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DS-10-744Inspection Number: INSP- 141933 Permit Number: DS -4 -10 -744 Scheduled Inspection Date: June 17, 2010 Inspector: Bruhn, Norman Owner: PIPER, SHERYL & MARK Job Address: 1311 NE 103 Street Miami Shores, FL 33138- Project: <NONE> Contractor: CHAMPION CONCRETE Building Department Comments June 16, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Type: Driveways /Sidewalks /Slabs Inspection Type: Final Work Classification: New Phone Number Parcel Number 1132050300110 Phone: (305)252 -8055 INSTALLATION OF A NEW PAVERS DRIVEWAY Passed a .-4b Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Page 6 of 20 05/11/2010 12:13 3055955633 ALEX SiNK CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL FLORIDA A1 SERVICES DIVISION OP WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO RE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUC'T'ION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 04/13/2010 PERSON: BASIUO FEIN: 2018/7735 BUSINESS NAME AND ADDRESS: JAMIE BASILIO CORP 11001 N.W. 83 Sr. #103 DORAL PL 33178 STA'L'E OF FLORIDA DEPARTMENT OF FINANCIAL, SERVIOES DMSION OF WORKERS' COISRTiON CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EKBRPr FROM FLORIDA WORic' COMPENSATION LAW EFFECTlVev 04/12/2010 EXPIRATION DATE: 04/12/2012 PERMO* JAIME A SASILIO FEIN 201817730 BUSINESS NAME AND ADDRESS( JANE 8.4.01110 Mee 11001 N.W. 03 4T. 1 103 DORM n. 33170 SCOPE OF BUSINESS OR TRADE 1- PAYING MU!) 2 - CONCRETE WQFl NVC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 EXPIRATION DATE 04/12/2012 JAIME A 04-13 -2010 PAGE 01 SCOPES OF BUSINESS OR TRADE: 1 — PAVING (6221) 2— CONCRETE WORK INP00TApTe Par. ,rpi to Chapter 440 • 08(141, F_L, as offieer ef e e section may not MOM beetles er compeer/eon enter this chapter. Funereal fa C h a t elects 0B , F.S., C ificatess of etecties o be e Rt... el order this e et nape of the Malaga of wade Ifates ae the eauca of eieenee to be a 4 ep apple only ifi the al election to be exempt shalt he subject to rename* if, et any time after Ming o the melee or 0. issuance Notices c 10 certificate. the perm" melee On (i thaoatims et eartificeta se Nagar meets the teneiremeels of this sectiou dot tssgaeue al certificate. The eepenmapt shot revoke 1 eeniffceie et any time for dente of the persoe named es the cerlificeie to meei the revamp/Mg pi this neuron, DWC -252 CERTIFICATE OF ELECTION TO DE EXEMPT REVISED 09 -06 QUESTIONS? 01503 413 -1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE IMPORTANT Pursuant to Chapter 440.05(14), F.S., en officer of a corporation who elects exemption from this chirpier by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. H Pursuant to Chapter 440.051121, F.S., Certificates of election to be f exempt.. apply only within the scoQe of the business or trade listed on the notice of election to be exempt E Pursuant to Chapter 441L05(131, F.S.. Notices of election to be exempt and certificates of election to he exempt shell 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 moots the requirements of this section for issuance of a certificate. The department shall revoke a certificate as any bane for failure of the person named on the certificate to meet the requirements of this Section. CUT HERE Carry bottom portion on the Job. keep upper portion for your records. QUESTIONS? (850) 413 -1809 FROM Accurate AC'O Q PRODUCER Accurate 8300 West Flagler Suite 114 Miami, FL 33144 Phone (306)226 -8727 INSURED Jamie Basilic Corp D/8 /A Champion Concrete 15330 SW 148 Terrace Miami, FL 33196- COVERAGES INSR i ADO'L LTR INSRD A El GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY 00 CLAIMS MADE J OCCUR 0 GEN'L AGGREGATE LIMIT APPUES PER: ❑ POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO r ❑ � l ALL OWNED AUTOS O SCHEDULED AUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS 0 0 GARAGE LIABILITY ❑ ANY AUTO 0 EXCESS/UMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION E WORKERS COMPENSATION AND EMPLOYERS' LABILITY ANY PROPRIETOR 1 PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below OTHER CERTIFICATE HOLDER Village of Miami Shors 10050 NE 2 Ave Miami Shors, Fl 33138 1305- 758 -8972 ACORD 25 (2001108) QF (TUE)MAY 11 2010 12: 05/ST.12: 03/No.7500000892 P 1 CERTIFICATE OF LIABILITY INSURANCE DATE (MOONY) 05/11/10 100609000003868 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 PQLIC ES BELOW. Fax (305)2264767 INSURERS AFFORDING COVERAGE NAIC X INSURER A: American Builders Insurance Co- INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDmoN 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POUCY DATE N D DATE 1MWDD#YYI 08/22/09 POLICY EXPIRATION 08/22/10 DESCRIPTION OF OPERATIONS1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED EXPIRATION DATE THEREOF, THE ISSUIN 30 DAYS WRITTEN NOTICE TO THE LEFT, BUT FAILURE TO DO 90 9 OF ANY KIND UPON THE INSURER, ITS AUTHORGED REPRESENTATIVE Lucia Estrella LIMITS EACH OCCURRENCE 'DAMAGE RENTED PREMISES (Ea oeeurence) MED EXP (Any one Person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS • COMP /OP AGG COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY • EA ACCIDENT OTHER THAN EA AC9 AUTO ONLY: AGG EACH OCCURRENCE AGGREGATE ❑ ORY u ndrrS ❑ R E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE EL DISEASE - POLICY LIMIT 1,000,000 100,000 5,000 1,000,000 1.000,000 1 ,000,000 CELLED BEFORE THE T R I ENDEAVOR TO MAIL 1. MOLDER NAMED TO • 1' it . ' LIGATION OR UABILTY Jlii iIE SENTATIVES. WV ® AC ■ - D CORPORATION 1988 Protect Address 1311 NE 103 Street Miami Shores, FL 33138- 1132050300110 Block: Lot: SHERYL & MARK PIPER 1 Owner Information May 11,2010 Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fees Due Bond Type - Owners Bond CCF Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $300.00 $3.60 $1.20 $125.00 $6.00 $4.80 $440.60 Address Contractor(s) CHAMPION CONCRETE Phone Cell Phone (305)252 - 8055 (786)402 -4802 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Permit Expiration: 11107 /2010 Parcel Number Phone Applicant SHERYL & MARK PIPER 1311 NE 103 Street MIAMI SHORES FL 33138 -2623 Approved: Yes Comments: Date Approved: 4/30/2010 : Yes Date Denied: Type of Work: DRIVEWAY Bond Retum : Additional Info: PAVERS Classification: Residential Amt Paid Amt Due Pay Date Pay Type Invoice # DS-4-10 -37726 05/11 /2010 Check #: 2458 $ 90.60 $ 350.00 04/29/2010 Check #: 2450 $ 50.00 $ 300.00 04/29/2010 Check #: 2451 $ 300.00 $ 0.00 Bond #: 1958 cen Valuation: Total Sq Feet: $ 5,100.00 750 1 Available Inspections: Inspection Type: Final Sidewalk Landscaping Foundation 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. May 11, 2010 ate 1 BUILDING PERMIT APPLICATION FBC 20 Value of Work For this Permit $ Notary $ Scanning $ (0° on Radon $ 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 Type: BUILDING ROOFING Owner's Name (Fee Simple Titleholder) f/$ttJ1 C p a f et_ Phone # 3o5 ate cip_1J' Owner's Address 13 f [ ;OE (03 s) State --,^- Zip 313P Tenant/Lessee Name Phone # Email Job Address (where the work is being done) � S 49/ -( City Miami Shores Villa. e County Miami - Dade FOLIO / PARCEL # Is Building Historically Designated YES NO Flood Zone Contractor's Company Name ) ®� 6 ^/01,�,e Phone # 3175 . o 57 'r <57 Contractor's Address 1.53 K$LZ I 1 2 - te 7-e em_ City ri te04041g State ' Zip 33)cl to, Qualifier Name ..J4-Iryye_ /j 4-qt Jj 17) 1 Phone # ?d6 (0 L �) eQ"z_ State Certificate or Registration No. Certificate of Competency No. O.S 63,S o0d'4S7 Contact: Phone 3v5 q7$ L E -mail Architect/Engineer's Name (if applicable) Phone # rn� Square / Linear Footage Of Work: 75 S / 0®_ Type of Work: ❑Addition ['Alteration ❑New ❑ Repair/Replace ❑ Demolition Describe Work: . f a 1PPJ�.�,tC� .r v-e ******* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ,F Submittal Fee $ ( ' Permit Fee $ / Training/Education Fee $ 1' DPBR $ Master Permit No. CCF $ Permit No. 1190 -.. 144— Zip CO /CC $ Technology _ ee $ 4- Bond $ Double Fee $ Violation date: /�� ((�`� Structural Review. $ Total Fee Now Due $ "R/O4 (O See Reverse side - MI IS Apk. 9610 Bonding 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 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 't be posted at the job site for the first inspection whiclyccurs seven (7) days after the building permit is issued. In th - absen e of such posted notice, the inspection will not be /prj e and a reinspection will be charged. Owner or Agent The fore _oing • trument was ac wle ed be me this �— day of � j � , 2010, by who 's sonally known to me or who has produced ' RA ntification and who did take an oath. Sign: Print: My Commission Expires: at4r9e ,YaF ***kvkdr #dr 9e** **** APPROVED BY (Revised 07 /10 /07)(Revised 06/10/2009) OT ign: ...(.. .,rl. .f. �r ` ti ss My Commission Expires:,* ' °;P, ` ; �, �' �, *** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** %!�C] Plans Examiner Engineer Signature /% / Contractor The fore oing ' stntme ZU� acb ged before 1 y VAnX J own to me or who has produced entification and who did take an oath. PUBLIC: ' /CS Zoning Clerk checked raw; ''' ft # 1 4 7 1 Z :NOter n a ,t of way far egsatittifitiaildfDfright.; deSO401k)134#000ed tf&H,nt.cix-: • • • fo: •H ieura 4 M iami Shores V 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) f f4KJL. C ' 6D 4L. hereinafter referred to as the owner of the following described property (address): 8311 tJ • ry 103 S 7f ri, WQM' S} nyo__ ?)3 o Legal Description Lot Block Subdivision Folio # Requests permission to install (describe work): ,AA,+t 9 (AhC1 fA '�i S Within the public right of way of (address) 1 31 ( Ne= (0 3 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 of Miami Shores Village (or his fully authorized representative). SIGNED, SEALED, EXECUTED AND ACKNOWLEDGE on this SIGNED - EAL AND DELIVERED in esence of: 2 day of , 20 (Owner's Signature ) VOTARY rTRLC `i7ATE STILORIDA CIfittkijA V. Cutql GS '- `Comp: a riDD717!23 i s ats SE1 23,2011 O:'D. IV E r�aa CO. INC. BONDED WIVE �� b } Address: /J // /VZ Acknowledged by: PERMIT CLERK INITIAL -'` RECEIPT PERMIT #: � WY DATE: ` ' 'Contractor ❑ Owner ❑ Architect Picked up 2 sets of plans and (other) G��- " From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the -'ans need to be brought back to Miami Shores Village Building Department to ".nti . - - permitting process. RESUBMITTED DATE: & 1 1 0 • PERMIT CLERK INITIAL: 1/ M iami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No: 10- 7‘7 Job Name , 2010 D / /� � �� Buil ing Critique Sheet 7 v ` *1OC Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 795 -2204 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Page 1 of 1 Planning and Zoning Criteria Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax (305)756 -8972 Owner's Name: SHERYL & MARK PIPER Job Address: 1311 103 Street Miami Shores, FL 33138- Planning and Zoning Criteria and Comments Approved: Yes Date Approved: 4/30/2010 : Yes Comments: Issue Date: Not Issued Expires:Not Issued Folio Number:1132050300110 Owner's Phone: Total Square Feet: 750 Total Job Valuation: $ 5,100.00 Contractor(s) CHAMPION CONCRETE Phone Primary Contractor (305)252 -8055 Yes STATE OF (FLORIDA) COUNTY OF (DADE) The undersigned Affiant, h,i-iLk pi A- , does hereby attest that (Property owner) The attached survey, performed by 94'Y J, Q'-?d ,SUAv e Y h )G (Name of surveyor's company) For address: 130 NE' t03 r. rlit.ANA ..3) Performed on (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits. Further, Affiant say e naught. Property Owner Signature p� SWORN TO AND SUBSCRIBED before me this 1 day of Affiant is personally known to me, produced r as identificatio Revised on 5/22/2009/ Revised on 6/12/09 SURVEY AFFIDAVIT NOTARY. R=iBLIC— �-RTE4'FLORIDA CkaHb ` L Cf1es Aft; r:o; mt;.sav 110 .7123 � F,x�) GEP. BON rvz GE 23, 2011 D ED WED ATLANTIC TIC BONDING CO., INC, M iami Shores Vivage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Props Owner Print Name Notary :M 2009 2008 axing uthority Applied Exemption/ Taxable Value: Applied Exemption/ Taxable Value: a venal: r 000/8127 ai , r 000/8127 c oun _ • r 000/8127, c ..... r 000/8127 386. :M 2009 2008 .. Homestead: 825 000 $25 000 ►nd Homestead: Miami -Dade My Home Show Me: Properly lltforttati Search By: Item My Home Text only Property Appraiser Tax Estimator Property Appraiser Tax Comparison Portability S.O.H. Calculator Summary Details: 05 -030 -0 311 NE 103 ST ailing ARK C PIPER &W SHERYL ddress: 1311 NE 103 ST MIAMI + HORES FL c 138 -2623 EPLAT OF TR B MIAMI HORES BAY PARK STS PB 63 -17 LOT 2 LK 6 LOT SIZE 90.000 X 108 OR 15876 - 2834 0493 OR 15876 - 2834 0493 01 Assessment Information: Exemption Information: Taxable Value Information: E TO igi tal Oithophotospaphy - 2007 0 111 ft My Home 1 Property Information I Property Taxes. 1 My Neighborhood 1 Property Appraiser Home I Using Our Site 1 About !Phone Directory! Privacy 1 Disclaimer If you experience technical difficulties with the Property Information application, or wish to send us your comments, questions or suggestions please email us at Webmaster. Web Site 2002 Miami-Dade County. MI rights reserved. 4/29/10 3:44 AM Legend Property Boundary Selected Property Street Highway Miami -Dade County Water http: / /gisims2.miamidade .goy /myhome /propmap.asp Page 1 of 2