DS-05-22-1123Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
349 NE 93RD ST, Miami Shores, FL 33138
Parcel Number
1132060136280
Contacts
GEOFFREY TULLY Owner Geoffrey Tully Applicant
349 NE 93 ST, 33138, 349 NE 93rd St, Miami Shores, FL 33138
Mobile:6468961123 tully.geoff@gmail.com Mobile:6468969339 tully.geoff@gmail.com
BRICK PAVER GROUP INC Contractor
JOSEFERNANDEZ
350 W. PARK DRIVE, #101, DORAL, FL 33172
NATHALIE@BRICKPAVERGRP.COM
Description: INSTALL PAVER FOR DRIVEWAY, WALKWAY LValuation: $ 13,514.32 Ins ect�on Requests:
APPROACH AND PATIO. REPLACE SIDEWALK 305 1"6 49�
et: 1,436.00,
Fees
Amount
Application Fee - Other
$50.00
CCF
$8.40
Concrete/asphalt/pavers, slabs, dways,
$100.00
swalks
DBPR Fee
$2 25
DCA Fee
$2.00
Education Surcharge
$2 80
Planning and Zoning Review Fee
$35.00
Scanning Fee
$9.00
Technology Fee
$3.75
Tota I :
$213.20
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$213.20
Credit Card
06/02/2022 $163.20
Credit Card
05/04/2022 $50.00
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 DAVI 11,
:I certify that all the foregoing information is accuregulating r ti and zoning
'�%F�ut�heprmor �I a%ut(h�o�rize the above named
4' C,
Authorized ignatu : Owner / Applicant / Contractor / c
(nd that all work will be done in compliance with all applicable laws
kractor to do the work stated.
it
Date
June 02,
Page 2 of 2
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: (305) 762-4949
FBC 20
BUILDING Master Permit NoX %' 1123
PERMIT APPLICATION Sub Permit No.
1g6LDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
10B ADDRESS: 1., �� i
City:
Miami Shores
County:
Miami Dade Zip
Folio/Parcel#:
, , ->>%< r -
)��j - r,�
`
Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type -Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ' 2s ci Phone#:
Address:
n_
City: ` \��`,����-��State:
Zip: Ly��
Tenant/Lessee Name: Phone#:
Email
CONTR
Add res
City: 0 State: �"����
Zip:
Qualifier Name: _)G � � 0_0i`i�� Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: II City: State: Zip:
Value of Work for this Permit: $ L4 . Square/Linear Footage of Work:.. ET
Type of Work. ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑Demolition
Description of Work: 1 ('- 4,/_' l l 1—�,) oc,;, l- li.
-
Specify color of color thru tile:
Submittal Fee $ .57�� , V`� Permit Fee $ too CCF
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
_ Training/Education Fee $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $
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
2M
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 rochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded noticeoAcomrqncement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is iss ft
e absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature C1 , 7'-`' Signatu
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of —Apr 1 20 by
�P0 + Y V J lki who is personally known to
me or who has produced 6 r% V0 - �,C !-L. as
NTRACTOR
The foregoing instr�m nt fos acknowledged before me this
day of r 1 20 .ate. by
L1Ose R-A ` (NS: A Z, who is personally known to
me or who has produced
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: KI Sign:
Print: VVENDY SOT 0 11 Print:
Seal: i `�=Notary Public -State of Florida
Commission # HH 211893 Seal:
My Commission Expires
January 12, 2026
as
tp. B i
`:Notary Public -State of Florida
_ Commission # HH 211893
My Commission Expires
January 12, 2026
************************************************************************************************************
APPROVED BY -S /3�h Plans Examiner I ZZ Zoning
7
Structural Review Clerk
(Revised02/24/2014)
W
N
W
IL
CK��.iaJ
M�V— 23-�
ilding Depart n
ism! Shores Vflla a Dateu/7—
Zoning
Dept. Date
Building Dept.
Subject to coand regulations.Federal, State
and County rules
Permit#
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No '
oo� ' OVERHEAD UTILITY LINES
FOUND REBAR
15E ALLEY
FOUND
(NO LD.)
iz-
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21'ASPHALT PAVEMENT
p •
IRON PIPE
(NOLD.)
985,
15—
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LOT 23. BLOCK 46
—
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P.B 10, PG. 70
FOLIO: 11-3206-013-6280
3.5'
LOT AREA: 6.375 SO. FT
I
TWO STORY
xl
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-
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H = 50.0' +/-
C = 30.0' +l-
04�
Lid
otia N.E. 93rd STREET
ono
_ - —
0-1— SITE PROPOSAL
75 PUBLIC RIGHT-OF-WAY
2V ASPHALT PAVEMENT
PH-EC.EIVED
O,V;
MIAMI SHORES VILLAGE
PUBLIC WORKS REVIEW
APPROVED _DATE S7�4Z
h2 architecture
UCENSE NUMBER AA26001991
1701 SUNSET HARBOUR DR. L706
MIAMI BEACH, FL 33139
AA26001991
xxw N2aIFMectur oRD
ANDRES HOLLMANN
LEED AP BCD-P A. 94333
CONCEPTDESIGN
HUGO WARES NLRB ARIA LEED AP
STRUCTURAL ENGINEER
A- SITE NOTES
NEWORNEWAYAPRCNVATHCHK:AGOBRICKPAVERE ORIVEWAYAPPROACHTOBE
CONSTRUCTED PER CITY STANDARDS
NEWCHICAGOBR(CKPAVERS WALKWAYIDRIVEWAY
NP. Dete CNHHYPL-
3 RETAIN ALL RNN WATER INSIDE PROPERTY
NEWCHICAGO BRICKPAVERSDECK
5 PROPOSED Sin FENCE. KEEP SILT FENCE S' IN FROM SIDE AND REAR PROPERTY LINES SEE
DETAILS
S MAV 24TH GEN REVISION
2022
6 SANITARY CLEANOUT. SEE PLUMS. -PLANS AN) A SEPTIC SYSTEM ENGINEERING, SHOF
T-ESE CRAWTKGE SFAL'-NC'M L'SEC FCF
DRAMANGE
CMS'RLYT-UNLESS T:Ev ARE —EC ME
8 DOMESTIC WATER SUPPLY BACKFLOW PREVENTER IN PRIVATE PROPERTY BUT NOT
FURTHER THAN S'0' FROM THE PUBLIC RIGNTOF WAY VERIFY LCCATION IN FIELD.
SELAEC ME FAVE BEEN A FFR.EC 61 TIE ELILDNC
CEFPFTMENi I'ISThECO\'PACiCFS
9 ACCU MOUNTED CONCRETE SLAB ALL ELECTRICAL EQUIPMENT MR CONDITIONING,
FESFCA5VU—C BUILC FRCV-FE VO-RLF-TO
PLUMBING APPLIANCES AND PLUMBING FI—RES. DUCT SYSTEMS, AND OTHER SERVICE
EQUIPMENT SHALL BE LOCATED AT OR ABOVE THE FEW BASE FLOOD ELEVATION PLUS ONE
FOOT
DATE AD CCMPLETE SET CFCMSTF LCTCN
COCL'MENT5 THE RELEASE AND AEE CF PAR•IAL
CLRINC DESIGN DEVELCFN&,1 :C &MNIG SHAL-
12 WWOE - HEIGHT GATE WITH SELF-CLOSING.SELF-LCCMNG WTH POSITIVE MECHANICAL-
NOT RELIEVE TFE GENERAL CCNTTACTCR OF
LATCHING' LOCKING INSTALLED A MINIMUM 54-ABOVE THE THRESHOLD
13 UPON PLACEMENT OETHE LOWEST EFI AND PRIOR TOFURTHER
"ISTER RESFCN51SIUTY FCF F..IFh.EN VCFNM'C
PE COCRD—ON WTI ILL TRADES
I—ITERTICAL
CONSTIIAENTF R EVIEWAON CERTIFICATE SNALLBE-ONGTEDTCN1133)LpNG
DEPARTMENT FOR RENEW AND APPROVAL IFBC 2014. BUILgNG SECTION 1133). ELEVATION
INCLUDE PHOTOGRA
SEAL Digitally signed
- 9 Y 9
NERT6 FICKESHALL
4 NEW 6'PICKET FENEC
T4E EXISTNGPENCE o'
15&K5'TRPSM—T.MINKOFPXS'TRPSMT.MIN/pFP
:.+
(!� by Andres
Hollmann
*
Date:
_
2022.05.25
-04'00'
PERMITISq'T48.41
PAVEMENT 562 K - A54%
6%
6.2.
-
W
THE TULLY
RESIDENCE
RENOVATION
SITE LEGEND
GPSCOMROLMONRIMENT
-, FIRE
349 NE 93 ST, MIAMI
HYDRANT
WATER VALVE
SHORES FL
CWATER METER
— - CENTERLINE
yV
`T POWER POLE
DUNE 9.2021
- POW ER POLE ANCHOR
.IF PALM TREE
C OAK TREE
Mnn br checAea bA
°26' EXISTING GRACE ELEVATION
AWIw CNecker
PROPOSED GRADE ELEVATION
pyMm
-OSPb5
--- PARCEL BOUNDARY LINE
f21052
------' PROPOSEDSWALE
Q
--- PROPOSED SILT FENCE
17 DRAWINGnTE
— — — SETBACKS
N
—X—X— FENCE - CHAIN LINK
V SITE PLAN
FENCE -WOOD
O
THIS PLAN IS NOT A SURVEY REFER TO THE ENCLOSED SURVEY FOR SURVEY
INFORMATION.
N ECA-E A,i--d
THE BOUNDARY SHOWN MUST BE VERIFIED BY THE LICENSED SURVEYOR
PERFORMING THE SITE STAKEOUT PROPERTY UNES MUST BE ESTABLISHED IN THE FIELD
-- ---
❑ PAGE
By THE LICENSED SURVEYOR PERFORMING THE STAKEOUT
A
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LEGEND OF SURVEY ABBREVIATIONS
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Geoff Tully
PROPERTY ADDRESS: 349 NE 93 St Miami, FL 33138
LOT: 93
BLOCK: 46 SUBDIVISION:
PROPERTY ID #: 11-3206-013-6280
PERMIT #: 13-SC-2351553
APPLICATION #: AP1714562
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1675667
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,050 ] GALLONS / GPD Septic CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 500 ] SQUARE FEET Trench configuration drainfi SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [] MOUND [ ]
I CONFIGURATION: [X] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: Int. crown NE 93 St & E PI. 10.20' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 4.80 ][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 34.80][ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 30.001 INCHES
0
T
H
E
R
*Inspector to verify the broken septic tank is properly abandon.
`Bottom of drainfield elevation & invert elevation to be no less than 7.30' NGVD and 7.80' NGVD respectively.
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
400 gpd.
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE:,'
Carlos M Icaza ` `--��--•'•
DATE ISSUED: 10/25/2021 ,
DH 4016, 08/09 (Obsoletes all previous edi`..tiansl a'V not�b' used;
( t 1, b[ 1. 6 c ( b
Incorporated: 64E-6.003, FAC �E� C 6 <C& <
AP171.4s5.
EXPIRATION DATE
SL1610 1.21
Dade CHD
04/25/2023
Page 1 of 3
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Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
349 NE 93RD ST, Miami Shores, FL 33138
Fees
Amount
Education Surcharge
$0.80
Public Works Permit Fee
$100.00
Scanning Fee
$6.00
Technology Fee
$2.50
Total:
$109.30 -
Parcel Number
1132060136280
Payments
Date Paid Amt Paid
Total Fees
$109.30
Credit Card
06/02/2022 $109.30
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 F A IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating n u ion and zoning. Futhermore, I authorize the above named c tr for to do the work stated.
Authori4 Sign ure: Owner / Applicant / Contractor / Agent Date
June 02, 2022 Page 2 of 2
MAY ® A m l
Miami Shores Village
Public Works Department BY:-JE
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property �]
Permit#:
Name of Applicant (if utility see below):a
Owner off the following described property:
Legal Description: Lot 2S //Block L & Subdivision
c
Folio#; � 1��� -O)�" 75_
Address: r1i
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME:
Qualifier/Authorized Age t:
Address: f-I u K
City: "-rx"
Telephone:
State Certification or Registration
ReqL
way:
ZIP:
Certificate of Compete
rmission to install (describe work, attach separate page if necessary) in the adjoining right of
Type of Work: P Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
State:
Email:
ZIP:
Registration #:
Value of Work for this Permit: $Square/Lineal Footage of Work:
Permit Fee $ 100.00
Notary $
Bond $
***** Fees *****
Training/Education $ 0.20 Technology Fee $ 0.80 Scanning
(if required) Total Fee Now Due $ I ___
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 �� , 7-
Applicant or Authorized Agent
The foregoirg instrument was acknowledged before
me this,a day of 20-QQ, by
who
is personally known to me or wh has produced
i�wIver S L.'a%rlsk as
identification.
2017-04-15
Signature
Company/Utility Agent
The foregoing instrument was acknowledged before
me this day of 20_ , by
who
is personally known to me or who has produced
as
idPntifiratinn
tY PUBLIC:
******************
Public Works Director, or Designee
CFN: 20220293528 BOOK 33120 PAGE 4739
DATE:04/08/2022 02:11:18 PM
HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY
�` ynonys
„ Miami Shores Village
Building Department
k-,s 10050 N.E.2nd Avenue
Ptee
<axm* Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner} Li,� t ;' It herei fter referred to as the _
owner of the following described pr perty (address):i 2 " M104; 7,6IL
Legal Description Lot
Block � Subdivision 1'
Folio # 1 1 '>1C (11?,
Requests permission to install (describe work):_ ,ITT=;:,�
WiWin the public right of way of (address) ='T 1 t L� qlj - _ �7�W_
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 dogs 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 of Miami Shores Village (or his fully authorized representative),
Signature L-) 7---
Owner or Agent
The foregoing instrument was acknowledged before me this day of I c,' 20`. , by
lge&Uu who is personally known to me or who ha roduce_d�r,���"'S
as identifi ation a d who did take an ath.
i
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
otary Public -State of Florid
commission N HH 211893
My Commission Sxplres
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Loca� Business Tax Receipt
County, Stcatt,,� of Florida
PAY
64
LB
O, EXPIRES
ltPxa"tlxint ors
Lffikit"It"o LIP
ew -Ca SI=C:- TYK €i3 WSMSS
Work .r kf j FPPL i i
Thir vocal BusinessTex Receipt only confirm$ payment of the Local Business ;ax. -fIto Receipt is €seta lican- -
Permit or e certification of the holder's qualifications, to du business. Holder must comply with any c=,:£.Rmwwnlo
or A009 VOrnmuattatt regulatory taws and requirements which apply to tiro business.
The RECEIPT NO, above must he displayed an all commercial vehicles- ianu -Dade rode S ; &1 2
for more information, visitWv,&yM g ��#€t ���t ��#,lgctrtr
Municipal n r ct r ec i
Miami -Dade Cnllnty_ .CitgtP. of Florida
—THIS 1S NOT BILL —DO NOT PAY
6402341 BUSINESS NAMEAOCATION RECEIPT NO. EXPIRES
BRICK PAVER GROUP INC NEW SEPTEMBER 30, 2022
350 W PARK DR 101 7617303 Must be displayed at place of business
MIAMI FL 33172 Pursuant to County Code
0" Chapter 8A — Art. 9 & 10
lm, ' '
OWNER SEC, TYPE OF BUSINESS IEIEIVEI
BRICK PAVER GROUP INC MMC SPECIALTY ENGINEERING CONTRA(rTTOLLELLECTTOROR
E0900115 C
$175.00 09/15/2021
Category(s) 1 FPPU05-21-004278
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 N0, above must be displayed on all commercial vehicles — Miami —Dade Cede Sec Ra-2.76.
For more information, visit www.miamidademov/taxcolloetor
ACORL70 CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
4/5/2022
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(les) 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
Acentria Insurance - Miami
8700 West Flagler St, Ste 402
CONTACT
NAME: Jorge Pena
PHONE
(A/C. N Exf : 305-262-5244 FAX Ne): 786 393-6414
ADDRESS: lorge.pena@acentria.com
Miami FL 33174
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Depositors Insurance Company
42587
INSURED BRICPAV-01
BRICK PAVER GROUP, INC.
350 W Parks Dr. #101
INSURER B : Progressive Express Insurance Company
10193
INSURER C : National Union Fire Insurance Company of Pittsburg19445
—
INSURER D : Insurance Company of the West
27847
Miami FL 33176
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1680615202 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
MM/DD
POLICY EXP
MM/DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
Y
Y
ACPGLD03059454854
8/21/2021
8/21/2022
EACH OCCURRENCE
$1,000,000
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L
X
AGGREGATE LIMIT APPLIES PER:
POLICY a PEC LOC
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
Y
Y
02626834-1
9/15/2021
9/15/2022
COMBINED SI SINGLE LIMIT
Ea accident
$ 1,000,000
_
BODILY INJURY (Per person)
_
$
ANY AUTO
OWNED X SCHEDULED
AUTOS ONLY AUTOS
X
BODILY INJURY Per accident
( )
$
HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
X
PROPERTY DAMAGE
Per accident
$
_
$
C
UMBRELLA LIAB
X
OCCUR
Y
Y
BE023632391
9/14/2021
9/14/2022
EACH OCCURRENCE
$ 4,000,000
X
AGGREGATE
$ 4,000,000
EXCESS LIAB
CLAIMS -MADE
DED I X I RETENTION $ 0
PRODUCTS/COMP OPS
$ 4,000,000
D
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE El
OFFICER/MEMBER EXCLUDED?
N/A
N/A
Y
WIL505492902
4/3/2022
4/3/2023
STATUTE EORH
EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
(Mandatory in NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Concrete paving.
Primary and noncontributory. Waiver of subrogation included. Excess policy follows form.
Miami Shores Village Building Department
100500 NE 2nd Ave
Miami Shores FL 33138
%,AN%,GLLA 1 IUN
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
.� c/ ��
@ 1988-2015 ACORD CORPORATION- All rinhtc racarvarf
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD