DS-11-1941Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 165690 Permit Number: DS -10 -11 -1941
Scheduled Inspection Date: November 01, 2011
Inspector: Rodriguez, Jorge
Owner: CHURCH,
Job Address: 602 NE 96 Street
Miami Shores, FL
Project: CHURCH
Contractor: QUIRINO CONSTRUCTION CO
Permit Type: Driveways /Sidewalks /Slabs
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)754 -9541
Parcel Number 1132060141410
Phone: (305)892 -1987
Building Department Comments
SEAL & STRIPE ASPHALT PAVING
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
PLEASE GO TO THE CHURCH OFFICE AND CHECK WITH THE
RECEPTIONIST FOR PERMITS.
A-5 60 for 77W G>
October 31, 2011
For Inspections please call: (305)762 -4949
Page 11 of 17
iJILIMNG
PERMIT APPLICATION
FBC 20
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
�
, `�7 � i
p -273 ce'
((c22 0 2011
Permit No. 1 J0 11 --194-1
!4'I
Master Permit No.
Permit Type: BUILDING ROOFING
,,tut
OWNER: Name (Fee Simple Titleholder): t kW, t v Pes.) &f rEetew Phone#: 5 D5 i 4 -9)--.44 I
Address: iPO j(e, g (p sr-
City: It lip t State:
Tenant/Lessee Name:
Email:
Zip: 1—
Phone #:
JOB ADDRESS: LeL91__ f'4 qke
City:
Folio/Parcel #:
Miami Shores County: Miami Dade
Zip: 3313 a
11 — 3 `014 -- /4 0
Is the Building Historically Designated: Yes NO CoN- Flood Zone:
CONTRACTOR: Company Name: d'11 o l' 0 COOS T1Z & i r i 4
At r. % Tic Edsi i9
Address: % � 7
City: fii, /414,4/ State: Fi-
Qualifier Name: .0 Al A` 1
State Certification or Registration #: C 8 C . all YO'0
Phone#: /3 tr5 :742 ° 1 q 8.7
zip: ri
Phone#: 3 0 5 g? 2 - g 7
Certificate of Competency #: ,�r�
Contact Phone #: 5a5 g 9'a 1981 Email Address: gala/N/0 c' 6 a A IN.
DESIGNER: Architect/Engineer: Phone#:
G oeuf
Value of Work for this Permit: $ 46200 Square/Lin' ear Footage of Work:
Type of Work: DAddition DAlteration ONew ORepair/Replace ODemolition
Description of Work: ''.°3C.,.- pL. I2tots STA.ci. PE. ? OA-LT TA\) 1 (J
G. on. +L- I ay D V I
**** * ** *$ ** ** **** k**N ***** **** ** ***** k*Fees ****** R*******ask� ******** k******w ***** ** ****
Submittal Fee $ Permit Fee $
ca CCF $
Scanning Fee $ Radon Fee $ DBPR $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
CO /CC $
Bond $
TOTAL FEE NOW DUE $1 5714
Bawling Company's Name (if applicable)
Bonding Company's Address
City State `9
Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State .r 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 ET,RCTRICAL 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
•1�r
Signature sir _._ `�. -
Con .actor
tmg instrument was ackn wledged before me this a
,20L , by
Owner or Agent
The foregoing instrument was acknowledged before me this The fore
day of , 20 tk , by U iD ICA IN&IR"
who is person own to me-Or-who has produced E---4S who is rson ally known o r who has produced
As identification and who did take an oath. as identification and who did take an oath.
, NOTARY PUBLIC:
, day of
NOTARY PUBLIC:
Sign:
Print
My Commission Expires:
.00
• or.,A
l ° a roy•�rd My Commission Expires
opt "° �, .
Q
APPROVED BY 710 r,2,_cir Plans Examiner C
Sign: ,o /
Print: - r /V / 4- /`/ al/€/c
NOTARY PUBLIC -STATE OF FLORIDA
f' Sylvia Halter
Commission # EE098053
,, Expires: JUNE 08, 2015
*180109313444 434117ABAKIW4a4A
0///
Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09)
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:1132060141410
Owner's Name: CHURCH
Job Address: 602 96 Street
Miami Shores, FL
Owner's Phone:
Total Square Feet:
Total Job Valuation:
(305)754 -9541
Contractor(s)
QUIRINO CONSTRUCTION CO
Planning and Zoning Criteria and Comments
Approved: Yes Date Approved: 10/21/2011: Yes
Comments:
From:Beverly Halsley FaxID:Roemer Insurance
Page 1 of 3
Date:10/31/2011 10:12 AM Page:1 of 3
OP ID: BH
A� R °' CERTIFICATE OF LIABILITY INSURANCE
INSR
LTR
°A�`/31/1 W"'
10/31/11
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 POLICIES
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 ADDITIONAL INSURED, the policy(ies) 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
W.F Roemer Insurance Agency
William F. Dowd
P.O. Box 190669
Fort Lauderdale, FL 33319
William F. Dowd
954 -731 -5566
954 -731
-8438
CONTACT
LIMITS
PHONE
INC. No. Ext):
FAX
(A/C, No):
E-MAIL
ADDRESS:
LIABILITY
COMMERCIAL GENERAL LIABILITY
CUSMER QUIRT -1
CUSTOMER ID*:
INSURER(S) AFFORDING COVERAGE
04GL000820478
NAIC #
INSURED Quirino Construction Co. Inc.
1987 NE 119 Road
North Miami, FL 33181
EACH OCCURRENCE
$
INSURER A: Mid - Continent Casualty Co
X
23418
INSURER B:
100,000
INSURERC:
X
MED EXP (My one person)
INSURER 0 :
Excluded
INSURER E :
PERSONAL & ADV INJURY
$
INSURER F :
CERTIFIC.
•
T1r1�10 IC TO ocRTII'Y�TIT..�IrIIATe�1�I[1 POLIOICO �orI'I {IINOUR�IANOCF LII�CTI D BELOW �[I�IpA�VCF DaC�CN ICCU CD TO TI IC INCURCD NAMED ABOVE ro TI IC POLIOY PERIOD
�9.1(?f EA I EN71211v IR'IJTS"1=ft.U- tf-IUI~AY FFSEK7AITIF WI ETINRa"CI KAN4l''t "-- At217P4 It "U l3Y�IHrtngFlgsr'BtRJ FI IUMIAEAnis I ftt:lPfOTATO I ti i JTlas,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
VINO
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/OD/YYYY)
LIMITS
A
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
OCCUR
04GL000820478
05/11/11
05/11/12
EACH OCCURRENCE
$
500,000
X
DAMAGETO RENTED
PREMISES (Ea occurrence)
$
100,000
CLAIMS -MADE
X
MED EXP (My one person)
$
Excluded
PERSONAL & ADV INJURY
$
500,000
GENERAL AGGREGATE
$
1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER' :
PRODUCTS - COMP/OP AGO
$
1,000,000
POLICY PRO-
JECT LOC
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
$
UMBRELLA LAB
EXCESS LAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
$
WORKERS COMPENSATION
AND EMPLOYERS' LABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
It yes, describe under
DESCRIPTION OF OPERATIONS
Y / N
N / A
WC STATU- OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT
$
below
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
Subject to policy terms and conditions.
CANCELLATION
MIAMIS2
Village of Miami Shores
10050 NE 2 Avenue
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
•
O 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
C, [ 2 0 2011
>llll X41
Miami Shores Village
APFt n`, 11
ZONINC
BLDG DR .,_r
SUBJECT TO
STATE AND Cc
CITE`
COPY
DATE
Al I fir