 2U2D _T 6r ar? �, 2.L CITY STATE FL ZIP 3.3020 BUSINESS PHONE: (q� ) Y23-tnqclq FAX NUMBER CELL PHONE ( )31+79815 QUALIFIER'S NAME: I SpATy QUALIFIER'S LIC NUMBER: CGL00�1-72 $ RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY Florida pk-� STATE OF FLORIDA DEPARTMENT OF BUSINE_S_S=AND. PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE GENERALCONTRACTOR HEREIN-1S'CERTIEIE.D UNDER THE PROVISION .,O'F'CHAPTER 489, FLORIDA STATUTES <; SEAY;. W1 LL- IAM. G~ WILLIAM`SEAY INC - - F 2020 TAYLOWST Ic HOLLYWOOD FL 33020 r► r LICENSE,.NU_: C MBERGC009728 EXPIRATONMATE'AUGUST 31, 2020 Always verify licenses online at MyFloridaLicense.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. BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2018 THROUGH SEPTEMBER 30, 2019 DBA: Business Name: WILLIAM SEAM INC Owner Name: WILLIAM G SEAY Business Location: 2020 TAYLOR ST 2C HOLLYWOOD Business Phone: 954-923-2142 Rooms Seats Employees 10 Number of Machines: Receipt#:GENERAL 30 CONTRACTOR (GENERAL Business Type:CONTR) Business Opened:09/16/2003 State/CountylCert/Reg:CGC O 0 9 7 2 8 Exemption Code: For Vending Business Only Machines Vendino Tvoe: Professionals Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 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 -regulatory in nature You must meet all County and/or Municipality plann:ng WHEN VALIDATED and zoning requirements This Business Tax Receipt must be transferred 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 it is in compliance with State or local laws and regulations Mailing Address: WILLIAM G SEAY 2020 :'AIL3R Si ,,,2C HOLLYWOOD, FL 33020 2018 - 2019 Receipt #lCP-17-00010977 Paid 07/11/2018 27.00 07/09/2018 Effective Date ACOI " CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YIYY) 6/18/2019 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(les) 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 BB Insurance Marketing Inc 10167 W Sunrise Blvd, 3rd Floor Plantation FL 33322 CONTACT NAME: Certificate Department PHONE FAX N Ext : 888 728-0817 ac No : 954-452-0450 DRESS: certificates bbimi.com AD INSURERS AFFORDING COVERAGE NAIC # INSURER A: West American Ins Co 44393 INSURED WILLSEA-01 William Seay, Inc. 2020 Taylor Street, #2C INSURER B INSURER C Hollywood FL 33020 INSURER D : INSURER E : INSURER F : !1n1/C0A/]Gc (RPRTIFIRATF KI"MRFR, 11 RAA7n7AA 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF I MM/DD/YYY POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR BLW54610628 10/18/2018 10/18/2019 I EACH OCCURRENCE $ 1,000,000 DAMAGE TORENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 X PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO 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 LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) ff yes, describe under DESCRIPTION OF OPERATIONS below N /A STERATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Remodeling Contractor located at 2020 Taylor Street, #2C, Hollywood, FL 33020. CFRTIFI(`ATF HOI DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village Building Department 10050 N.E. 2nd Avenue Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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: 4/11/2019 PERSON: WILLIAM SEAY FEIN: 611437992 BUSINESS NAME AND ADDRESS: WILLIAM SEAY, INC. 2020 TAYLOR STREET, 2C HOLLYWOOD. FL 33020 SCOPE OF BUSINESS OR TRADE: Licensed Genera! Contractor EXPIRATION DATE: 4/10/2021 EMAIL: BILCCCCC@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 "0 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 electron to be exempt shalt be sublect to revocation it. at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certd cate no longer meets the requirements of this Section far 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