RC-07-20-1631, 9333 N Miami Ave (4)Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762.4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
=, ZI0
FBC 20
Master Permit No. f2,,.C. " 01 • Z Q I %31
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING M MECHANICAL (]PUBLIC WORKS..WHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: —1 -;k 3 7�) &) iM; at Vy►1, A J C.
City: Miami Shores County: Miami Dade Zip: 2)31 , v
Folio/Parcel#: Is the Building Historically Designated: Yes NO.
Occupancy Type: SF Q Load: Construction Type: Ga 5 Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �06 � % e- e o. 9,L^ t Phone#: V • `' s 3
Address: 91 3 3N PA; IN.JL
City: 1-&t No%d - r1 State: F; L. Zip: .+ 20 15 0
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: U V"-VeN, L. i �-w � O wyIPY K di.ApPhone#: 3a s - ;�;lLtv- ) f
Address: 3 to a Graves A e.
City: State: L- Zip:
Qualifier Name: ��.+r" 5 [r��• SD >i Or. Phone#: '.'!:!S �"'� • �'31 ,`�
State Certification or Registration•#: t (A C. 15.1?44 Q Certificate of Competency #: t t p�•
DESIGNER: Architect/Engineer: w SGu ._& S�G�� bw.D`� Phone#:
Address: 111 1616 Z=L- AJe. City: 6A I CA- State: �.•- Zip:
Value of Work for this Permit: $ h J ® 00 Square/Linear Footage of Work: 1 p Cz� Gj
Type of Work: am Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: t d C• a 4o.�a.1 IL [ o�nvt r 4a� �'►
Specify color of color thru tile:,
Submittal Fee $ Permit Fee $
Scanning Fee $
CCF $ CO/CC $
Radon Fee $ DBPR $
Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
Bond $
(RevisedO2/24/2014)
TOTAL FEE NOW DUE $ ` ( () `
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 c ified copy of the recorded notice of commencement must be posted at the job site
for the first ' ch en (7) s after the building permit is Issued. in the absence of such posted notice, the
inspectio ill not be app ved nd a rein cti ee will be charged.
SiQnatur Signature
OWNER & AGENT
The foregoing instrument was acknowledged before me this
OP` day of I> 20 -2-10 by
'► crc.. �t+�� Gt.c:� , who i ersonaliy known
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC: l
Sign:
1 t
Print
NATELEGE NATAKI POWELL
Seal: _y MY COMMISSION # GG 146583
EXPIRES: September 27,2021
Bonded Thru Notary Public Underwriters
The foregoing instrument was acknowledged before me this
�o1= day of 1> Gc w.,,1..r 20 0 by
C {now u (;, bS+r• ,who Is4Le—rs-5—na7ry-Fn"ow—
Pto
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal:
- MY COMMISSION # GG 146583
l aN= EXPIRES: September27,2021
F ° ' Bonded Thru Notary Public Underwriters
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 fro he contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU KNOW GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENT
Signature:
Owner
State of Florida
County of Miami -Dade
The fore oing was acknowledge before me this 3-1`4 day of b Qi _,r m& C 20 A .
B6%& Pd#\ % el\e, f O who i personally known 'tom r has produced
as identification.
Notary: o A L GE NATAKI POWELL
I ION # GG 146583
SEAL:
�•' EXPIRES: September27, 2021
'rFOF d�4 Bonded Thru Notary Public Underwrites
r
December 3, 2020
State of Florida
County of Miami -Dade
Before me this day personally appeared CHARLES GIBSON who, being duly sworn,
deposes and says:
That he will be the only person working on the project located at 9333 N. Miami
Avenues Miami Shores, FL for the cqmpany.
Charles Gibson
Lemon City Coi
CGC 1527440
Sworn to (or affirmed) and subscribed before me this 3 day of December 2020 by
Charles Gibson who is Personally known to me.
Notaryublic
My commission expires:
NATELEGE NATAKI POWE7
#: MYCOMMISSION # GG 146583
EV IRES: September 27, 2021
Bonded Thru Notary Public Undewite,s
r_
3634 Grand Avenue
Miami, FL 33133
Phone: 305.777.0397
E-mail: info@lemoncity.com
www.lcmoncity.com
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:
04%
BUSINESS ADDRESS:. 634 crica AAjc. CITY STATE._ ZIP � 131
BUSINESS PHONE: () FAX NUMBER �_)
CELL PHONE(. �) AP - $315 QUALIFIER'S NAME: VA a► i L t 5 60�f%
QUALIFIER'S LIC NUMBER: C Cry C, t (� 0.q L�LA0
n
Ron DeSantis, Governor Halsey Beshears> Secretary
�� 11d�
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
THE GENERAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE
9,,1
ATUTES
:,: 7X-�- -.
HARLES ANTHONY
LEMON CITY CONSTRUCTION LLC
3634 GRAND AVENUE
MIAMI ;, FL 33133
LICENSE NUMBER: CGC1527440
EXPIRATION DATE: AUGUST 31, 2022
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.
003135
Local Business Tax Receipt
Miami -Dade County, State of Florida
THIS IS NOT ABILL -DO NOT PAY
7228504
BUSINESS NAMEAOCATION
LEMON CITY CONSTRUCTION LLC
3634 GRAND AVE
MIAMI EL 33133
RECEIPT NO. EXPIRES
RENEWAL SEPTEMBER 30, 2021
7513470 Must be displayed at place of business
Pursuant to County Code
Chapter 8A - Art. 9 & 10
OWNER SEC. TYPE OF BUSINESS
LEMON CITY CONSTRUCTION LLC 196 GENERAL BUILDING CONTRACTOR PAYMENT RECEIVED
C/O CHARLES GIBSONGR CGC1527440 BY TAX COLLECTOR
$45.00 08/11/2020
Worker(s) 2 CHECK21-20-075811
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license,
permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276.
For more information, visit www.miamidade.govhaxcollector
AC PRR CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
F1217/2020
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 poMcy(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 Neu of such endorsements .
PRODUCERjjWj
Munro Insurance Services,LLC.
Daniel Munro s_ W
780-821.3844 �aL.LY4. Not: 780-780.1853
PHONE —y- P FAX _-1 �6
W
1155 Sportfisher Drive, Suite 140
DenlslMunraftmall.com
Oceanside, CA 92054
_ .__INSURER(sLMt0tDeIGCOVERA94 _ m =
NAIC III
INSURER A: Preferred Contractors Insurance Company, RRG
12497
INSURED
Lemon City Construction LLC
INSURER B
Charles Gibson
INSURER C .
3634 Grand Avenue
INSURERD:
Coconut Grove, FL 33133
'NSURERE:
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.
INOLR POLICY EFF IF OF P43URANCE POLICY NUMBER
T �(P LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$1,000,000
✓ COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
$ 50 000
MED EXP (Anyone persons
$ 3 000
PERSONAL&ADVINJURY _
$-1000000
A
_ _
X
PC355353
05/14/2020
05/14/2021
GENERAL AGGREGATE
$ 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER;
PRODUCTS • COMP/OP A0G
$1..000
✓ POLICY MOT LOC
$
AUTOMOBILE LIABILITY
EFI UCOIdeM?
ANY AUTO
BODILY INJURY (Per person)
$_t=_
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
O
$
R DAMAGE
$.._-_
HIRED AUTOS AAUUTON OWNED
$
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
EXCESS VA13
CLAIMS -MADE
$
DED RETENTION
WORKERS COMPENSATION
WC STATU- OTH-
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICEMMEMSEREXCLUDEDI
NIA
E L EACH ACCIDENT I---
= _- -------
- _
$- w.-
E L DISEASE - EA EMPLOYE
$
(Mandalay In NH)
It ,desaibeunder
DESCRIPTION OF OPERATIONS below
--_
E.L. DISEASE - POLICY LIMIT
`.,.._•• . ..-- ___.= u.._
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD f01, Additional Remarks schedule, if more apace Is required)
CGC 1527440
CERTIFICATE HOLDER CANCELLATION
MIAMI SHORES VILLAGE BLDG DEPT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
10050 NE 2ND AVE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI SHORES, FL 33138
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
JIMMY PATRONIS
CHIEF FINANCIAL 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: 9/24/2020
PERSON: CHARLES A GIBSON
FEIN: 822017061
BUSINESS NAME AND ADDRESS:
LEMON CITY CONSTRUCTION LLC
3634 GRAND AVENUE
MIAMI, FL 33133
SCOPE OF BUSINESS OR TRADE:
Contractor -Project Manager,
construction Executive,
Construction Manager or
Construction Superintendent
EXPIRATION DATE: 9/24/2022
EMAIL: CGIBSON@LEMONCITY.COM
IMPORTANT: Pursuant to subsection 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 subsection 440.05(12), F.S., Certificates of election to be exempt issued
under subsection (3) shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or
trade listed on the notice of election to be exempt. Pursuant to subsection 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-DWG-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01232588 QUESTIONS? (850) 413-1609
Miami Shores Village
RP,CEIVED Building Department
Dr
2020 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
By, Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N. C-- 0 -4- - 2 0- I (o3 1
Owner's Name (Fee Simple Title Holder): 1'a.+ricif► Pz,,:,clne•r'o Phone #: 611 Le - -4-Q (P 3
Owner's Address: G 333 1.1 Miavvc% pae.
City: M;avwi SvIvo!'eS State : F 1- Zip Code: 33150
Job Address (Of where work is being done): Q 3 33 N M % awe , 1A.re-
City: Miami Shores State: —Florida Zip Code: 3 3 1576
Contractor's Company Name: S 2 , �, rp Phone #:
Address: 3 3 3 S F 2=e
City: Wliarwi State: (= 1— Zip Code: IV 31
Qualifier's Name: e I C ^b 1--e- A ,,v S. Lic. Number. G C7 C 1 SZ-3 4 30
Architect/ Engineer of Record Name: W et, �� �' a� W kew S Phone #: 78 4' - 2 1 b ^ `6 3 3 6-
Address: ?� )3 SE 2-�' lNyc S..KAm- 20co
City: il" li a-V-x State: F L. Zip Code: 3 3 131
Describe Work: Wt, ®n /&ejpsvt'c-
I hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwilling to comp]4te the contract. I hold the Building Official and the
The foregoing instrument was aknowiedged befor me.thisdday of N c�.2020,by akC%tia i• 6
Who so I kno to me r who has produced
indentifrcation.
Notary Publi
Sign:
Seal:
NATELEGE NATAKI POWELL
�: •,,_
a
MY COMMISSION # GG 146583
EXPIRES: September 27, 2021
•5
Bonded Thru Notary Public Undenrtitem
The foregoing instrument was aknowiedged before me
this �0� day of f- 201by WCU� WU-05
who malllyknoVto me or who has produced
nation.
Nota4 Public:
Sign:
Seal: hYo% NATELEGE NATAKI POWELL
z• _ MY COMMISSION # GG 146583
a' EXPIRES: September 27,2021
Bonded Thru Notary Public Underwriters
r