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DS-09-22-2252 & PW-09-22-2253Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: DS-09-22-2252 Permit Type: Driveways/Walkways/Slabs Work Clossification: Addition/Alteration Permit Status: Approved Issue Date: 10/21/2022 1 Expiration:04/21/2023 Location Address Parcel Number 9225 NE 12TH AVE, Miami Shores, FL 33138 1132050270390 Contacts IVAN KASANZEW Owner GL PROJECTS Applicant 9225 NE 12 AVE, MIAMI SHORES, FL 33138 JONATAS DANTAS Mobile: 9547095712 coastpaverspermits@gmail.com GL PROJECTS LLC Contractor GIANCARLO PANTONE 727 SE 4 AVE, DEERFIELD BEACH, FL 33441 Business: 9544481837 coastpaverspermits@gmail.com Mobile: 9547095712 Description: BRICK PAVER DRIVEWAY INSTALLATION Valuation: $ 7,000.00 Inspection Requests: 305-762-4949 Total Sq Feet: 1,500.00 ....rr. .. .. __ Fees Amount Application Fee - Other $50.00 CCF $4.20 Concrete/asphalt/pavers, slabs, dways, $100.00 swalks DBPR Fee $2.25 DCA Fee $2.00 I!ducation Surcharge $2.10 Planning and Zoning Review Fee $70.00 Scanning Fee $12.00 Technology Fee $15.00 Total: $257.55 Payments Date Paid Amt Paid Total Fees $257.55 Credit Card 09/02/2022 $50.00 Credit Card 10/21/2022 $207.55 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 i s;gulating construction and zoning. Futhermore, I authorize the above kamed contractor to do the work stated. V, 5 -71 � 2L Authorized Signature: Owner / Applicant / Contract87 / Agent Date October 21, 2022 Page 2 of 2 NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. TAX FOLIO NO. I6- 3ZOS-0Z7 0 3 90 STATE OF FLORIDA. COUNTY OF MIAMI-DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided In this Notice of Commencement. 1. Legal description of property and 2. Description of Improvement: 3. Owner(s) name and address: Interest in property. Name and address of fee simple titleholder: 4. Contractor's name, address and phone,p 5. Surety: (Payment bond required by owner from contractor, if any) Name, address and phone number: Amount of bond $ R I anrlpr'e name and nrtrimasl- CFN 2i B22FtO624919 OR Bk 33327 P3 549 1 Pas EC:ORDED i8/08/2022 12-13:37 HARVEY RUVI'rir CLERK. OF COURT MIAMI-GAGE COUNTY, F_ORIDA Space above reserved for use of recording office 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes, Name, address and phone number: B. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Name, address and phone number: _ B. Expiration date of this Notice of Commencement: (the expiration date is 1 yew from the date of recording unless a diMaent date Is specified) WARNING TO OWNER: ANY PAYMENTS MADE BYTHE OWNER AFTER THE EXPIRATION OFTHE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BET -THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH$TAM 0NFERR *IC fJBB iBBkOMA IMME OR RECORDING YOUR NPOTIcf O COMMENCEMENT. I HEREBY CE T1FY that this i copy of the0-11 Signature(s) of O er(s or ne (s)' Au o cer/Director/PartneR��6fd i eon y of Prepared By Prepar D 20 Print Name L-t» ,t A_0 C �.S(+t�t` Print N�'Wt E S my)ha t and , I al. Title/Office Title/Of �Y m, A f Ci ounty ourts n STATE OF FLORIDA By D.C. couN COUNTY OF MIAMI-DADE �pp Z L The foregoing instrument was epkyowledged before me this _(_y1_ day o V L 2 By 61Ji Cu. Qj0dividually, or ❑ as- UJPersonally known, or for produced the following type of Identification: "` > J 0 N Signature of Notary Public: ;' I ,,:Notary Public -State of Florida Print Name: 0 (S ni,no•` May 30, 2025 VERIF1 ION PURSUANT TO SECTION 92.525, FLORIDA STATUTES Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in It are true, to the best of my knowledge and belief. Signature(s) of Owner(s) or Owner(s)'s Authorized Officer/Director/Partner/Manager who signed above: By By W-M-52 PAaE3 an2 Miami Shores Village ENTERED Building Department SEP02zozz 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY; Tel:(305)795-2204Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 BUILDING Master Permit No. bS•-Q1- 2-2-2252 PERMIT APPLICATION Sub Permit No. p%A/-09-27,22n ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: % Z Z J N F / Z AV City: Miami Shores County: Miami Dade Zip: 3J O!5 Folio/Parcel#: % _3 Z.o.,�- D z? - 03 q O Is the Building Historically Designated: Yes NO r/ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): L0V2its CJ 1� R-PANZ(-w Phone#: 16-3,SSII2(4 Address: g Z Z S AI 17 �-V (. City: m/ f qm ( i lwakS State: F—L Zip: -73 1 1?1 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Address: -IL-� S F- ri LL(. �I 6Lv IS EAud , FL, 33 9Sq-4kb-I63� Email: C� QS iPAV6 i n� �iTS(9� 6 AA, l,. C0?,1 Qualifier Name: G-IfWCt1ii�-L-& rpnrjTO017 Phone#: q -70ci S1IZ State Certification or Registration #: C @ G l L•G 3T1 Certificate of Competency #: NIA DESIGNER: Architect/Engineer: Address: City: State: Zip: Value of Work for this Permit: $ q00 0 Square/Linear Footage of Work: a✓S� Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 21 AJ Specify color orhfcolor thru tile: Submittal Fee $ S V , OD Permit Fee $ )00' W CCF $ "I • Zd CO/CC $ Scanning Fee $ 1 Z • 00 DCA Fee $ % ' 0C) DBPR $ 2 • Notary $ Technology Fee $ ) 5 Training/Education Fee $ ?� • 10 Double Fee $ Structural Reviews $ P&Z Review $ ZO' C'" Bond TOTAL FEE NOW DUE $ 2-0-7 - SS (Revised04/05/2022) 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 on 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 Signature '6014 OWJ or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this 79 / day ofrl gk—, 20 Z Z by ,I,aVb&U M1 (V4nf OJ/ , wh ' rsonally known o me or who has produced as identification and NOTARY PUBLIC: Print: Seal: NATAS GOMES DANTAS 11 Notary Public -State of Florida Commission # HH 109014 YIW Ry Commission Expires ,�pnna��� Aay 30, 2025 The foregoing instrument was acknowledged before me this O) day of f �\PM^L IM`n , 20 Z Z , by G IAocAQ,w NITONE- wh s personally known o me or who has produced as identification and who I NOTARY PUBLIC: Sign:_ Print: Seal: APPROVED BY M` J0) 1')i Z-7— Plans Examiner Commission it HH 109074 My Commission Expires Zoning Structural Review (Revised04/05/2022) Clerk 7/23122, 3:20 PM Property Search Application - Miami -Dade County Address Owner Name Folio SEARCH: 9225 ne 12 ave miami shores 33138 Suite Q Back to Search Results PROPERTY INFORMATION Folio: 11-3205-027-0390 Sub -Division: BAY LURE Property Address 9225 NE 12 AVE Owner IVAN KASANZEW LOURDES B KASANZEW Mailing Address 9225 NE 12 AVENUE MIAMI, FL 33138 PA Primary Zone 1100 SGL FAMILY - 2301-2500 SO Primary Land Use 0101 RESIDENTIAL -SINGLE FAMILY:1 UNIT Beds / Baths / Half 3/2/0 Floors 1 Living Units 1 https://w.miamidade.gov/Apps/PA/propertysearch/#/ 1/8 ENTERED c i) UU 2 22022 slr: 1___Y Miami Shores Village Building Department SURVEY AFFIDAVIT STATE OF (FLORIDA) COUNTY OF (DADE) 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 The undersigned Affiant, t"Z b tS {; RSA ? 6W does hereby attest that (Property owner) The attached survey, performed by S 1/AIR H J V IZV E �Wb 9 M/VAI& (Name of surveyor's company) For address: q ZZ s Nt 2 /Wt Performed on 0 1 ' 0 t _Z0fN(dale of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may ffec final in pections as applicable to this or other permits. Fu er, A nt ay e h naug . 1/ rLJ eQ -In Property Owner Signature Property Owner Print Name SWORN TO AfSUBSCRIBED before me this 26 day of JUG Affiant is _personally known to me, produced as identification. `d'r">'j,�o�� JONATAS GOMES DANTAS ,;Notary public -State of Florida Mmmission s HH 109 14 y Commission Expires tary May 30, 2026 Revised on 5/2212009/ Revised on 6/12/09 CITY COPY Miami Shores Villa Building Depart e t Zoning Dept. Date �� " zZ Building Dept. Date -L Subject to compliance with all Federal, State and County rules and regulations. Permit# DEI—U4-2�0— ZZsz PvV -Ol' 22 - 225 WAP OF BOUNDARY SURVEY _ j ' ' 1 D n ! �. NOM ^ r� ri IT, C .SII 4- T• � N 'v Y � <ry`\ f e tt� aN WTI K=2 m is It, Q WIN K=; sv �(L11 iR ONE STORY CBS rye 9225 LOTL p BI,OO(t IlP tlb I.T e p� `kI SE9'2745T 55.3T 9 1. A --- ■ way aw .e�avasnss ;t .wRemrs L.sn.sssu d 0.wF: ..anw mp � •wre m •ww�d � (' KNWCBL- ���f (IM YI��Y1,.w �u LJ L' Juan A. 1 F.. yf..6D0� A Rni . M IYO p� 11Y V Y 4.LL .. slle q r• .p. 1,i1 {'O s .9 wslMse.e6 s Y0 s�u�iMV[9� M wow. 'i M.I. OY�st W s .r sa+r Dues uc wvnw .t(t A M F6f O 1M1 YOYW IIO WR O i1 a[f.4M K IY.f M WYY M1V W MN v v.nw re.III.OR M wvns ,y R f Glaf, .R01f RYiA naM Mier :.Juan A. ERR. -- e° 1 .- 'Stra x _�.. •m L i4s. ? 8[1'. 0 Ron DeSantis, Governor Melanie S. Griffin, Secretary p STATE OF FLORIDA dbr DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE BUILDING CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES y y = i 11 PANTONE, GIANCARLO LUCIANO G L PROJECTS LLC 727 SE 9TH AVE DEERFIELD BEACH FL 33441 LICENSE NUMBER: CBC1263774 EXPIRATION DATE: AUGUST 31, 2024 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 19 2022 THROUGH SEPTEMBER 30, 2023 DBA: Business Name: GL PROJECTS LLC Owner Name: GIANCARLO LUCIANO PANTONE Business Location: 727 SE 9 AVE DEERFIELD BEACH Business Phone: 9 5 4 4 4 818 3 7 Receipt #:AL9-3064 6 L OTHER TYPES CONTRACTOR Business Type: (BUILDING CONTRACTOR) Business Opened:0 6/ 10 / 2 0 2 0 State/County/Cert/Reg: CBC 12 6 3 7 7 4 Exemption Code: Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: 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 planning 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: GIANCARLO PANTONE Receipt #WWW-21-00234449 727 SE 9 AVE Paid 07/07/2022 27.00 DEERFIELD BEACH, FL 33441 2022 .2023 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2022 THROUGH SEPTEMBER 30, 2023 DBA: Business Name: GL PROJECTS LLC Owner Name: GIANCARLO LUCIANO PANTONE Business Location: 727 SE 9 AVE DEERFIELD BEACH Business Phone: 95 4 4 4 818 3 7 Receipt #: 18 9 - 3 0 64 61 Business Type: ALL OTHER TYPES CONTRACTOR (BUILDING CONTRACTOR) Business Opened: 0 6/ 10 / 2 0 2 0 State/County/Cert/Reg: CBC 12 6 3 7 7 4 Exemption Code: Rooms Seats Employees Machines Professionals 1 Signature For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.001 0.00 27.00 Receipt #WWW-21-00234449 Paid 07/07/2022 27.00 ACCOR0 CERTIFICATE OF LIABILITY INSURANCE DATE (MWODNYYY) 08/16!2022 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 1NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on :-its certificate does not confer rights to the certificate holder in lieu of such endorsement(s). *RODUCER CAONTACT ANGEL GRAFFE _ __----- ---- ._.___ _..__._._._ _._.__. _._-. ----- CKSTER INSURANCE SERVICES INC. PHONE 954-315-4000 FAX 954-420-9174 1761 W Hillsboro Blvd ADDRESS: info@chesterinsurance.com _ Suite 204 _ . _ INSURER(S) AFFORDING COVERAGE - NAIC III _ Deerfield Beach fL 33442-15b1 INSURER A: THE BURLINTON INSURANCE INSURED GL PROJECTS LLC 727 SE 9th Ave Deerfield Beach FL 33441 INSURER B _ .. . INSURER C : INSURER D : 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. �_ _.__....._. ___ _ _ ......._.........._._.._. _.................�..... _..... _..._.,.._...._...............-.........._........._......._.w..._.._..._........_..._...__..........._....... . __._.. NSR ADDL;SCfRRi POLICY Eft= ' POLICY EXP i LIMITS LTR TYPE OF INSURANCE ! POLICY NUMBER MMIDD/Y DIYYYY X, COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ................... GLAIMc X-Rftf»MI !~S 9a ! Qe S . OQ.{Z�) j MED EXP An one persona § 00 Y 864BO10649 05/13/2022 05/13/2023 ! PERSONAL & ADV INJURY $ 1,000,00t) I......,.-......................................................... �..,........... ........................ .................. _...»........ .................. ; C,zEN-1 ACURFGAI E LIMIT APPLIES FIER GENEf2AL AGGREGATE $ 2.000,G00 Pilo. x f'(): iC;Y JECT LOC I PRfl[IUCTS • GflMP/OP AGG � S 2,000,Ct)0 j S 'COMBINED StNGit... LIMIT S AUTOM081LE LIABILITY (i€L4d..n�1__.._..........._......,...,. _......... .... _ ....._... ..................... ANYAUTO i E BODILY INJURY (Per person.. j.._..._._ ......_._-_ __....._.__......._._....__ ' OWNEDI SCHEDULED `:. BODILY INJURY (Per accident) S _. i AUTOS ONLY ...._...._ ALITOS HIRED NON -OWNED _-p 'PRO ERTY DAMAGE __.. S AUTOS ONLY - -» AUTOS ONLY E._LFI L a . l__.___._._......_......_.................... ............. _. _ _....._.............. .__4' j S I UMBRELLA LlAB OCCUR ;EACH OCCURRENCE -.... .__ __.._ i EXCESS LIAR } CLAIMS•MADE' - :AGGREGATE —� S . f non i ! DCTcu�nAl G _--- S WORKERS COMPENSATION ' • `• • I . AND EMPLOYERS* LIABILnY -- STATUTE_ �ER YIN ANYPROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT I OFFICERIMEMBEREXCLUDED? N 1 A ; (Mandatory In NH) E.L. DISEASE - EA EMPLOYEES ft yes. �Idescribe under E.L. DISEASE - POLICY LIMIT $ DESCRPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space Is required) MIAMI SHORES VILLAGE BLDG DEPT LISTED AS AN ADDITIONAL INSURED WITH RESPECT TO THE GENERAL LIABILITY INSURANCE POLICY r_FRTIFICATE HOLDER CANCELLATION MIAMI SHORE VILLAGE BLDG DEPT 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. ACORD 25 (2016103) The ACORD name and logo are 1988-2015 ACORD CORPORATION. All rights reserved. marks of ACORD DocuSign Envelope ID: 7F832C77-5E82-4787-9F4B-A3E4354F8807 ENTER.:,:._ August 25, 2022 State of Florida County of Broward Attn: City of Miami Shores Building Department Re: 9225 NE 12 Ave Miami Shores, FL 33138 Projects LLC (CBC ) will be overseeing/qualifying the above paving project with Coast )avers Inc who has been contracted to do the installation at the above mentioned address, Coast Pavers carries their own liability and workman's comp policies. GL Projects has been added to Coast Pavers insurance as a certificate holder. Please see attached policy. Cby 8/25/2022 Contractor Signature- GL Projects LLC CDocu5lgneC by- mAN� paws 8/25/2022 A88028A89C8645C_. Contractor Signature- Coast Pavers Inc. 4CC?RO►' ` CERTIFICATE OF LIABILITY INSURANCE 08252022D/YYYI) 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 endorsements . 30DUCER CONTACT Paychex Insurance Agency Inc NAMEa PAYCHEX INSURANCE AGENCY, INC. 225 KENNETH DRIVE PHONE 877-266-6850 FAX . 585-389-7426 E-MAIL Certs@paychex.com ROCHESTER, NY 14623 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Technology Insurance Company 42376 )AST PAVERS INC. ' )53 KILTIE CT INSURER B: INSURER C: LRAY BEACH, FL 33446 INSURER D: INSURER E: INSURER F: OVERAGES 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. iR TYPE OF INSURANCE 4 ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY �CLAiMS MADE�OCCUR DAMAGE TO RENTED PREMISES (Fa occurrenca) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: POLICY = PROJECT= LOC PRODUCTS -COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED - Autos , AUTOS OpWNED HIRED AUTOS �� A OS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ _ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE $ DEO RETENTION $ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY TWC4115485 05/212022 05/21 /2023 X WC STATU• OTH- E.L. EACH ACCIDENT $ 1,000,000.00 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) r nY NIA E.L. DISEASE - EA EMPLOYEE $ 1,000,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 It yes, describe under :SCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ERTIFICATE HOLDER CANCELLATION GL Projects LLC 727 SE 9 AVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY Deerfield Beach, FL 33441 PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE CORD 25 (2016/05) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 IVULIL:e LU UVVrler - VVOrKers" l.Ompensation insurance tXemDtion 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 � day of W Wr 20 LZ . SEAL: KAJiq 96W who is p re sonally known tole or has produced Notary�Public-State of F1 a Commission # HH logo"' MY Commission Expires ENTEaBD SY: SEP 0 2 '- Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: PW-09-22-2253 Permit Type: Public Works Work Classification: Public Works Permit5tatus: Approved Issue Date:10/21/2022 Expiration: 04/21/2023 Location Address Parcel Number 9225 NE 12TH AVE, Miami Shores, FL 33138 1132050270390 Contacts IVAN KASANZEW Owner GL PROJECTS Applicant 9225 NE 12 AVE, MIAMI SHORES, FL 33138 JONATAS DANTAS Mobile: 9547095712 coastpaverspermits@gmail.com GL PROJECTS LLC Contractor GIANCARLO PANTONE 727 SE 4 AVE, DEERFIELD BEACH, FL 33441 Business: 9544481837 coastpaverspermits@gmail.com Mobile: 9547095712 ns e Description: BRICK PAVER DRIVEWAY INSTALLATION Valuation: $ 7,000.00 Iction Requests: Total Sq Feet: 1,500.00 Fees Amount Education Surcharge $2.10 Public Works Permit Fee $100.00 Scanning Fee $3.00 Technology Fee $10.00 Total: $115.10 Payments Date Paid Amt Paid Total Fees $115.10 Credit Card 09/02/2022 $50.00 Credit Card 10/21/2022 $65.10 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. o- Z/"ZZ- Authorized Signature: Owner / Applicant / Contractor / Agent Date October 21, 2022 Page 2 of 2 Miami Shores Village ENTERED Public Works Department ;i F 1' 0 2 2022 (305)795-2210 Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FM138 , PUBLIC WORKS PERMIT APPLICATION Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property Permit#: PW-Oq'ZZ- 2Z5-3 Name of Applicant (if utility see below): L- 0l iZ b N Owner off the following described property: Legal Description: Lot�_Block_Subdivision 941 %_(/RC' Folio #; II-3Z0S•oZ3-oJ90 Address: G Z L S­ IV L" / 2 "&- M /"1 UTILITY NAME Qualifier/Authorized Agent: Address: City: Telephone: State Certification or Registration #: CONTRACTOR NAME: (7 Qualifier/Authorized Agent: Address: � L } � E R1/ City: r I D i Telephone: (%--ms-JIL State Certification or Registration Email: State: f ZIP: Certificate of Competency # of Competency Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of T way: Uy 4 r'uNL DA(Vc�-jTAUAIIDA/ Type of Work: [6 Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation ❑ Landscape• ❑ Antenna ❑ Other: DESIGNER: Architect/Enginwer; Address: City: State: ZIP: Telephone: Email: Registration # Value of Work for this Permit: $ Square/Lineal Footage of Work ***** Fees ***** Permit Fee $ 100.00 Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ Bond $ (if required) Total Fee Now Due $ ilk Bonding Company s Name (if applicable): Bonding Company's Address: City: State: ZIP: Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in this jurisdiction. I understand that separate permits must be secured for APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with applicable laws regulating construction and specifically construction in the right-of-way. "WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value exceeding $2,500, 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 the 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 public works permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection will be charged. Signature pplica uthorQ Agent A The foregoing instrument was acknowledged before me this. —day of J!�PMM (3k , 20�ZL by who ersonally known t me or who has produced as identifica JONATAS GO ES DANTAS Notary Public -State of Florida NOTARY h' Co mission Y HH 109014 M lesion Expires 0.2025 Sign: Print: Tatra 8�� SEAL: 14 Signature (�i ny/Utility Agent The foregoing instrument was acknowledged before me this d# day of d'EP 2 .20J by who i ersonally known me or who has produced as identification. JONATAS GOMES DANTAS o`O{6� NOTARY PUBLIC: _ •gsNPublic-State of Florida Commission - I•_ Commission N HH 109014 My Commission Expires Sign: 01 ` May 30, 2025 Print: Jbff lg� Im TIM SEAL �r j APPROVED BY: Public Works Director, or Designee 2017-04-15 Miami Shores Village Public Works Department (305)795-2210 Public works forms are available from the building department, 10050 NE 211" Ave., Miami Shores, FL 33138 COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY �iliiliillliilllllillllllllllllllllllllllll CFN 2022RO624920 OR Bk 33327 P3 550 1 P3s RECORDED OB/ R/2022 12:13:37 HARVEY RUVIN, CLERK. OF COURT r1AMI-DARE COUHTY, FLORIDA Whereas, (hereby referred to as the owner) CN V f �1'll-1/4 A/ Z-(-yV Of the following described p operty: 4 Legal Description: Lot Z Block nZ , , Subdivision / LU )Folio #; f l _ 3Z0J''Q Z �--®J f0 Address: I Z Zr V 6- f Z X ife Requests permission to install (describe work; attach separate page if necessary) in the adjoining right of way RJ ONSIDERATION of the approval of this permit by the village, 4he owner agrees as follows: 1. To maintain and repair, when necessary, the above -mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Miami -Dade County to make repairs or maintain said items within the public right of way including restoration of the street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does herby agree to indemnify and hold Miami Shores Village or Miami -Dade County harmless from any and all liability, which may rise by virtue of permitting the installation of these items within the public right of way. 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 14 days' notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns until such time as this obligation has been cancelled by an affidavit filed in the Public Records of Miami STATE OFp�LORIBbI(Ufdyl&1'r Village (gi his fully �uthbrized representative). I HEREBY �ERTIFFYY that this is a y of e I( 1n I 1jeJIY.'1_' ffice on of original fil fh� Signature NESs m han o unit a a1. ner or A thonzed Agent HAR uvi Circt it a unty Courts By D.C. State of P14Pi69 County of NL r"I The foregoing instrument was acknowledged before me this 4 day of 20 by La as identification personally known tdl me or who has produced NOTARY PUBLIC: `o~;;,..'�,JONATAS GOMES DANTAS Sign: [�` _+ c Notary Public -State of Florida n ^ ��' "•n,.,� Commission A HH 109014 0 fs" t�/.1V" ye \ SEAL: �� Y Commission 5 Tres Print: t— ' """� May Commission on E,p Documents are recorded at the Clerk of the Courts, MIAMI-DADE COUNTY RECORDER, COURTHOURSE EAST, 22 N.W. First Street, 1st Floor, Miami, FL 33128. 2017-04-11