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RF-10-1175Scheduled Inspection Date: September 02, 2010 Inspector: Rodriguez, Jorge Owner: NUNEZ, CARLOS Job Address: 49 NE 110 Street Miami Shores, FL 33161 -7043 Project: <NONE> Contractor: JOHN WILLIAM BLACK JR Building Department Comments September 01, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 150589 Permit Number: RF -6 -10 -1175 For Inspections please call: (305)762 -4949 Permit Type: Roof Inspection Type: Final Roof Work Classification: Repair Roof Phone Number (305)965 -2222 Parcel Number 1121360040270 Phone: (305)785 -3300 CHIMMINEY LEAKING SEAL CRAKES AND BULL WITH MEMBRANE Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 150224. CREATED AS REINSPECTION FOR INSP- 147023. No ladder Fasteners for counter flashing must be sealed. Tile must be white. NB Page 14 of 20 BUILDING PERMIT APPLICATION FBC 20 Permit Type: BUILDING OWNER: Name (Fee Simple Titleholder): Carlos O. Nunez Phone #: 3 0 5- 9 6 5 - 2 2 22 Address: 49 NE 110 St . City: Mi ami Shores State: FL Zip: 33161 Tenant/Lessee Name: Phone#: Email: cnunez@live.com JOB ADDRESS: 4 9 NE 110 St . City: Folio/Parcel #: Miami Shores County: 11 -2136- 004 -0270 Is the Building Historically Designated: Yes CONTRACTOR: Company Name: 3 ' O\' N L 11 I J tt� Vh NA„C t Address: / b 5 �t' L L [ l 9 )'E r }" city: .4 U� W1 ^ � State: ) n a' 1 C G\ Qualifier Name: ` N 1.k OWN k N s ) (2_ State Certification or Registration #: CGC U?6 r 2 3 d Certificate of Competency #: Contact Phone#: 3 ' d0 Email Address: DESIGNER: Architect/Engineer: Phone #: CSD Value of Work for this Permit: $ ° C ) Square/Linear Footage of Work: Type of Work: OAddress UAlteration Description of Work: OteNAJV f'i'b -t e\w'A,, Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No. i'� r'! 0 1 ` \i Master Permit No. Miami Dade Zip: 33161 NO X Flood Zone: X Phone#: . 3 0 5 rS 33 zip: 3 Phone#: J r735 iCe� 1 ONew 2IRepair/Replace ODemolition S'eo \ Q124:65 INN Nni COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: ******** * *** * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * ** * * * * * * * * * ** * * *** * * * ** Submittal Fee $ a Permit Fee $ 4QQ CCF $ CO /CC $ Scanning Fee $ �ha Q Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ 0 off® Technology Fee $ 0 • Fr D Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 5 9 . B onding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S All 'N'IDAVIT: 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 App promise in whose pro for the fir inspectio NOTARY PUBLIC: ant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site ction hich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the be ap oved and a reinspection fee will be charged. Owne or Agent The foregoing instrument w acknowledged before me this 7 5 day of lqM -a.. , 20 9 by eAr k 5 �a�✓v '�-- who is personally known to me or who has produced A JESSIE G ' MEZ MY COMMISSION #DD594471 EXPIRES: SEP 12, 2010 Bonded through 1st State Insurance Sign: Print: My Commissi Y}' xpires: V ath. ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY •%;%� Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6/4/10) Contractor The foregoing instrument was acknowledged before me this 2 - 5 day of 3; ' , 20 I G b Je;t"A" LV I( 1 rAtIck r who is personally known to me or who has produced Sign: NOTARY P Print: My Comm . j Ex es: 1EZ MY COMMISSION #00594471 RES: SEP 12, 2010 d through 1st State Insurance th. Zoning Clerk r ZONIr,: DEPr BLDG DEPT STATE AND Priof- 05_ SUBJECT 10 CLNIPLIANCE WITH ALL FEDERAL DATE • •• ••• • • . • ••• • • • .. • • •• • •• • • • • • ••. • • • • • • . • • ••• •..... t • • • • •• • • ••.. • •• •• • 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 REOUCED BY PAID CLAIMS. s h LTR TYPE OF INSURANCE ti .. _ (N8R A las ... POLICY NUMBER (MM D SMtD LIMITS A GEMS UAEILI LIABILITY AGL87433 ? 02/10/10 02/10/11 i- EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL PRE MISES »Ea octwre€ $ 100,000 X I CLAIMS-MADE L_ J OCCUR MEO EXP (Any one person) s5,000 Prop. $1,000ded PERSONAL & ADV INJURY $ 1 , 000 , 000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS • COMP/OP AGG $ 2 7 00 0 , 0 0 $ !POLICY JECT ) j LO C AUTOMOBILE LIABILITY ? t COMBINED SINGLE LIMIT ¢Ea accident) ANY AUTO BODILY INJURY (Per Demon} son} $ ALL OWNED AUTOS BODILY INJURY iPer acc dent) $ SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) 8 ' HIRED AUTOS -- NON -OWNED AUTOS $ $ UMBRELLALIAB ■ OCCUR 1 EACH OCCURRENCE $ T EXCESS LIAR CLAMS -MALIE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRQPRIETORtPARTNERJEXECUTIVE OFFICER /MEMBER EXCLUDED (Mandatory In NH) n yes ; describe under DESCRIPTION OF OPERATIONS Y r N N A 1 WC STATU• i I OTH- TORY LIMITS 1 t ER EL EACH ACCIDENT $ J U t tasty E L DISEASE - EA EMPLOYEE $ E . DISEASE - POUCY LIMIT $ DESCRIPTION OP OPERATIONS 1 LOGAT(ONS 1 VEHICLES (Attach ACORD 101, AddlUOna( Remarke Sahadu(e k more space Is requlrsd) Remodeling, repair commercial and res for ba and kitchen tile of the house. 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. R T: if a cert ate older is an TI s N , 1. ' f ° ° D, he po cy(ies moat =, endo t' *T ATI «" WA , s V ct to the terms aexi conditions of the policy, certain policles may require an endorsement, A statement on this certificate duos not confer rights to the cert ificate holder in lieu of such endorsement(s). PRODUC INSURED COVE Insurance Marketing Center 2500 N. W. 79th Ave. #208 Miami FL 33122 Phone:305 -593 -1449 ES CERTIFICATE HO John William Black, JR 16521 S.W. 297th St. Homestead FL 33033 ER CERTIFICATE OF LIABILITY INSURANCE OP ID BM CERTIFICATE NUMBER: Lt2t�71bt£:l HAMS. Jessie P HON E Ate o E"`) 30 -216 -900 ADDREss si agomez €bellaouth . net cu STCi� INSURERA: Appalachian LS ere Snc INSURER B : INSURER C : INSURER D : INSURER E CN9URER F : CANCEL TION 88- Via. ACORD 25 (2009/09) The ACORD name and logo are registers r marks of ACORD INSURER(S) ABPB:<•RDING COVERA©.: FAX (A1 No): REVISION NUMBER: DATE (MMJDO/tY'YY 06 25/10 MIAMI SHORES VILLAGE 10050 NE 2 AVE MIAMI SHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE Date 1 1/13/2010 Producer Lion Insurance Company 2739 U.S. Highway 19 N. Holiday, FL 34691 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 # Insured: South East Personnel Leasing, Inc. 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Lion Insurance Company 11075 Insurer B: Insurer C: Insurer D: Insurer E: Coverages 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 at the terms, exclusions. and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. INSR LTR ADDL INSRD Type of Insurance Policy Number Policy Effective Date (MM/DD/YY) Policy Expiration Date ( MM/DD/YY) Limits GENERAL 1 , General D LIABILITY Commercial General Liability Claims Made Occur Each Occurrence $ Damage to rented premises (EA occurrence) $ Med Exp $ Personal Adv Injury $ aggregate Omit applies per: Policy ❑ Project ❑ LOC General Aggregate $ Products - Comp /Op Agg $ AUTOMOBILE LIABILITY Any Auto All Owned Autos Scheduled Autos Hired Autos Non -Owned Autos Combined Single Limit (EA Accident) $ Bodily Injury (Per Person) $ Bodily Injury (Per Accident) $ Property Damage (Per Accident) $ ■ EXCESS /UMBRELLA LIABILITY Occur ❑ Claims Made Deductible Each Occurrence Aggregate A Workers Compensation and Employers' Liability Any proprietorIpartner /executive officer/member excluded? If Yes, describe under special provisions below. WC 71949 01/01/2010 01/01/2011 X I WC Statu- tory Limits I 1 OTH- ER E.L. Each Accident $1,000,000 E.L. Disease - Ea Employee $1,000,000 E.L. Disease - Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AM B # 12616 Descriptions of Operations /Locations/Vehicles /Exclusions added by Endorsement/Special Provisions: Client ID: 31 - 65 - 662 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. that are leased to the following "Client Company": John William Black, Jr. Coverage only applies to Injuries incurred by South East Personnel Leasing, Inc. active employee(s) , while working in Florida. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937 -2138 or by calling (727) 938 -5562. Project Name: FAX: 305- 675 -8411 & MAIL HOLDER / ISSUE 12 -07 -09 (TD) / RENEWAL 17 -17 -09 (SH) / REISSUE 01 -13-10 (TD) Begln Date: 11/3/2009 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUI LDING DEPARTMENT BUI N 2 AVENUE MIAMI SHORES, FL 333139 Should any of the above described policies be canceled 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 shag impose no obligation or liability of any kind upon the insurer, its agents or representatives. f + /.. �rro --