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RC-10-1285Inspection Number: INSP- 148561 Permit Number: RC -7 -10 -1285 Scheduled Inspection Date: March 29, 2011 Permit Type: Residential Construction Inspection Type: Final Building Owner: HERNIQUEZ, ZAIDA & WILLIAM Work Classification: Alteration Job Address: 9906 N MIAMI Avenue Miami Shores, FL 33138- Inspector: Bruhn, Norman Project: <NONE> Contractor: HOME OWNER Building Department Comments March 28, 2011 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Phone Number Parcel Number 1131010180540 2 BATHROOM AND KITCHEN REMODELING PassedW?jf Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments For Inspections please call: (305)762 -4949 Page 1 of 11 f ,0-14 ANA i 1 BUILDING PERMIT APPLICATION C 20 Permit Type: BUILDING ROOFING Owner's Name (Fee Simple Titleholder) Owner's Address d i r City , . i.:' State Tenant/Lessee Name Contact Phone Miami Shores Village Bu ld ng. Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 7561,8972 INSPECTION'S PRONE NUMBER: (305) 762.4949 <s' 1 caJ Value of Work For this Permit $ D v Type of Work: aAddition _ °Alteration °New ❑ Re air e 1 ce Describe Work: P �P� ************* * ** * * * * * * * * * * * **** * * * * * * * *F * *** * * * * * * * * * * * ** * * * * * Submittal Fee $ Permit Fee $ Square / Linear Footage Of Work: Training/Education Fee $ Radon $ DPBR $ Violation date: so I Permit Ew. C e0 r ,,,,, Master Permit No. Vf ph e # •"', ?' Zjp ?i,-5-0 Phone # Email W [74 a. t° au &l cx co t)- Job Address (where die work is being done) City Miami Shores Villan@ County 1Vliami- Dade," Zip FOLIO / PARCEL # Is Building Historically Designated YES NO Flood Zone Contractor's Company Name 612m Phone # Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # * * * * * *** * ** CCF $ CO/CC $ Notary $ Scanning $ Double Fee $ Structural Review. $ Total Fee Now Due $ 90:' Technology Fee $ Bond $ See Reverse side a 0 Demolition Bonding Company's Name (if applicable) Bonding Company's Address City Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 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 peen t must be secured for ELECTRICAL WORK, PLUMBINLT, 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will• be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice;.. the inspection will not be approved and a reinspection fee will be charged. Signature Sign: Print: Owner or Agent The foregoing instrument was acknowledged before me this, 1S day of (CM 20 10, by U, V1J∎.l4r' H-lfta- ttt,Q,Z who is personally known to me or who has, l3 ced annul � V "mss As identification � wht d k taboiajh. NOTARY PUBLIC: My Commission Expires: r + ' ** * ** *fir* APPROVED BY I cRevised 07J10107)(Revised 06110 /2009) State Zip cb'c--I a Nom' Or- r rix ' r � iu � Plans Examiner Engineer Zip Signature Contractor The e foregoing instrument was acknowledged before me this day of , 20 ._..__,`by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBIC: Sign: Print: My Commission Expires: Zoning C'lerk checked cictob /-$ t - 33 4 Roo Grl • • • • • • • • • • • • /1/ 77(4)/ ijJ !tAkk( Ave k0 0M5 --4 •••,,, 4,, )(IS 71 e.; 1 E 9 . 4 HilL)LP„(\L • • ; 4oe/ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • (16; /4/.?/frj GAR/ • . 4. • • • • • • • • • • • : a2, • • • • • • • • • • •• • • iffee) • • • • • Loc4ok)l)ez 200A juL 1 4 2010 )< (TaH 1\1 Pi•IL r , , " t CAL se/r/e v fee WO p PC, -- q q06 - ki r,o i A ve - Cc: 33164 C Lec - fretc RIfchEA) GPI 0 /51- W/151-48- R ptspos,o GP/ G FI 4141- G K I 1"C N L N " 1 !i u 70 c. # ( y 1 dd 5°itirs/� li .� c✓, �-t,- '�rLc� C) 7' 0A'1L d d ems' 4) - rc' bw &,Z /:‘ 0 e2". (It -4( PgtcaoW sr, - 22 D V G Fl • • • • • .... • .... • .... •• • • •. •• J y c!J .•••• •••• •• • •• . . •• •• •• •• • • •••• •• . •• ••\ • ••••\ . . 3 • • • • ••• • • ••• •. • • • • • 04 ,. • •• • • • l - A , c0P AC II) I> • •` JV V':f ;'OP $&'V22416•i 9 ?? 3 e 2 /0cu ti CO GR QuA 2tt 1 2OO g906 - J /J(I Av Ave - co 33/sG -� call? /JerAL la 0 l 0 N 0 J ( SIG N ED) 5.0.§-1110.11d - CONCRETE DRIVE CROSSING THE SOUTH SIDE OF LOT. -THERE ARE FENCES NEAR THE BOUNDARY OF THE PROPERTY AND CROSS THE - SIDEWALK CROSSING THE EAST LOT LINE. FENCE 0.2'W CVO S I.R 1/2" LB #6135 FENCE.O 2'w,0 7'S r 3.3' 105.83' 'HALL 0 9S 89'4'49' 0 0 vi 16.4' x 109 rsi OPEN c LOT 27 PATIO L •BLOCK 5 O W FCP 1/2" / •' ¢ a NO I 90'16'11" ° "I — — �. , P . / ES7wM _ ANC! -OR 5 o R (18 ASPHALT) LOT 28 BLOCK 5 80 73' ROYAL ROAD (P) N.W. 99th STREET • • . •• • • ••• SURVE YQRS CER TIFICA TE I HEREBY CERTIF THAT T IS BOUNDARY SURVE • E RE •SURVE ) IeROoR *Y DIRECTION •ARJ« VA4) wiiHOUj AN au TaENTICA TED EL EC TRON,C • S4VA TL j AND AUTHEM'IC* TED EL EC TRON,C SEAL OR•4 RAWED EM6p!SED S!AL AND SIGNATURE 0 11101■11 Clyde C �^ ' • +u •, • • I/IcN O 0 20 , 00107 r: 14 :y CL YOE 0 MCNEAL, PAOFESSIChI : S )P4YOR,ANO MAPPEIO x2883 3 �1 CORNER „" FALLS IN WALK WEST LOT LINE. C8 - P LANT E R 60, 3' PLANTER PAGE 2 OF 2 PAGES .RQUNDARY SURVEY F 1 P 1/2" NO iD ' 5Ow 90'17'2t" 298' WALK • O . \I n 30 2' PP • J 0 If). CORNS . S .N A_ LB P6135 35 DC CORNEA FALLS hN TARGET SURVEYING, EYING, INC. SERVING ALL FLORIDA COUNTIES 5601 CORPORATE WAY SJITE 210 WEST PALM BEACH FL 33407 PHONE (561)640 -4800 FACSIMILE (561) 640 STATEWIDE PHONE (800) 226 - 4E07 STATEWIDE FACSI)IIL_ ;800) 74i -0575 rr, Z i1 SURVEY NOT S - CONCRETE DRIVE CROSSING THE SOUTH SIDE OF LOT. -THERE ARE FENCES NEAR THE BOUNDARY OF THE PROPERTY AND - SIDEWALK CROSSING THE EAST LOT LINE. FENCE 0.2'w (VI SLR 1/2" LB #6135 FENCE.0.2'w.0 7 - 3 9'41.'49" 11.9' 0 0 16.4 P 1/2" NO LD. 0 • P.P. / p'7 w .. ANCFOR 10.9' • •PATIO °PEN e LOT 27 Lt BLOCK 5 ••• • g 87' / 146 3' COVERED PORCH LOT 25 BLOCK 5 23.6' ROYAL LOT 28 BLOCK 5 LOT 26 BLOCK 5 80.73' 105.83' WALL.° 9 36 CROSS 4 1 STORY RESIDENCE #9906 7' THE WEST LOT LINE. CORNER FALLS iN W ROAD (P) N• W. 99th STREET 50 R/W (18 ASPHALT) 0 F 1/2' NO i 0 5 O' w .'\ gy p; D c<fr,+ C 8 —� CORNER ALES its; CORNER A_K 35 00 • • • (SIGNED) • / • PAGE 2 OF 2 PAGES • • . •$QUNDARY SURVEY L8 46135 • • •• • • • •• SURVEYORS CERTIFICATE I HEREBY CERTIF THAT r IS BOUNDAR r SURVEY •IS CT QRESENTATIONOFA •SURVE 14 PREPARED R i (V 06R 141 DIRECTION • *Apt VAL WI =HDUj AN ALIT OENTICA EL ECTRONIC S44AT AND AU THENSIC.R TED EL EC IRONIC SEA( OR64 RA:6ED EM60l9ED SPAL AND SIGNATURE n cN fl vyn.0 •• _ it f a. 201001 y, I: == =9 CL YDE O MCNEAL P FE3SIpNA! $ yOR•�NO ;2B d3 Clyde TARGET SURVEYING, EYING, INC SERVING ALL FLORIDA COUNTIES 5601 CORPORATE WAY SUITE 210 WEST PALM BEACH FL 33407 PHONE (561) 640 -4800 FACSII•AILE (551)540 -0575 STATEWIDE PHONE 1800) 226807 STATEWIDE FACSimtLE ,000) 7 - 0576 • lei f - N o AN v acii-11-, BUILDING PERMIT APPLICATION F13C 20 ra o (A) j /// a, J(°t c_ 1�',► C,0 Contractor's Company Name 0 (4,11 ey Contractor's Address Value of Work For this Permit Submittal Fee $ Permit Fee $ 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 Training/Education Fee $ BONE JUL 1a 21 Permit :No. Master Permit Nit! \O` \7 Permit Type: BUILDING ROOFING Owner's NM* (Fee Simple Titleholder) I l /lca1 j /SAC t/l Y e °? Phone # .: S - �) --/ 7 Owner's A$c#tas q ( ) KZ% /4 laid-Li / City Tenant/Lessee Name State ` zip 3 /SO Phone # Jim Address (Where the watt is - being done) L % e 44, /4 z Z`-f/ City hijAmi Shores Village County ,Miarni -Dade lip 3 /.` FOLIO / PARCEL Is Building Historically Designated YES NO ` Flood Zone Phone# 3 4(S" 0 ^ 3 . City State Zip Qualifier Name Phone State Certificate or Registration No. Certificate of Competency No. Contact Phone E-mail Architect/Engineer's Name (if applica e) Phone # 1 Square / Linear Footage Of Work: 1 ID Type of Work: Ad ditio ❑Alteration ONew 0 Repair/Replace 0 Demolition _/ Describe Work: 3 lf7 Y 00 t R.:0 d KR 'VOA-4y Q�° // l✓7 42-14 *IV** * * *ot**i * Diet :r ** ******X* ** * *** * **:F* * * ** ** CCF $ CO /CC $ Notary $ Scanning $ Radon $ DPBR $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ See Reverse side --> Technology Fee $ Bond 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 ofa 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 Sign: weer or Agent The foregoing instrument was acknowledged before me this 12 day of i , 20 tO, by Di licArn acitt Q.UJa -- who is personally known to me or who has produced c"t- t As identification and who did take an oath. NOTARY PUBLIC: Signature Contractor The foregoing instrument was acknowledged before me this day of , 20 __, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: 0 , ' 011111111 ' L i► Print: ?'° �S�'t T My Commission Expires: ° ,,,��� \°'�\ m ***** ***:c ** ** ***** * * ** ** * * * * ** //� 41 ` ** � r ** * ** * * * * *** * * * * * *;t * * ***** * ** * ** * **** * ** *x * * ** * ** ,�; *** * * * * *:�:r APPROVED BY (Revised 07 /10 /07)(Revised 06/10/2009) Plans Examiner Engineer Sign: Print: My Commission Expires: Zoning Clerk checked OWNER BUILDER DISCLOSURE STATEMENT r y , NAME: LL ) / / �t L l ?? DATE: C + f ` ) l i ADDRESS: ! ( 6 At � II' 1-L-14: et • t 1 d1"1 5 �Yf Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two - family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and with - holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner - builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. M iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Initial Initial Initial 2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. Initial s" 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption. Initial tali Initial LL 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance. 7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner - builder permit that erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner - builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my property. Initial 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by me, which means that 1 must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow these may subject to serious financial risk. 9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and requirement that govern owner - builders as well as employers. I also understand that the Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. 10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http: / /www.myfloridalicense.com /dbpr /pro /cilb /index.html Initial O 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information that I have provided on this disclosure. a Initial t.1.71 Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner - builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued, this disclosure statement must be completed and signed by the properly owner and returned to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this t' L day of , 20 t< By who was personally known to me or who has Produced there License or to • aF. �90 / z RI P " gYitier)tification. I P;7r, "'-2, Initial Initial Initial '/ // OWNER BUILDER DISCLOSURE STATEMENT NAME: tt.�t /l ?,mot 71 y / '- 1 ' DATE: i2 2i)/0 ADDRESS: 1 c / M iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two - family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and with - holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner - builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. 2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. 5, I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. Initial Initial 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. j Initial tzE- f" 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption. Initial -v Initial 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance. Initial 7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner - builder permit that erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner - builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my property. JJ �� Initial 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow these may subject to serious financial risk. Was acknowledged before me this i day of L , 20 LL-. Initial 9. I agree that, as the party legally and financially responsible for this proposed Construction activity, l will abide by all applicable laws and requirement that govern owner - builders as well as employers. I also understand that the Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. Initial 10. I understand that 1 may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http: / /www.myfloridalicense.com /dbpr /pro /cilb /index.html Initial 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: Initial Ga)-( 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information that I have provided on this disclosure. Initial Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner - builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued. By who was personally known to me or who has Produced there License or as identification. Inspection Number: INSP - 151296 Scheduled Inspection Date: September 17, 2010 Inspector: Hernandez, Rafael Owner: HERNIQUEZ, ZAIDA & WILLIAM Job Address: 9906 N MIAMI Avenue Miami Shores, FL 33138- Project: <NONE> Contractor: HOME OWNER Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Permit Number: PL -7 -10 -1286 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1131010180540 2 BATHROOM AND KITCHEN REMODELING 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- 148575. need to finish kichten sink September 16, 2010 For Inspections please call: (305)762 - 4949 Page 4 of 5 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) Owner's Address City Tenant/Lessee Name Email 1-V 6A o) U-i a 0 !l '- k < (- 4:11 )- Job Address (where the work is being done) FOLIO / PARCEL # Is Building Historically Designated YES NO Contractor's Company Name ilIJ0F „7- Architect /Engineer's Name (if applicable) Value of Work For this Permit $ ;4 Type of Work: ❑Additio ❑Alteration Describe Work: c h -V0004 av7 Notary $ Scanning $ Double Fee $ Structural Review. $ Miami Shores Village 1303gW31 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 2 c 7966 : / /7z City Miami Shores Village County Miami -Dade Zip ,j 3 / S Contractor's Address City State Zip Qualifier Name Training /Education Fee $ Radon $ DPBR $ Violation date: Zip Master Permit No. RC.- ICS Phone # OS F- /) ? Phone # Phone # Phone # State Certificate or Registration No. Certificate of Competency No. Contact Phone E -mail Phone # Square / Linear Footage Of Work: New ❑ Repai /Replace c 4 Total Fee Now Due $ C6' Permit No. ft— 10 .— I Flood Zone ❑ Demolition ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ /.$ C` CCF $ CO /CC $ Technology Fee $ Bond $ See Reverse side -* 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 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 NOTARY PUBLIC: Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of75 C , 20t , by LC '1 day of , 20 , by who is personally known to me or who has produced -. (r who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: Sign: Print: - = Print: `'4C\'%\ p�� \n r n z • ai My Commission Expires: '�'a8A415 \\\` My Commission Expires: APPROVED BY (Revised 07 /10 /07)(Revised 06/10/2009) l (C Plans Examiner Signature Zoning Engineer Clerk checked Scheduled Inspection Date: September 16, 2010 Inspector: Devaney, Michael Owner: HERNIQUEZ, ZAIDA & WILLIAM Job Address: 9906 N MIAMI Avenue Miami Shores, FL 33138- Project: <NONE> Contractor: CALEX ELECTRICAL CORP Building Department Comments September 15, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Phone Number Inspection Number: INSP- 151295 Permit Number: EL -7 -10 -1292 For Inspections please call: (305)762 -4949 - \(1565 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Parcel Number 1131010180540 Phone: 305 - 271 -5164 UPGRADE ELECTRICAL SERIVCE RELOCATE THE RECEPTACLE AND RELOCATE RECEPTACEL IN BATHROOM Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /6 g a, 7 Page 20 of 23 BUILDING PERMIT APPLICATION FBC 20 Permit Type: ELECTRICAL Owner's Name (Fee Owner's Address City pia, f , Tenant/Lessee Name Email FOLIO / PARCEL # Is Building Historically Designated Contractor's Company Name Contractor's Address City Qualifier Name ef State Certificate or Re No. Architect/Engineer's Name (if applicable) Submittal Fee $ Notary $ Scanning $ Double Fee $ Structural Review. $ imple Titleholder) 70 l, y tof State j t 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 YES Wyt.otoe Phone# 3© 7 — Z3 5 ? 7LM ve. Phone # Job Address (where the work is being done) / 90 ( /24) y /* ! ? `" 4v City Miaml Shores Village County Miami-Dade l S t?.. c‘yre,6-7, (6/4'6 Ra,J 6: State NO Permit Fee $ 2.r6 i ' 4 Permit No. IC° I 2 q Master Permit No. ( 9.') 31 B Certific to of Competency No. � Total Fee Now Due $ f 0 ) 3 Gf�B1�I� � � JUl Y 4 1010 Flood Zone Phone # 7r6,- z to 17// Zip 331 ?J Phone # - r , Z74/7 ,1 Contact Phone f "(rr - 2. (0 17 E -mail iQ l� (mac 1 X / iA7 Q. i Phone # Value of Work For this Permit $ Z Y (7 ©. tag Square / Linear Footage Of Work: Type of Work: ❑ ddition thAtteration DNew ® R lace ep 0 Demolition Describe Wor : t 1 de £ wee yn�i / Spy() fife D 1_ee/1 &AI *******************************F * *** *.* * * * *** ** CCF $ CO /CC $ Training/Education Fee $ Technology Fee $ Radon $ DPBR $ Bond $ Violation date: See Reverse side -3 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 val promise in good faith that a copy of the notice of commencement and construction lien 1 whose property is subject to attachment. Also, a certified copy of the recorded notice of for the first inspection which occurs seven (7) days afier the building permit is issue inspection will not be approved and a re- inspection fee will be charged. Sign: Print: My Commission Expires: * * * * * * * * * * * * * * * * * * * * ** APPROVED BY Owner or Agent Contractor The foregoing instrument was acknowledged before a this 9 The foregoing mstrument was acknowledged before me this tit day of J 20 C , by WI 1u '1 I ru i y of (JL• , 20 Cv , by PJtIc. -Z. , why s personally kno . o me or who has produced 1 _D As identification and who did take an oath. NOTARY PUBLIC: \ 0 01tiu 1 1111 1 , • 7:(7) T .- : o = r o a ° o: Qj :f�Z:;) h (Revised 07 /10 /07)(Revised 06/10/2009) '1 V // / rgll \\`\ ********************** * * ** * ** * * * * * * ** * * * * * * * * *** * * * ** °7 f � 4 Plansminer Engineer Signature I ,tom Print: T . , \\ My Counnuss • ures ng $2500, the applicant must ure;will be delivered to the person encement must be posted at the job site the pence of such posted notice, the who is personally Willi i e or who has produced_.. tD \a on and who did take an oath._ N ;► ) �. _ ' * * * * * * * * * * * * * * * * * * * * * ** Zoning Clerk checked CITY OF MIAMI SHORES 10050 N.E. 2ND AVER AMI SHORE - , FL 33138 CITYMIS SHOULD ANY oP THE ABOVE DQswR19ED POLICIES BE CANCELLED BEFORE THE PJIPIRATON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS - AUTHORIZED REPRt:SENTAT IE Don McCartney A * CERTIFICATE OF LIABILITY INSURANCE LATE (IAMIDDIYYYY) T H I� Co ' R TIFICATE 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. R"TAN'T: 11 the certificate older an A r r ITION INSU •, the polloy(ies must be endorse . f SUB OGA • N 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 certlflcate holder in lieu of such endorsemeflt(0). PRODUCER INSURED 07/27/2010 09:01 3056668014 McCartney Insurance Agency, Inc 6739 Bird Road Miami FL 33155 -3705 Phone :305-666 -4444 • GENERAL LIABILITY ACORD 25 (2009/09) Calex Electric Corporation 10150 zIi. SW 33173 TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS•MADE © OCCUR GEN L AGGREGATE LIMIT APPUES PER; POLICY - JEG - LOC CERTIFICATE HOLDER POLICY NUMBER 09AL062501 NAM MCCARTNEY INS Pr {{ tAIGA,LO, EM: ADDRESS: PRODUces cuSTOMER ID.Th OP 1D AM 1 rite. N0)r CALEX -1 INSURER(S) AFFORDING COVERAGE INSURER A : Nova Casua t:Y 1a s . Company INsuRERB: F.'tf.B.A. (NSURERG Progressive Insurance Co. INSURER D : INSURER E: INSURER F : CANCELLATION REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: THIS IS T• CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDmON or ANY CONTRACT OR OTHER DOCUMRNT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUC1ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • LIMITS PAGE 01/01 07/27/10 ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NAIL 0 10193 AUTOMOBILE LIABILITY ANY AUTO All OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON•OWNED AUTOS UMBRELLA LIAR EXOESSk1AO OCCUR CLAIMS -MADE DEDUCTIELE RETENTION $ wpm 5 •rdPENSATWN AND EMPLOYERS' LIABIU Y Y / N ANY PROPRIETORIPARTNERJEXECUTNC I OFFICERG EMBER EXCLUDED? J mummy In NH) If yee, describe under DESCRIPTION OF OPERATIONS balm 05390941-1 106 -430 (MM/DD 03/10/1 04/2x/10 04/07/10 03/10/11 04/20/7.1 04/07/1. EACH OCCURRENCE • • ❑•. PREM Spa eacurreme) MED EXP (Arty one Pe►wn) PERSONAL R ADV INJURY GENERAL AGGREGATE PRODUCTS • COMP/OP AGG COMBINED SINGLE LIMIT Ifle neddem) BODILY INJURY (Per parson) BODILY INJURY (Per acdder:t) PROPERTY DAMAGE (Per aeeldent) EACH OCCURRENCE AGGREGATE T • RY LIMITS E L EACH ACCIDENT E.L DISEASE - EA EMPLO E.L. DISEASE • POLICY LIMIT $ 1,000,000 6100,000 $5,000 $1,000,000 62,000,000 52,000,000 0 1,000,000 1 $ 500,000 $500,000 $500,000 DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES (Reich ACORD 101, Addl oral RSmerk' Sahadu e, If morn Spaoe Is required) s 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: PERSON: FEIN: BUSINESS NAME AND ADDRESS: CALEX ELECTRIC CORPORATION 10150 SW 66TH STREET MIAMI FL 33173 SCOPES OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR PEREZ ALEXIS 650234372 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 440.05112), 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 440.05113), 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 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 EFFECTIVE: 05/27 /2009 PERSON: ALEXIS PEREZ FEIN: 850234372 BUSINESS NAME AND ADDRESS: CALEX ELECTRIC CORPORATION 10150 SW 66TH STREET MIAMI, FL 33173 SCOPE OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR 05/27/2009 EXPIRATION DATE: 05/27/2011 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 EXPIRATION DATE: 05/27/2011 CUT HERE 03 -30 -2009 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 L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be H exempt... apply only within the scope of the business or trade listed on E the notice of election to be exempt R E Pursuant to Chapter 440.05113), 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. * Carry bottom portion on the job, keep upper portion for your records. * * QUESTIONS? (850) 413 -1609 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. ALEX SINK EFFECTIVE DATE: PERSON: FEIN: BUSINESS NAME AND ADDRESS: CALEX ELECTRIC CORPORATION 10150 SW 66TH STREET MIAMI FL 33173 SCOPES OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 05/27/2009 PERSON: ALEXIS PEREZ FEIN: 650234372 BUSINESS NAME AND ADDRESS: CALEX ELECTRIC CORPORATION 10150 SW 66TH STREET MIAMI, FL 33173 SCOPE OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR 05/27/2009 EXPIRATION DATE: 05/27/2011 PEREZ ALEXIS 650234372 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 EXPIRATION DATE: 05/27/2011 CUT HERE 03 -30 -2009 * Carry bottom portion on the job, keep upper portion for your records. * * 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 440.05112), 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 440.05113), 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) 413-1609 IMPORTANT O 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 L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E 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 -1609