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DS-11-1337Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 162451 Permit Number: DS -7 -11 -1337 Scheduled Inspection Date: August 08, 2011 Inspector: Bruhn, Norman Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 415 NE 105 Street Miami Shores, FL Project: <NONE> Contractor: HIGH TECH STRIPING INC Permit Type: Driveways /Sidewalks/Slabs Inspection Type: Final Work Classification: Repair Phone Number (305)758 -0539 Parcel Number 1122310430010 Phone: (305)884 -0166 Building Department Comments STRIPING LINES PER NO PARKING AT DRIVEWAY APPROACH PasseliVeri Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments August 05, 2011 For Inspections please call: (305)762 -4949 Page 18 of 37 Miami Shores Village Building Department IY�I ') 2011 BY: ...00....,o,. „.o, '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 No.OE 11"-- / PERMIT APPLICATION Master Permit No. FBC 20 Permit T ' e: IUILDING ROO ` G OWNER: N. __ •.a Beholder): yr Address: //5 W E. S` City: Nim S e-es State: Tenant/Lessee Name: Email: / ectisg-e- 50.4- S CIA-c3 c) (. 'o f Phone #: 3 CS cam' 7 3 `( -c)3 c 3 Zip: 3It Re Phone #: S05– t?ii _ C3 53 JOB ADDRESS: 9/5- City: Miami Shores County: Miami Dade Folio/Parcel #: zip: 3313 p Is the Building Historically Designated: Yes NO Flood Zone: 0 CONTRACTOR: Company Name: r y` li { zv/ Sh' ! fD/ 1.-,,,, Phone #: ®S� 024/ Address: 777 CO -&4) 7 4' ' /4 City: /rite --,& State: i- (_ Qualifier Name: -FS Phone#: 06 State Certification or Registration #: it i4 Certificate of Co i petenc #: q 813 5 C 0 / `7 % Contact Phone #: 66c) S8 7' --CS ( (a(p Email Address: DESIGNER: Architect/Engineer: Phone #: Zip: ,�%�o l 30 �j {5�d ��l Value of Work for this Permit: $ t 2b0 Square/Linear Footage of Work: Type of Work: ❑Addition ❑Alteration UNew ❑Repair/Replace ❑Demolition Description of Work: S I7 9.9 i t �es l/N.®� ;9 ” Tniut Cap Proceci i V ************ * * * * * * * * ************ * * *** ** Fees+ x* **** *+x*** **x:********** ****** *********ma *** Submittal Fee $ Permit Fee $ / 2Q °a 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or Agent The forego' ' nstrument was acknowled e before me this The foregoin instrument was acknowledged before me thi day of J , 20 // , by i day of > 20 IL, by who is personally known to me or who has produced As identification and who did take an oath. _ k/ /A as identification and who did take an oath. who is personally known to me or who has produced NOTARY PUBLIC: Sign: Print: ERNESTO D. DIAZ glary Public, State of Florida mmission #DD801249 EVvu.) My Commission Expires: ommissian Expires Jun. 26, 2012 7 NOTARY PUBLIC: Sign: Print: My Commission Expires: STO D. DIAZ Public, State of Florida sion #DD801249 Jun. 26, 2012 ***************************** ********************* **** ************ ******* * ** *** ** ******* ***$ *** *****m** * ** APPROVED BY Plans Examiner 1-26 Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Construe-ton Trades Qusiifying Board B1 `-liiNIESS CERTIFICATE OF COMPETENCY 98 HIGH TEC D.B.A.: REYES MICHELLE Is certified under the provisions of Chapter 10 of Miami-Dade County `JAL D FOR CONTRACTING I.1-NTIL09/30/2012 THIS IS NOT A BILL — CO NOT PA'' REOEIPT NO. 30- 4163317 CC NO: 98BS00177 BUSINESS NAME / LOCATION HIGH TECH STRIPING INC f776 NW 7 CT, IW�NNR :HIGH TECH STRIPING INC SEE BACK OF RECEIPT FOR A- OF NON- PARTICIPATIPIG MUNICIPALITIES Receipt holder must register in the city where work is to be done. PAYMENT R CEIVED mtAmp, APE001;1 TY ?01 TAXI /0 �54 _0.2 FIRST -CLASS U.S POSTAGE PAID NAM FL PEEIIIIT NO. 231 RECEIPT HQLDER MAY DO BUSINESS AS A CONTRACTOR AS SPECIFIED HEREON. SPECIALTY BUILDING CONTRACTOR DO NOT FORWARD HIGH TECH STRIPING INC PAUL REYES PRES P 0 BOX 667855 MIAMI FL 33166 11141111111 111111111 .h 111i1111111111111111111f1�i1§ SjJ THIS IS NOT A BILL -- DO NOT PAY RENEWAL 416331-7 CC 4 984M00177 E -0-PCAPPN :CH — PING INC CT EY OWNER- _ HIGH TECH STRIPING INC 3ec Type of Buslness --IALTY BUILDING CONTRACTOR HIS IS ONLY A LOA , SUSINFq5 TAX ggQVIPTAT otwOrt THE EFOLFREW fp140yAwANT CISTING REOOLATORY OR ZONING LAWS OF THE DO NOT FORWARD u OR CITIES. twar4 FRO1 ANY OTHER OR JA04.7gois HIGH TECH STRIPING INC NO -CERTIFICATION OF BOLOBBs talAUFicA- TiONt. PAUL REYES PRES P 0 -BOX 667855 MIAMI FL 33166 A WORKER/S 50 PAYMENT RECEIVED ItRAIWMADE counrry TAX COLLECTOR: 07/02/2010 001 SEE OTHER SIDE 37 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 415 NE 105 Street Miami Shores, FL 1122310430010 Block: Lot: ST ROSE OF LIMA CATHOLIC CI Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD MIAMI FL 33138 -2970 (305)758 -0539 Contractor(s) HIGH TECH STRIPING INC Phone Cell Phone (305)884-0166 Approved: Yes Comments: CHECK WITH SCOTT DAVIS TO SEE IF HE HAS ANY ISSUES. Date Approved: 7/26/2011: Yes Date Denied: Type of Work: PARKING STRIPS Bond Return : Scanning: 1 Additional Info: Classification: Commercial Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.00 $2.00 $0.40 $100.00 $3.00 $1.60 $110.20 Pay Date Pay Type Amt Paid Amt Due Invoice # DS -7 -11 -41546 07/25/2011 Check #: 14305 $ 50.00 $ 60.20 08/02/2011 Check #: 14353 $ 60.20 $ 0.00 Available Inspections: Inspection Type: Final 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. August 02, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date August 02, 2011 1 '4 °R°� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 8/2/2011 PRODUCER (305) 595 -3323 FAX: (305) 595 -7135 Eastern Insurance Group, Inc. 9570 SW 107 Avenue Suite 104 Miami FL 33176 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED High Tech Striping Inc 7776 NW 73RD CT Suite A Miami COVERAGES FL 33166 INSURER k Bridgefield Employers INSURER B: INSURER C: INSURER D: INSURER E THE ANY MAY POLICIES. INSR— r: POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS O)SUCH AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. i. -: • Sr _ • .: I: .. _ POLJCYNUMBER POLICY EFFECTIVE POUCY EXPIRATION .. bihha WAITS GENERAL. LIABILITY COMMERCIAL GENERAL UAI3IUTY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ GERI. —1 PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ AGGREGATE R GATE UM APPLIES PER: PRODUCTS - COMP /OP AGG $ POUCY I j—I_,IFLaT LOC AUTOMOBILELIABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS COMBINED SINGLE UM11T (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS 7 I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ A WORKERS AND EMPLOYERS' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER (Mandatary If yes, describe SPECIAL COMPENSATION LIABILITY Y/N � EXCLUDED? 1 830-39892 9/6/2010 9/6/2011 X ToCRlSUht TS EAR EL EACH ACCIDENT $ 1,000, 000 EL DISEASE - EA EMPLOYEE $ 1,000,000 In NH) under PROVISIONS below EL DISEASE - POLICY UMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Parking Lot Striping and Remodeling CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2 Avenue Miami Shores, FL 33138 SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 'David Lopez/AMANDA ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 (2oostn).o1 The ACORD name and logo are registered marks of ACORD ,��p �:::9 CERTIFICATE OF LIABILITY INSURANCE OP ID ML DATE (MMIDDIYYYY) 08/02 {11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDJTJONAL INBRED, the poilcy(les) must be endorsed. If SUBROGATION 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 certificate holder in lieu of such endorsement(s). PRODUCER BROWN & BROWN OF FLORIDA INC 14900 NW 79th Court Suite #200 Miami Lakes FL 33016 -5869 Phone:305 -364 -7800 Fax:305 -714 -4401 WNIA(I NAME: 1�o. Ext): ( C, No): ADDRESS: PRODUCER CUSTOMER ID #: HIGHT -2 INSURER(S) AFFORDING COVERAGE NAIC# _ INSURED High Tech Stripping Inc. P.O. Box 67855 Miami FL 331666 INSURERA: Scottsdale Ineuraaoe Company 41297 INSURERB: Commerce and Industry Ins Co 19410 INSURER C: CLAIMS -MADE INSURER D • MED EXP (Any one person) INSURER E : INSURER F : PERSONAL&ADVINJURY COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS INDICATED. CERTIFICATE EXCLUSIONS WS LTR IS TO CERTIFY THAT THE POLICIES OF NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH POLICIES. INSURANCE of INSR X THE UMITS aulsw WVD LISTED BELOW HAVE BEEN ISSUED TERM OR CONDITION OF ANY CONTRACT NSURANCE AFFORDED BY THE POUCIES SHOWN MAY HAVE BEEN REDUCED POLICY NUMBER BSC0024134 TO THE INSURED OR OTHER DESCRIBED BY PAID PO�.ICy EFF� oPiag /1'YYY) 02/24/11 NAMED DOCUMENT HEREIN CLAIMS. PO EXP (MMlU 1YYYY) 02/24/12 ABOVE FOR THE POLICY WITH RESPECT TO WHICH IS SUBJECT TO ALL THE TERMS, LIMITS EACH OCCURRENCE PERIOD THIS $1,000,000 TYPE OF INSURANCE A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR PREMi E; ?Eroc=nce) $ 100,000 CLAIMS -MADE X MED EXP (Any one person) $ 5, 000 PERSONAL&ADVINJURY $ 1,000,000 GENL GENERAL AGGREGATE $ 2, 000, 000 AGGREGATE LI MIT APPLIES PER LOC PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY X JECT Emp Ben. $ 1,000,000 AUTOMOBILE UABiuTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ B X UMBRELLALIAB EXCESS LIAO X oCCUR CLAIMS -MADE 33E034233428 05/25 /1102 /24/12 EACH OCCURRENCE $2,000,000 AGGREGATE $ 2 , 000 , 000 DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY EXEC YIN ANY PROPRIETOR/PARTNEW UTIV OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) if yes describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- TORY OMITS ER E.L. EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ El. DISEASE - POUCY UMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedu e, if more space Is required) Job Location: Various Miami Shores Village are included as additional insured with respects to the General Liability when required by written contract. CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2nd Ave Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2009 ACORp CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD 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 Folio Number:1122310430010 Owner's Name: ST ROSE OF LIMA CATHOLIC CHURCH Job Address: 415 105 Street Miami Shores, FL Contractor(s) HIGH TECH STRIPING INC Owner's Phone: (305)758 -0539 Total Square Feet: 0 Total Job Valuation: $ 1,200.00 Planning and Zoning Criteria and Comments Approved: Yes Date Approved: 7/26/2011: Yes Comments: CHECK WITH SCOTT DAVIS TO SEE IF HE HAS ANY ISSUES.