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RC-11-523Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 161262 Permit Number: RC -3 -11 -523 Scheduled Inspection Date: June 23, 2011 Inspector: Bruhn, Norman Owner: CYRIAQUE, RODRIQUE & JACQUELINE Job Address: 225 NW 111 Street Miami Shores, FL 33168- Project: <NONE> Contractor: HOME OWNER Permit Type: Residential Construction Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1121360010670 Building Department Comments REMODELING BATHROOM Passed Failed Inspector Comments Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. June 22, 2011 For Inspections please call: (305)762 -4949 Page 30 of 32 l2. Miami Shores Village Q MoM Building Department MAR 1 7 2011 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: BUILDING Permit No. S' ` X523 Master Permit No. OWNER: Name (Fee Simple Titleholder): akaggLig -/j3,4 £/E Phone #: (23ID37 Address: 2Z5 fl W / //f City: I ONlti a S&P/0.A F State: Zip: a a Tenant/Lessee Name: '1&O' � Cy e 49 0 t° Phone #\ )7 7L9-- f �C /V //9" Email: JOB ADDRESS: 2. (5— /U L J 1/1 Sb City: Miami Shores County: Miami Dade Zip: .331655 Folio/Parcel #: Is the Building Historically Designated: Yes NO) Flood Zone: iV D CONTRACTOR: Company Name: 6-;)h■Ri601 ("' l ()b04. tc D & Phone #: Address: 2,2,6 Ai (I) 1 l l - / City: WI 1 (i fyrti State: / Zip: r t3A6e [ Phone #: Qualifier Name: State Certification or Registration #: Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $_ Square/Linear Footage of Work: Type of Work: OAddress ,CTAlteration UNew ORepair/Replace UDemolition Description of Work: Pe Ed ;¢ a _ tisIo 144 COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: ***** * * * * * * * * *** *** ** *** * * ****** * * ** Fees * * * +***, ter**** * * * * * * **** * * * *** ** * * ******** ** Submittal Fee $ c...\ Permit Fee $ �i2 ° CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 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. 1 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 Signature Owner or Agent _ Contractor The foregoing instrument was acknowledged before me this V-1 The foregoing instrument was acknowledged before me this day ofl(a55t- nn-4' _, 2011, , by __Iaat_elt r1 D-day of , 20 _, by who is personally known to me or who has produced 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. NOTAR ak,w: NOTARY PUBLI"C: `\�t� ;3• �© 3�% '' 1065 Sign: Pint: i ,iltta 1,00 = Print: M Coi'►lmit* <i,1. r. My Commission Expires: ',,, • , SA11O' 'r�\ � '''/,,'�4,e f.. I S• SV \\\\\\�� r * * ** ** *f/,k1- 444 %4t * * ****** ** *** * * * ** ** * * *** ****** **** * **, *** * * * ** *** * * **: ** *** * *** * *t**>ti, **** * * *** *** * *** 11 APPROVED BY (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6/4/10) Plans Examiner Zoning Structural Review Clerk NAME: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT DATE: ADDRESS: 22,5" it ak 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. !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 1, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. Initial le. C 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. Initial k e c 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 R. cn .._ 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. �p Initial .4. c 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. Initial k . e 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 R. 7. I understand that ft 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 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. Initial �® 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 govem 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 P'C d 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 htto:// www. mvtloridalicense .com /dbprlpro /cilb /index.html Initial e e 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 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 contractors workers compensation coverage. Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and retumed 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 V-1_ day of p v `a-.64 20 1 By i7D . CAA- I zt & who was personally known to me or who has Produced there License or .0001111111/11/4, ' \\Vera ' tlfcati* :- *'% STATE ®F / "/11111111110�\ NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT N01.01\---52.3 TAX FOLIO NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 111111111111111111111111111111111111111111111 CFN 20111 R 0241. 501 OR 8k 27653 Ps 1819; (fps) RECORDED 04/14/2011 13 :08t02 HARVEY 1~UVIWIr CLERK OF COURT MIAMI -DAVE coUNT'f r FLORIDA LAST PAGE Space above reserved for use of recording office 1. Legal description of property and street/address: 2- N to /1 st 2. Description of improvement: 3. Owners) name and addr Interest in property: Name and address of fee simple titlehold r: 4. Contractor's name, address and phone number. 5. Sure . (Payment bond required by owner from contractor, if any) Name, address and phone number. Amount of bond $ 6. Lender's name and address: 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes, STATE OF FLC^iDA, COUNTY C.0 DADE Name, address and phone number. I HERESY CERTIFY Wi this F. N. 171.0 cop- cf �t orgfrrcf 6,Iorl tr L;:S v` ?.. 8. In addition to himself, Owners designates the following pe 713.13(1)(b), Florida Statutes. Name, address and phone number. • . • a -k o .i ;mow f L ;ivied See/ , CLERK, 0'C/7 ar enor's Notice as roi S Cis 9. Expiration date of this Notice of Commencement: (the expi : on date is 1 year from the date of recording unless a different date is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Signature(s) of Owner(s) or Owner(s)' Authorized Officer/Director/Partner /Manager Prepared By Print Name r; Qa�'c.i0-(,1 t, STATE OF FLORIDA COUNTY OF MIAMI -DADE Tye trek t jti trnent p�,�rfrr (,l(JCJ 10 IA st, Individually, r ❑ a ❑ Personally known, or . -S; .. i.1:.- 1 Prepared By Print Name Title /Office 371C g d before me this 14 day of produced the following type of identicati Signature of Notary Public: Print Name: (SEAL) VERIFICATION PURSUANT TO SECTION 92.525. FLORIDA STATUTES Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. Signatu By v.r = NoTAR! FOLIC °Tt GTLCFDA Claudia V. ett'r.21C3 'eCom 1i si'on;V'D X7179'23 ;; 1-. 23, N11 AriAl:1 sOWD;iceea,Ii ) of Owner(s) or Owner(s)'s Authorized Officer /Director /Partner/Manager who signed above: 123.01 -52 PAGE 9 �G 6 C /RiriQUe" By S.knot.k_v_r t &TI C-r a E.> raOrn 0.6 t.Q.A Q&L ttGu CF, NIX/4 NINK‘ Y•M n4.3ck-b C‘ 34-11-6(Z. ipmNI,713 mAR 4 2011 c_4\-Re3 4 Miami Shores Village APPROVED B BY D DATE ZONING DEPT BLDG DEPT SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS . J eic )=( .••■■•••••■• ADD SMOKE/CARBON MONOXIOEDETECTORS ANY AND ALL CLOTH AND RUBBER*--- INSULATED CONDUCTORS TO BE REPLACED — 7s Ct BATHROOM RECEPTACLE ON 20 AMP CKT AND G.E 1 PROTECTED (AA-la- tex-A u.iaktesa&A ao avok, c--4 frO Nu1/4-3 01 MvorYn cAytorteS YM6T. Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 158251 Scheduled Inspection Date: June 22, 2011 Inspector: Devaney, Michael Permit Number: EL -4 -11 -634 Owner: CYRIAQUE, RODRIQUE & JACQUELINE Job Address: 225 NW 111 Street Miami Shores, FL 33168- Project: <NONE> Contractor: RAYS ELECTRICAL SUPPLY INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360010670 Phone: (786)236 -2777 Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Passed L1/ Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments 2 June 21, 2011 For Inspections please call: (305)762 -4949 Page 9 of 21 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 BUILDING PERMIT APPLICATION FBC 20 Permit No. . �k BY: ... •4444 oac0000 Master Permit No. l '(.02_,1:5 Permit Type: ELECTRICAL Owner's Name (Fee Simple Titleholder) Q..ob 211 G•tke G L at I4 ( Qty KPhone # Owner's Address " 1Zq" Al (xi I e l F City 'NV k **- -t`rl I ca4 Q State Tenant/Lessee Name Email X Job Address (where the work is being done) 1-/-2..-.V • Zip 'N% (C Phone # W. City Miami Shores Village County Miami -Dade Zip 33 (C FOLIO / PARCEL # Is Building Historically Designated YES NO Flood Zone b" Contractor's Company Name t ocAP Contractor's Address 24/5 /,4 649 8 Z. do City vi164 40G ' State / /._. Zip .,.; , Qualifier Name 15 0./ ,q d/1, /22 f Phone # Phone # 3 0 f ,, ? fr 7/JJ State Certificate or Registration No. Certificate of Competency No. Contact Phone 7P'/ 2.10- 7777 E -mail Architect/Engineer's Name (if applicable) Phone # ' Value of Work For this Permit $ Z.60 Square / Linear Footage Of Work: Type of Work: DAddition DAlteration DNew 0. epair/Replace Describe Work: Q.-e QL A-L cp jD a kj 1 t-r 1---1 err ❑ Demolition ONe ***************************************r ees * *, **** x**** ** * ** *** **** *** ** *x * *** * * * *** ** Submittal Fee $ Permit Fee $ /.3 re•O GC !s' li CCF $ CO /CC $ Notary $ Training/Education Fee $ Scanning $ Radon $ DPBR $ Double Fee $ = Violation date: Technology Fee $ Bond $ Structural Review. $ Total Fee Now Due $ 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 re- inspection fee will be charged. "C-‘71"--erefe Signature D CAC Contractor The foregoing instrument was acknowledged before me this day of 20 /r , by , day of e, 201I , by who is personally known to me or who has produced who is personally known to me or who has produced as identification and who did take an oath. Signatur Owner or Agent The foregoing instrument was acknowledged before me this As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expire arw fit*'*******71tY1 **** 1i'**Yk'ff*******fif*Yif' ****3C1t**11tt1 **lti7t '*****1k*'Jt***BCYYtY****** Yti*** ****** t{***** **** **SY1Y****9TC9(****71'7Y'! **'1 *** VALTY'R MY COMiVIISSJON 19, M 14 EXPIRES: rw. -w IIiscrnt l 2Q . Co. My Commission Expires: APPROVED BY //it-7x Plans Examiner Engineer (Revised 07 /10 /07)(Revised 06/10/2009) Zoning Clerk checked FEB -02 -2011 14:55 INSURANCE AGENT 305 596 9780 P.03/03 14 `l NL1, CERTIFICATE OF LIABILITY INSURANCE 1 LIMb∎NOVI /WITTTy! TYPE OF INSURANCE PRODUCER Koski & Co. , Inc. 9875 SW 72 Street P. 0. Box 164739 Miami, FL,.33116 THIS CERTIFICATE IS ISSUED AS A MATTER OF ONLY AND HIS CERTTIFIC CERTIFICATE ROES UPON AMEND, ALTER THE COVERAGE AFFORDED BY THE POLICIES INFORMATION EXTEND OR SELO r u W. NAIC 1 INSURERS AFFORDING COVERAGE tN9 rgim Ray's Electrical Supplies Inc. 2023 Opa Locka Blvd. Opa Locka, FL 33054 MAMA: TECHNOLOGY INS. CO. INSURER B: UABIUTY COMMERCIAL GENERAL UARIUTY :NSuRERC, ,PATE INSURER D: e INSURER E: 1 CLAIMS MADE OCCUR 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHAWN MAY HAVE SEEN REDUCED SY PAID CLAIMS. LTR INSRD TYPE OF INSURANCE POLICY NUMBER U EFFECTIVE IMMIDDlYY1 POLICY EXPIDATUON pN4T! tMMIT10/YY1 LIMITS - EACH OCCURRENCE a MENERAL. UABIUTY COMMERCIAL GENERAL UARIUTY NO COVERAGE ,PATE , l,!t • •171 7. PREMISES TEO oaw+rance) e 1 CLAIMS MADE OCCUR MEP EXP IAnY Otto Iwiscttl $ PERSONAL & ADV INJURY $ G�IFJiAL AGGREGATE $ GEN'L ACME-GATE LIMIT APPLIES PEA: POLICY ELMS- n LOC PRODUCTS - COMPIOP AGO $ T AuTOMO$ILF uABIUTY ANY AUTO AL OWNED AUTOS SCHEDULED AUTOS HIRED AUTO$ NON -OWNED AUTOS NO COVERAGE LIMIT a _ BODILY IJ.IURV {er per) 8 _ 9001LY INJURY leer aerxeenrl $ PROPERTY DAMAGE {Per acdd.Rt) a GARAGE UALBunr ANY AUTO NO COVERAGE AUTO ONLY - EA Accia $ — EA ACC 0 AUTO ONLY: AGG $ _ EXCESS/UMBRELLA LIABILITY NO COVERAGE EACH occURRENCE a ... I OCCUR III CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION e 0 e $ A woRlcERscamPENBATioNAND EMPLOYERS' UABIUTY ANY PROPRIETOR/PARTNEWBXECUTIVE OPPICERWMEMBER EXCLUDED/ �'Es If Yoe, describe undo? SPEC AL PROVISIONS below TWC3265193 -... 01/31/11 01/31/12 ocYTanT- � X � E L EACH ACCIDENT a S 0 0 a 0 EJ,. DLSEASB • BA EMPLOYEE $ 100,000 EL DISEASE - POLICY uMT $ 500 0 0 0 OTHER _ NO COVERAGE DESOIIPIION OF OPERATioas 1 LOCATIONS / VfOBOLES 1 EXCLUSION$ ADDED BY ENDORSEMENT / SPECIAL PROVMIONB Electrical Supplies & Contracting - 10 days cancellation notice applicable to nonpayment. All terms, conditions, limitations & excluaions of the policy & the insured's warranties apply. Miami Shores Village Building Dept. 10050 N.E. 2nd Ave Miami Shores, Fl 33138 ACORD 25 (2001/08) CANCELLATION $MOULD ANY OF THE ABOVE Malmo POLICIES RE CANBELLED $EFORE THE MOVIARON BATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR To MAIL DAYS WRi rrN NOTICE TO THE cBmiRCATE NaWER NAMED TO THE LIST. Sur FAILURE TO DO SO SHALL IMPOSE NO OBUQATION 011 UABIUTY OF ANY KIND UPON 1-1IE UMW, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Koski & CO". N 1988 TOTAL P.03 ut,1 cI LUIU I[1U UI.UJ AM hUUNIAINLULLAU INb. FAX No. HU52216261 P. UU2 /UUU ACORD,„ CERTIFICATE OF LIABILI aoDUCeR 305 -221 -0082 FONTAINEBLEAU INSURANCE CONSULTANTS 8250 W FLAGLER ST #118 MIAMI, FL 33144 SURED RAY'S ELECTRICAL SUPPLIES, INC 2023 OPA LOCKA BLVD MIAMI, FL 33054 TY INSURANCE OATS (MM/ADAM 10/21/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THI, CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR THE C0VERAG AFFORI D <3Y THE POLICIES IE}t»LOW INSURERS AFFORDING COVERAGE INSURERA NATIONAL GROUP INSURANCE COMPANY INSURER 0; INSURER 0: INSURER 0: INSURER E: AVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS. 3R TYPE OF INSURANCE POLICY LIMBER ...... 'p���rr ' dl`:ISI7�I�T��J�7.Y1�,)4f��A 10/20/2010 '"�1� T�(' 10/20 /2011 IMITS . GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GMG - 000000137 EACH OCCURRENCE s 1,000,000 FIRE DAMAGE (Any one Era) $ 100,000 OLAIMS MADE 1 X, OCCUR MRD EXP (Any one Inman) $ 6,000 PERSONAL & ROY INJURY 5 1,000.000 GENERAL AGGREGATE. $ 2,000,000 $ 1,000,000 'd�EN'. GGRG$ATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG I POLICY , RO- EOT LOC AUTOMOBILE _ __ ..— LIABILITY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON�QWNED AUTOS (a aden SINGLE LIMIT accident) $ BODILY INJURY (per person) ODILY INJURY per accldent) PROPERTY DAMAGE (Par acc1dant $ GARAGE LIABILITY ANY AUTO • AUTO ONLY. EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ -E-X-�CIESS LIABILITY EACH OCCURRENCE $ I OCCUR I I CLAIMS MADE AGGREGATE $ DEDUCTIBLE$ RETENTION 5 $ WC 5TATU- O /Fi_ TORY LIMITS�I �. . $ WOREERs COmsPENSATION AND EMPLOYERS' LIABILITY _I E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER :$CRIPTION OF OPERATIONSILOCATIONSIVEHICI .ESIEXCLUSIONS ADDED BY ENDORSF_MENTISPECIAL PROVISIONS ERTIFICATE HOLDER X ADDITIONAL INSURED. INSURER LETTER: CORD 25 -S (7197) Miami Shores Village Building Dept. 10050 N.E. 2nd Ave Miami Shores, Fl 33138 CANCELLATION SHOULD ANY OF THE MOVE DSSCRIGDO POLIGINS DE CANCELLED DNPORN THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL. 30 DAYS WRITTEN NoTU U TO THE. CIIRTIFICATK HOLDER NAMED TO THE LEFT, BUT FAILURE TO PO 60 t;HAU. IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON T RER, ITS AGENTS OR RI:FRI:$ T T S. ` ? AUTHORIZED REPRESENTATIVE D CORPORATION 1988 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 157591 Scheduled Inspection Date: June 22, 2011 Inspector: Hernandez, Rafael Permit Number: PL -3 -11 -524 Owner: CYRIAQUE, RODRIQUE & JACQUELINE Job Address: 225 NW 111 Street Miami Shores, FL 33168- Project: <NONE> Contractor: HOME OWNER Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360010670 Building Department Comments REMODELING BATHROOM Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments June 21, 2011 For Inspections please call: (305)762 -4949 Page 7 of 21 Miami Shores Village F °T2' MAR2 ?Q11 Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Bui Y: Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): Rb1)R � Cy R1 [f ; Phone #: Address: City: r l t i '1✓Y1 i Ho /2 Co State: fr ( Tenant/Lessee Name: DIRi 6 t1 E 611Q �+�j1U g Email: iN I /9- JOB ADDRESS: 2,245 , J (1/ t Permit No. ?L 6.2'4 Master Permit No. 751.1(_ / City: Miami Shores County: Folio/Parcel #: Is the Building Historically Designated: Yes Zip: 3 R Phone #:( aS) 7iV Miami Dade Zip: S3 1,c37 2 NO Flood Zone: CONTRACTOR: Company Name: l)k0$ /Yi (i is4 ( ('j ,5 Phone# 3 a 52 / 7 - l //j,,,& Address: 2,25 /UW 111 .%,Z- City: VY1 I 0Jkin c 5 Ho a.P1, State: fr/ Zip: 33 / f g e Qualifier Name: Phone #: State Certification or Registration #: Certificate of Competency #: Contact Phone #: DESIGNER: Architect/Engineer: Phone #: Email Address: Value of Work for this Permit: $ 0 0 Square/Linear Footage of Work: Type of Work: DAddress Description of Work: -ke ti'1 '� ���} L -th 4 Vv� $Alteration New ❑Repair/Replace ❑Demolition ******** * * * * * * * ** * ****** * * *** **** *** *** Fees************* ** ** * * * * ** ** * ****** **** ** * * ** ** Submittal Fee $ Permit Fee $ if �� ® CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 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. Owner or Agent The foregoing instrument was acknowledged before me this VI day of V‘A.'1°1-1L1:2-`4" 20 , by who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: C�rf ••� 6591aQ •. �.io �OIa51>If�1 °� pT s: 901% : ? ** �a�"4� ' u,x,x � I!9 APPR&DBY 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: Sign: Print: My Commission Expires: ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** 1, Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Zoning Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT NAME: !e 0 l�ReG LI C _ I a1q 2L < DATE: bC_ ADDRESS 22 4k0 111 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. Initial 1 C 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. Initial R. i 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 R , C 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 Re 11. 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. Initial R u C 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 aRl o c. 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 l ° e. 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. Initial 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 govem 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 p• e. 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. mvfloridalicense .com /dbpr /prolcilb /index.html Initial ie. e 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 R.,e 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 ire 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. Was acknowledged before me this day of Va 120 1'1 By VA-U& et was personally known to me or who has Produced there License or /OWNER c4e, c-t— A as iden\tt fioativn., e\ l � s l i v: or • �\\ �� ��, Hurl