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DS-05-22-1187Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 254 NE 101ST ST, Miami Shores, FL 33138 1132060134620 L�] Contacts Andrea Ehlebracht Owner STORE ZONE INC DBA S.F. CONCRETE Applicant 254 101 TECHNOLOGY Mobile: 7862087450 EHLEBRACHT@ICLOUD.COM CHARLES GERMI Home: 7862087450 11121 SW 161 PL, MIAMI, FL 33196 Mobile:3053427047 charles.sfconcretetechnology@gmail co m STORE ZONE INC DBA S.F. CONCRETE Contractor TECHNOLOGY CHARLES GERMI 11121 SW 161 PL, MIAMI, FL 33196 Mobile:3053427047 charles.sfconcretetechnology@gmail co m Description: REMOVE EXISTING PAVERS FROM APPROACH, Valuation: $ 9,943.00 Inspection Re uests REMOVE GRASS AND INSTALL NEW CONCRETE IN APPROACH � AND DRIVEWAY Total Sq Feet: 306.00 Fees Amount Application Fee - Other $50.00 CCF $6.00 Concrete/asphalt/pavers, slabs, dways, $50.00 swalks DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $2.00 Planning and Zoning Review Fee $70.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $193.50 Building Department Copy Payments Date Paid Amt Paid Total Fees $193.50 Credit Card 06/24/2022 $193.50 Amount Due: $0.00 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. / 1n U� �C- S G c r^ i � Z�(2 Z Authorized Sin : Owner / Applicant / Contractor / Agent Date June 24, 2022 Page 2 of 2 Miami Shores Village ENTERED Building Department MAY 11 2022 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 BUILDING Master Permit No. —2-2 -• -7 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 254 NE 101 Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-3206-013-4620 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Remodel Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Andreas Ehlebracht, Guylaine Ehlebracht phone#: 786-208-7450 Address: 254 NE 101 Street City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Email: C�'1 c-h f c^ C- i C, ov C • GUI on CONTRACTOR: Company Name:' Store Zone, Inc. DBA S.F. Concrete Technology Phone#: 305-342-7047 Address: 11121 SW 161 st Place City: Miami State: FL _ Zip: 33196 Qualifier Name: Charles Germi Phone#: 305-342-7047 State Certification or Registration #: Certificate of Competency #: 14BS00477 DESIGN ER:-Pfehrieieer:" C-� `�Y C S o CU i�l Y �) e Phone#: Address Zip: Value of Work for this Permit: 0 i �1 Square/Linear Footage of Work: 1-bee- y00 Type of Work: ElAddition 0 Alteration ❑New ❑ Repair/Replace Demolition Description of Work: Remove existing paver's from approach, remove grass and install new concrete in approach and driveway. Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ CCF $_ Radon Fee $ DBPR $ Training/Education Fee $ CO/CC $ Notary $ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ 1'I ';7—' 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 Zi 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. Signature Signature OWNER or AGENT 6NTRACTOR The foregoing instrument was acknowledged before me this day of 20 ZZ , by I'N , L'°wQg �h���` , FioIs personally known to me or who has produced ` DV-Pe-Ir L as identification and who did take an oath. NOTARY PUBLIC: Sign: i---- Print: 5���( ��C7E'1�►` The foregoing instrume t was acknowledged before me this rd.ay of (>< L) , 20 'Z�- , by (t•�1 �i 4'6,Y-&, who is personally known to me or who has produced-\--')(`,\tA( `,\ U0 as identification and who did tale an oath. NOTARY PUBLIC: Sign:_ Print: Seal: �,ro� SANDRAGARCIA Seal: ARMANDO MALDONADO �?Qr NotaryPublic • State of Florida ,i\� Notary Public - State of Florida GG 255075 Commission Commission X GG 945040oF -'o� _ n" a My Comm. Expires Jan 7, 2024 ............ My Comm. Expires Sep 3, 2022 Bonded through National Notary Assn. APPROVED BY H- ti Plans Examiner Structural Review ( 'L "51Z, Zoning Clerk (Revised02/24/2014) Property Search Application - Miami -Dade County Page 1 of 1 OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11-3206-013-4620 Property Address: 254 NE 101 ST Miami Shores, FL 33138-2423 ANDREAS EHLEBRACHT Owner GUYLAINE PRIME PIERRE EHLEBRACHT Mailing Address 254 NE 101 ST ..__ ....... .._.....__..._....__.._.__.._.......... __...........................__........ ................. MIAMI SHORES, FL 33138 USA -__.......__..___.__.__...._..__._.___...._____.___.....__...._.__..__...........__.___._ PA Primary Zone 1000 SG FAMILY - 2101-2300 SQ 0101 RESIDENTIAL - SINGLE Primary Land Use FAMILY: 1 UNIT Beds / Baths / Half 3/2/1 Floors 1 Living Units 1 Actual Area 2,283 Sq.Ft Living Area 2,283 Sq.Ft Adjusted Area _..__...__..__..______....____........_..___________ 2,128 Sq.Ft ... _.............. .......................................... _...._._._...._........_......_ Lot Size 8,625 Sq.Ft Year Built Multiple (See Building Info.) Assessment Information Year Land Value 2021 __......._._._._... _... _..... $276,535 2020 _ ._.___.._.._.__.....____...._...._..__.._.__._..__._. $276,535 2019 $258,854 Building Value $310,072 $313,796 _ $317,520 XF Value $34,837 $35,225 $35,614 Market Value $621,444 $625,556 $611,988 Assessed Value $621,444 $625,556 $611,988 Benefits Information Benefit _............._..._...__.....__....�.......... ._ . Homestead Type _.....__............ .-.. Exemption 2021 $25,000 2020 $25,000 2019 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 1 AMD PB 10-70 W1/2 OF LOT 5 & LOT 6 BLK 34 LOT SIZE 75.000 X 115 OR 19891-3620 08 2001 1 Generated On : 5/11/2022 Taxable Value Information 2021___.... 2020 2019 ................. _._..____..__............ _.._......................_____...._.._.._...._..___......____________._............._..____.._.________�..___ County Exemption Value v $50,000 $50,000 $50,000 Taxable Value J $571,444 $575,556 $561,988 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $596,444 $600,556 $586,988 __..._ ------- _._._.._._.................... ._ ...__... ..._.... ........_.._.._............._......_....._..........._...._...__.______ _ City Exemption Value $50,000 $50,000 $50,000 Taxable Value $571,444 $575,556 $561,988 Regional ............... _..... _____..._,_._____.___.._..._._.__.._____._.__.__ Exemption Value $50,000 $50,000 $50,000 Taxable Value $571,444 $575,556 $561,988 Sales Information Previous OR Book - Price Qualification Description Sale Page __ 09/19/2017 $775,000 30699-3889 Qual by exam of deed Corrective, tax or QCD; min 09/16/2016 $133,900 30240-3121 consideration 08/12/2013 $630,000 28832-2782 Qual by exam of deed 05/12/2011 $530,000 27697-0719 Qual by exam of deed The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp Version: https://www.miamidade.gov/Apps/PA/propertysearch/ 5/ 11 /2022 ^A 4O [Argilm ADJACENT 4' CLF N.E. 101st STREET (Publicly Dedicated Per Plat) /�.VV �I'.Y. u C I SALLEY c 0.49' C ' w "' 0.19' C r r(Publicly Dedicated Per Plat) �n' ACDW AI T DAVFMF IT Ln Surveyor's Notes: • All clearances and/or encroachments shown hereon are of apparent nature. Fence ownership by visual means. Legal ownership of fences not determined. • Encroachments Noted: 3 • Underground structures, if any, not located. • Bearings, if shown, are based on assumed meridian or Plat of Record. • Lands shown hereon were not abstracted for easements and/or right-of-ways of records. • Legal description provided by client. • This certification is only for land as described. It is not a certification of title, zoning, easements, or freedom from encumbrances. ABSTRACT NOT REVIEWED. • There may be additional restrictions not shown on this survey that may be found in the public records of this county. ABSTRACT NOT REVIEWED. • This BOUNDARY SURVEY has been prepared for the exclusive use of the entities named hereon. The Certificate does not extend to any unnamed party. • This survey was based on the monuments found on the field. No construction in any manner should be made without the prior written consent of the Surveyor. 11A M1 SHORES VILLAGE PUBLIC WORKS REVIE APPROVED. ( - _ ATE LEGAL DESCRIPTION: Location Sketch Miami Shores Vill Building Depart ent Zoning Dept. Date i Building Dept. Date '1-t. Subject to compliance with all Federal, State and County rules and regulations. Permit# >S-oS-ZZ I1 � PIS bl zz - 2(ay Lot G and the West 1/2 of Lot 5, Block 34, AN AMENDED PLAT OF MIAMI SHORES SECTION NO. 1, according to the Plat thereof, as recorded in Plat Book 10, Page 70, of the Public Records of MIAMI-DADE County, Florida. CERTIFIED TO: Andreas Ehlebracht; Ana Maria Angulo, Atty.; Old Republic National Title Insurance Company; Caliber Home Loans, Inc., its successors and/or assigns. PREPARED FOR: Andreas Ehlebracht, 254 N.E. 101 Street, Miami Shores, FL 33138 Encroachments: 1. The brick drive is encroaching over the North boundary line into the street Right -of -Way (N.E. 101 st Street). 2. Portion of the 5 foot high wood fence is encroaching over the South boundary line into the abutting alley. 3. Portion of the damaged 5 foot high wood fence is encroaching over the East boundary line. LEGEND A - Central Angle A = Arc A/C = Air Conditioner ASPH = Asphalt BBO = Barbecue C = Calculated CB = Catch Basin CBS = Concrete Block Structure CH = Chord Chatta. = Chattahoochee = Center Line CLF = Chain Link Fence Cl. = Clear Conc. = Concrete D = Deed 0 = Diameter DH = Drill Hole DME = Drainage & Maintenance Easm't Easm't = Easement Enc. = Encroachment F.H. = Fire Hydrant FIP = Found 1/2" Iron Pipe FIR = Found 1/2" Iron Rebar FPL = Florida Power & Light ID = Identification I.P. = Iron Pipe LB = Licensed Business LME = Lake Maintenance Easement L.P. = Light Pole M = Measured MAINT. = Maintenance ME = Maintenance Easement y = Monument Line Mon. = Mom Imort N/A = NOL Applicaole N,'D = Nail & Disc I IT = Numuer FITS n/ S = Not tJ Scale. , • tau e = Offset O.U.L. = Overhead Utility Lin�,n , • . o III = Pla, ° G = Pla. Book • • o . I PC = Point of Curvature I XP = Pern,an r,tControl Point PG = Page ° P... ' = Point of Intersection PKW'' = Parkway _ R = Property Line PI = Planter 'LS ` = PrGfessiohal Land Surveyor P.O.B. = Point of Peginning P.O.C. = Point of Commencement P.P. = Power Pole PRC = Point of Reverse Curvature PRM = Point of Reference Monument PT = Point of Tangency R = Radius Res. = Residence R.L.S. = Registered Land Surveyor RNG = Range R/R = Railroad RSM = Registered Surveyor & Mapper R/W = Right -of -Way Sdwk = Sidewalk Sec. = Section T = Tangent TWP = Township U.E. = Utility Easement UTIL. = Utility W.F. = Wood Fence W.M. = Water Meter WME = Wall Maintenance Easement n 0 m 0 0 w 0 24.0 O .x a)L E CD o c E N a- O �0 z o '-0 3 v 20.00ft 10 ,_. U° • i ou wn •` "-- p -' CD i .1> 0! IGINAL LOT LINE 0 n 27.30' O L O x E CL U E N "r LU y UO a4Q- r OL m O CL =' p ZUmd3co 22.66ft q= h 37.50` I. . N.E. 1O 1A STREET , (Pui;NictyDedicated PerPlall t 20' ASPHALT PAVEMENT 7.14ft 10.3L.I. Old paver driveway to, . .�� be removed. r� 554.32 sq. ft. 22' PARKWAY 30.8611 3/.70 f t ` Fria. r®2 ONc •SOWK 75.'00' �' (No I D) . �99 nl (S 1 Csr Y kf z (7 r € rr 6' W.F. TKED WALKW7 AY � 135 WALL r 10 30' �- ... ' r 6' W F.� 21.40' �.. ", { (O0Q i r f t 1,F,4 L k 1 t 1!�t3f1I �-2— U.—OW�� a CONC, STEP' r 835' 3.45'%� SHED a one St® � Q{ LA { ® s Residences �. •� k 4 s> i NO. 254 1 } t 1,8,�5� ®I , � x SAS.—�'.9S' iu -T! 2.1.5s, jDAMAGED) �. t� sae,tF ct,����, ADJACENT- f .iJfl' sa 1 t t l C*Epji/� �I;�.LI -1t; 6 ve e.� a Ls.e.c La,► �I 4' CLF p tft sxy L LI L LLLI,LLLl.L4t / , �� f / 12.95' POUT, PAVERS c+5W ECat11PtUEttil30. 25.00' V h POOL 9 N Sri (,Sj� € r k 61 fir;. x ''+; r Z. 0.29 t. —1.20' Enc }, rn i D F3n. 2' Rebor (No I.D.) 75.00' '' P.P. ;; (No I..) � . s IS' Ate+ ._' c 0 49' O/S South (Publicly Dedicated Per Plat) i9!0 Edit N s I V ASPHALT PAVEMENT ,,, DoOoo 0 O 0 D0000 0 0 0 0 0 0 0000 o D 0 0 0 0 00000 0 0 00000 0 0 0 0 0 0 L U co 0 L — U C U C6 N � C � O U U U Z w a109'0 4.4 L U N L O O O .; CD HE UU �CD -0 U M M X L E O Q'X U D N Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 254 NE 101ST ST, Miami Shores, FL 33138 1132060134620 Ll Contacts Andrea Ehlebracht Owner STORE ZONE INC DBA: SF CONCRETE Contractor 254 101 TECHNOLOGY Mobile: 7862087450 EHLEBRACHT@ICLOUD.COM DAVID MONTERREY Home: 7862087450 Business:7869045729 SFCONCRETETECHNOLOGY@GMAIL.CO Mobile: 3053427047 M Description: REMOVE EXISITING PAVERS TO INSTALL NEW Valuation: $ 4,000.00 Inspection Requests: d PAVERS$y ' Total Sq Feet: 306.00 Fees Amount Education Surcharge $0.80 Public Works Permit Fee $100.00 Technology Fee $2.50 Total: $103.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $103.30 Credit Card 06/24/2022 $103.30 Amount Due: $0.00 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 appl.cable laws regulating constr ti and zoning. Futhermore, I authorize the above narped contractor to do the work stated. re: Owner / Applicant / Contractor / Agent June 24, Date Page 2 of 2 DOCUMENT COVER PAGE For those documents not providing the required 3 x 3 inch space on the first page, this cover page must be attached. An additional recording fee for this page must be remitted. Document Title: L_l\ 4( ✓\ - (Mortgage, Deed, Etc.) C) Return Document To / Prepared By: CFN 2022R t386392 OR BY, 33152 P9s 1051-1052 (2Pgs) RECORDED 1j5/11/21j22 13:i)l °3y HARVEY RUVINr CLERK OF COURT MIAMI-DADS C:OUNTYP FLORIDA '------------------------------------- (Space above this line reserved for recording office use) Con 5lrCL C, flan, W,+1n `'\ � 4— Rule 2.520 (d) On all ... documents prepared ...which are to be recorded in the public records of any county. . 3 - au3.ispace at fine top right --hand corner onthe firstpage and a 1- inch by 3 -inch space at the top on each subsequ.entpageshallbeleftblankandreservedfor use by the clerk of court a 3 -inch by CLK/CT 155 Rev. 08/16 Clerk's web address: www.miami-dadeclark.com mil/ OR BK 33182 FIG 10_152 LAST PAGE Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY Whereas, (owner) A n d f e Q^ S� k I e b cc, C- h -►- owner of the followin described property (address): 2.SI-d hereinafter- 01s�ef red tos�t he 3�1 38 Legal Description is ' 7CJ Lot _lock Subdivision ;owl Folio # __►I - 3 Zak c0 I Sptm equests permission to install (describe work): o V C X cor--1 a fooAc1� CMoV� rasS and aca►) dew c creFr� ;� mPPtpc�ci� � � Wit in the public ri t of way of (address) 2 J A/ F. ro I S-T Nl; oAv� 1 � 6 rest �f' IN CONSIDERATION of the approval of this permit by the Village, the 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 Dade County to make repairs or maintain said items within public right of way including restoration of 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 hereby agree to indemnify and hold Miami Shores Village or 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 60 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 obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager'"iami,$,hpres Village (gr fps fully authorized representative). Signature Owner or Agent -Th . foregoing instr ment.was acknowledged before me this f I day of 20 C�Q -Cf4tk"iis personally known to me or who has produced } as identi fication and who did -lake an oath. ,�pPY PV NOTARY PUBLIC- 2° �° IGORE.KMDBARALT Sign: MY CO aMS10N # 92525 Print: aDnnlf OUNTY OF MIAMIZADEC('�Co 9 COUN, FY that this Is a true copy of theMyCommi sion Expires: Z orig'r Iled i tlisoffceon day of WITNESS nay h n and Crfficial Seal. HARVEYbUVIN, Ierk of Circeit and County Courts #201144 ENTERED Miami Shores Village ° Public Works Department MAY 11 Z022 (305)795-2210 Public works forms are available from the building department, 10050 NE 2"d Ave., Miami ShopYL 33138 PUBLIC WORKS PERMIT APPLICATION Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property Name of Applicant (if utility see below): Charles Germi Owner off the following described property: Legal Description: Lot 5&6 Block 34 Folio #; 11-3206-013-4620 Address: 254 NE 101 Street, Miami Shores, FL 33138 UTILITY NAME: Qualifier/Authorized Agent: Address: City: Telephone: State Certification or Registration #: Email: Permit#:—QS—US" ZZ — ik8', P W - 0 2. - 22 -Z(o y Subdivision Miami Shores SEC 1 AMD State: CONTRACTOR NAME: Store Zone, Inc. DBA S.F. Concrete Technology Qualifier/Authorized Agent: Charles Germi Address: 11121 SW 161st place ZIP: Certificate of Competency # City: Miami State: FL ZIP: 33196 Telephone: 305 342-7047 Email: sfconcretetechnology@gmail.com State Certification or Registration #: Certificate of Competency #: 14BS00477 ., Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of way: Remove existing paver's from approach, remove grass and install new concrete in approach and driveway. Type of Work: ❑i Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation ❑ Landscape ❑ Antenna ❑ Other: DESIGNER: Architect/Engineer: Address: City: Telephone: Registration #: State: Email: ZIP: Value of Work for this Permit: $ 3 �Ii c 0 0 Square/Lineal Footage of Work: � 0 G Permit Fee $ 100.00 Notary $ Bond $ ***** Fees***** _ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ (if required) Total Fee Now Due $ 1 0 - 'S0 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 254 NE 101 Street 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 5� 090, Applicant or Authorized tb The foregoi nstrume t was acknowledged before me is ay of 20 :7— , by I(1 who is personally known to me or who has produced T r ClC as identification. NOTARY PUBLIC: Sign: .ram O Signature pa /Utility Agent The fore oinVnstr ent was acknowledged before RV this day f MU�� 20�,by is personally known to me or who has produced l�1 C Uk U VL- as identification. NOTARY PUBLIC: Sign: Print: Print: SEAL: _ _ _ _ SEAL: ::4jjir a�,'e'•.. .. SANDRA GARCIA ?°; �,y ,,+ Notary Public -State of Florida y' St[ vo ` Commission ; GG 945040 ry?c My Comm. Expires Jan 7, 202- Bonded !hrough National No Assr. t�YP'4 �r•: ARMANDO MALDONADO Notary Public - State of Florida moo_ oF Commission # GG 255075 .•. My Comm. Expires Sep 3, 2022 ******* * ********** ************************ APPROVED BY: 1!� �L- Public Works Director, or Designee 2017-04-15 who CTgB Construction Trades uaBfying Board BUSINESS CERTIFICATE OF COMPETENCY 14BS►00477 STORE ZONE INC • �_D.B.A.. S F. CONCRETE TECHNOLOGY INC �� �C/ ONTERREY DAVID Is certified under the provisions of Chapter 10 of Miami -Dade County 1600583 Local Business Tax receipt Miami -Dade County, State of FloridaLBT THIS S-NOTABILL-DONOTPAY 7177927 y�y BUSINESS NAMQWCATiON RECEIPT No. EXPIRES SF CONCRETE TECHNOLOGY RENEWAL SEPTEMBER 30, 2022 11121 SW 161 ST PL 7458009 Must be displayed at place of business MIAMI FL 33`196 Pursuant to County Code EI ©' Chapter 8A - Art: 9 & 10 l7 '` OWNER SEC. TYPE OF BUSINESS PAYMENT RECENED STORE ZONE INC 196 SPECIALTY BUILDING CONTRACTOR ByTAx fAuzToR , C/O DAVID MONTERREY 14BS00477 $93.75 01/09/2022 Worker(s) t INT-22 229074' 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 holders 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 he displayed on all commercial vehicles - Miami -Dade Code Sec Be-276. For more information, visit wwwmiamidade.govkaxcollector ACORO® CERTIFICATE OF LIABILITY INSURANCE �� DATE(MMIDD/YWY) 01 /27/2022 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 GVNIAkol NAME: Russ Deboo FAX A/C No Hxt : (561) 477-9339 (A/C, No): Deboo Insurance Agency IL ADDRESS: russ@debooins.coin 1430 S Federal Hwy Ste 301 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Cypress Property & Casualty Insurance 10953 Deerfield Beach FL 33441 INSURED INSURER B : INSURER C : Store Zone Inc DBA S.F. Concrete Technology INSURER D : 24186 SW It 3 PASSAGE INSURER E : Homestead FL 33032 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR Al 'TOEM PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A FGL 5025287 01 05/23/2021 05/23/2022 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICYEl PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY (Ea accident) $ _ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPF k'TY$ (Per accident) $ UMBRELLA LIAB OCCUR EACH $ HCLAIMS-MADE _OCCURRENCE AGGREGATE $ EXCESS LIAB DED RETENTION $ $ WORKERS COMPENSATION ND EMPLOYERS' LIABILITY Y / N STATUTE I ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYEE $ Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 254 NE 101 Street, Miami Shores, FL 33138 CONTRACTOR lic. #14BS00477 IC Miami Shores Village Building Department 10050 NE 2nd 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 Mark 5weeKey ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ACOR 78CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 01/27/2022 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in lieu of such endorsements . PRODUCER CONTACT PHONE (855) 222-5919 FAX (A(C.N%fPw {/l/¢, (Ig):._ Next First Insurance Agency, Inc. PO Box 60787 Palo Alto, CA 94306 _ _ _ . E-MAIL su ortnextinsurance.com ADDRESS: pP INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: State National Insurance Company, Inc. 12831 INSURED INSURER B : Store Zone, Inc. DBA S.F. Concrete Technology 11121 SW 161 at PI INSURER C : , Miami, FL 33196 INSURER D : INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER:4239903 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 LTRCOMMERCIAL TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR PRE I FSJk4 occ r,.�{ rQnca� $._— EXP An person) __MED _qne PERSONALBADVINJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 11 JECOT- LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SI-- L LIMI BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ ~ PROPERTYDAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ _ AGGREGATE _ _ $ ^ ` EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A NXTNU71BGBAI-WC 03/21/2021 03/21/2022 X I STATUTE I ERH E.L. EACH ACCIDENT $100,000.00 E.L. DISEASE -EA EMPLOYEE $100,000.00 (Mandatory in NH) II yyea, describe under DESCRIPTIO OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000.00 _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space is required) 254 NE 101 Street, Miami Shores, FL 33138 Contractor Lic. #14BS00477 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd 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. I AUTHORIZED REPRESENTATIVE n CQ,J(l Ali ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD