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PT-10-1080Protect Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Owner information MARY SAXON 1285 NE 95 ST MIAMI SHORES FL 33138 -2549 1 Contractor(s) JOHN G DONAHUE LLC Phone 305- 945 -0374 CeII Phone Type of Work: Exterior Color. Additional Info: PAINT Classification: Residential Color: _Approved Color. _Approved_ Code Comments: ROOF WHITE ONLY Color: _Denied Fees Due CCF Education Surcharge Notary Fee Permit Fee Technology Fee Total: Amount $1.20 $0.40 $5.00 $60.00 $1.60 $68.20 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. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Address Parcel Number Phone Pay Date Pay Type Amt Paid Amt Due Invoice # PT -6 -10 -38183 06/14/2010 Check #: 4083 $ 68.20 $ 0.00 June 16, 2010 Date Expiration: 12112/2010 Applicant Cell Available Inspections: Inspection Type: Final 1 June 16, 2010 1 THE POLICIES OF INSURANCE USTED 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 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_ AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MMIDD/YY) POLICY EXPIRATION DATE (MM /DD/YY) LIMITS A INSURER B: GENERAL LIABILITY COMMERCIAL GENERAL immure 090004899466 2 04 06/01/10 06/01/11 EACH OCCURRENCE $ 50 0 0 0 0 X UAMAIi� U K N tU PREMIBES(Eaoccurence) $100,000 $ 5,000 $ 500000 CLAIMS MADE X OCCUR MED EXP (Any one person) PERSONAL 8 ADV INJURY GENERAL AGGREGATE $ 1000000 GEML — I AGGREGATE LIMIT APPLIES PER: POLICY n JECT El LOC PRODUCTS - COMP /OP AGG $ 1000000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON•OWNEDAUTOS (Es COMBINED INGLE LIMIT $ — _ BODILY INJURY (Per per $ — _ BODILY INJURY (Per accident) $ — PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ R OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION S il $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABIUIY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 1 WRY L MITI I 1 TH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS FAX #: 305 - 756 -8972 .ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID LZ DONAHUI DATE(MMIDD/YYVY) 06/16/10 PRODUCER Todd- Dorroh Insurance, Inc . 4388 Clinton St. Marianna FL 32446 Phone : 8 66 -482 -2310 Fax: 850- 482 -7042 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC It INSURED John G. Donahue North Mia #D 0 INSURER A: Bankers Insurance Company INSURER B: INSURER C: INSURER D: INSURER E MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI SHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPO + _ LIGATION OR LIABI CF ANY KIND UPON THE INSURER, ITS AGENTS OR / REP " TATIVES. ` � — Inn ro N T / sne odd 06/16/2010 12:39 FAX COVERAGES C [7J 001 /001 © ACORD CORPORATION 1988 BUILDING PERMIT APPLICATION FBC 2004 Pet-mit Type: PAINT PERMIT �((��' %//i/S% Onn C � � er's Name (Fee Simple Titleholder) % airOr1/ /G4 4bedi Phnnt # _Ya■< 7//"'7 ej Owner's Address / 76 Cite j441 s of i,24e-c State 4.o ief eh Zip ,ev.001P Tenant/Lessee Name Phone # E -MAIL: OWNER BUILDER: Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Zip '/ f FOLIO / PARCEL # Is Building Historically Designated YES NO Contractor's Company Name (.../.01:41 Peitioth.te Miami Shores Village m G m n Y Building Department >0050 N.E.2nd Avenue. Miami Shores, Florida 33138 %it (305) 795.2204 Owra (305) 756.8972 Permit No. Master Permit No. AA 9S �/ -- e---CZ k Phone # e ,c3 Contractors Address t'eaD /4' j `7/ J5 e7`" City d/14/l// �� State 'Le, / Zip Z5S/,‘0 Qualifier Name \./p//vll ig .Z 44IL,te Phone # 'YF a 71 State Certificate or Registration No. Certificate of Competency No. 812 Value of Work For th's Permit Type of Work: ❑ Addition / ❑ Alteration / ❑New / ❑ Repair/Replace Describe Work: 1✓ //li/ p/>/ /fie. Application is hereby made to obtain a pennit 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 pennit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS. WELLS, POOLS, FURNACES, BOILERS, HEATERS. TANKS and AIR CONDITIONERS. ETC "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE F R IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFO E RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to .-ipplicant: .4s a condition to the issuance ofa building permit with an estimated rah ue exceeding $2500. the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will he delivered to the person whose property is subject to attachment. Also, a certffied copy of the recorded notice. of commencement nmst be posted at the job site for the first inspection which occibs seven (7i 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. ******** * * **** * * * * ** * * * * * * ** * * *** * * *,** Fees**************** * * *,* * * *** * *,* * * * * ** *,* ** * * * * ** Permit Fee S CCF $ Technology Fee: Training/Education Fee $ Notary $ Code Enforcement $ Double Fee 5 Zoning $ Total Fee Now Due 5 k L) ?Pi 0 See Reverse side Signatu PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be painted Directions: Please circle corresponding number to appropriate color sample. Walls: 1 Fascia: 1 Drip Cap/Drip Edge: Soffit: 1 Roof: l Flower Bins: 1 Shutters: 1 Awnings: 1 Chimney: 1 Doors and Door Jams: Garage Doors: 1 Railings: Fences: 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 1 2 3 4 1 2 3 4 All brick (simulated or regular): 1 2 Stucco Banding: 1 2 3 Any other Stucco Features: Accessory Buildings 3 Other: OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in complia with all ap cable laws regulating construction and zoning. Owner or A ent u The foregoing instrument was acknowledged before me this 1 - 1 dav of f . 20 I b 5CU I 1 g 515' l� j'( —� who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: sii /1 Sign: — .`` Print: My Commission Expires: 03 106 1 Signature Contractor The foregoing instrument was acknowledged before me this IN da of . 20 K., by N N who is personally known to me or who has produced E--L- as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: NOTARY PUBLIC My Commission Expires: NOTARY PUBLIC Commission l Commission # , *.******x.****.* ** ****** p68I691RR\,1x** ******> tR**.> t***> Y*.**R*S�y+;ti.I+6�I6�TM�,�,�**.****. • ' l F Ifs `o amitt``A\e�� APPLICATION APPROVED BY: _ Plans ner (a lid Attach color samples with name and number. 1 0\ �III1 1111 lII /��� A ;,%; Z i/1 °i 7 II 111W 031 Preservation Board Code Enforcement (Revised 04 2. 05 -25 -2010 ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 05/25/2010 EXPIRATION DATE: 05/24/2012 PERSON: DONAHUE JOHN FEIN: 830443200 BUSINESS NAME AND ADDRESS: JOHN G DONAHUE LLC 3862 NE 171 STREET 4 NORTH MIAMI BEACH FL 33160 SCOPES OF BUSINESS OR TRADE: 1- PAINTING * * IMPORTANT: Pursuant to Chapter 440. 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of 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. QUESTIONS? (850) 413-160 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 Inspection Number: INSP - 146052 Permit Number: PT -6 -10 -1080 Scheduled Inspection Date: June 28, 2010 Inspector: Bruhn, Norman Owner: SAXON, MARY Job Address: 1285 NE 95 Street Miami Shores, FL Project: <NONE> Contractor: JOHN G DONAHUE LLC Building Department Comments PAINT Passed /f//J 9ESi Failed Correction Needed Re- Inspection Fee June 25, 2010 No Additional Inspections can be scheduled until re- inspection fee is paid. Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspector Comments 'G For Inspections please call: (305)762 -4949 Permit Type: Paint Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060144020 Phone: 305 - 945 -0374 Page 14 of 27