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PL-10-2125Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 (O21\ Inspection Number: INSP- 153855 Permit Number: PL -12 -10 -2125 Scheduled Inspection Date: July 22, 2011 Inspector: Hernandez, Rafael Owner: DUBOFF, PATRICIA Job Address: 795 NE 95 Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: PARKWOOD POOLS INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Pool - Private Phone Number (305)758 -7402 Parcel Number 1132060142180 Phone: (954)583 -3355 Building Department Comments POOL PIPING Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments July 21, 2011 For Inspections please call: (305)762 -4949 Page 1 of 9 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 ®i_ 2010 Permit No. T LI 4--2\ ZS Master Permit No. Permit Type: PLUMBING QQ / ,/ itpa,40 14P OWNER: Name (Fee Simple Titleholder): /-Gt ual .4 "11 /�e,✓�/� Phone #6.341"1 7V "642-SY Address: 7 5 A/ e ?5 67/(-e2.1" City: /tt (A-7,K T SA -S State: 1=C Tenant/Lessee Name: A//4 Email: a- 71 @' du.66 #/a,v.3 rht • c4 JOB ADDRESS: 79S' /i/" C . 7S ,574-ee,/— City: Miami Shores County: Zip: 3 /3A7 Phone#: Miami Dade zip: ,33/3 ? Folio/Parcel #: //- 34206. -0/5/ a /,O Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: / d4,1K.u/Od d tend S T/✓ C Address: t 76 ( • S ,be vri &' oL City: 7010--0-1-4- State: Qualifier Name: j9'V J. State Certification or Registration #: C,G /(/ r. % 8 71 Certificate of Competency #: Contact Phone #: C l s 13 — C/` Z Email Address: p ��,�oS Le / - Ak� 1 [ DESIGNER: Architect/Engineer: Phone #: Phone#: (u) s 713 Zip: 333/ 3 Phone #: v`S/)er 33 - 33,5-45— � <$2 ---- Value of Work for this Permit: $ c Square/Linear Footage of Work: Type of Work: ❑Address °Alteration ew ❑Repair/Replace °Demolition Description of Work: t2 11, n/ �i a************* *** *+x*+x**+x********aaa. *+ ** Fees**** ***************** ***+x **+x********** *** *** Submittal Fee $ Permit Fee $ 2 .P-S-- CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ ip 1, ,99 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) .tin Mortgage Lender's Address City State Zip ,a/A 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 no,J,� e approved and a reinspection fee will be charged. r Agent The foregoing instrument was ackno lleddged before thisZf day of , 20 /0 , by i C.1A* 1 4j7 '19 , who is personally known to me or who has produced C4r7.treL.S /i -' 2 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print My Co Contractor The foregoing ment was acknowledged before me this / day of ci ,20/0 , by Oj9-a/i d /4 0.4; —s aiho is personally known to nor who has produced as identification and who did take an oath. NOTARY PUBLIC: Lre Gf o,. JT ssion Expires: 3v/. Sign: i ` ti LUCRECIA SARMIENTO-RIOS mr_ MY COMMISSION # DD 633067 • slit EXPIRES: March 11, 2011 •r ®5nded Thru Notary Public Undenvrfers Commission Expires: -i Ammo-RIGS : % MY COMMISSION # 1 633067 EXPIRES: March 11, 2011 a Bonded Tuna Netari Pita llnUerWT tars * * * * * * * * * * * * * * * * * **** Kai ***** +x****+i **** +x+x+x+xa>b*>a>g+x>x***** *** ** ** *** ********w***** **** A***** *** F>R*+s*»<*****+ * ** APPROVED BY (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Plans Examiner Structural Review Zoning Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. / COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Pia/214,ddod, COMPLETE COONTRACTOR'S INFORMATION BUSINESS NAME: 8-0/.5 .Tt•✓- BUSINESS ADDRESS:676/ W. 5o,✓r;s` gluct CITY Pl dr, -reon4 STATE r( ZIP CODE 333/3 BUSINESS PHONE: ( 9.11' ) _ $ 3- 3 3,5-S- FAX NUMBER ( f,14/ ) 583 -300 ? CELL PHONE ( 1Y ) 7v7- 194'7 QUALIFIER'S NAME: Ora-vi ci A QUALIFIER'S LIC NUMBER: C.-PC- /'16 7 7 9 E -MAIL ADDRESS (IF APPLICABLE): ea..ILea awers L. 6f d-er.. .. N .e� Created on 3119109 BY MLDV I RV 3126109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 ADAMS, DAVID WILLIAM PARKWOOD POOLS INC 6761 W SUNRISE BLVD #16 PLANTATION FL 33313 -6000 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better.: fJ For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Departments initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! (850) 487 -1395 DATE BATCH NUMBER P7614. if( From:Teresa Schnetzka FaxID:(954)4520450 Date:9 /24/2010 04:14 PM Page: 2 of 3 OP ID: TS ACCORD. CERTIFICATE OF LIABILITY INSURANCE 1 �' 0912 /10 09124!10 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: Ii the certificate holder is an ADDITIONAL INSURED, the pancy{ies) must be endorsed. It SUBROGATION 1S WAIVED, subject to the terms and conditions of the policy, certain pones may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of sudl endorsemenijs). PR ER 954 - 452 -4900 BB Insurance Marketing, Inc. 954 - 452,0450 P.O. Box 551267 Fort Lauderdale, FL 33395.1267 Paul Applegate REACT PHONE FAX WC. No. la Not POLICY EXP iMMIDD/YYYYI PRODUCER CUSTOMER OMPARKW -4 INSURER(,) AFFORDING COVERAGE NAIC II INSURED Parkwood Pools Inc 6761 W Sunrise Blvd 516 Plantation, FL 33313 INSURERA:Associated Industries Ins. Co. INSURER B: INSURER C: INSURER O: $ INSURER E : INSURER F : $ COVERAGES REVISION NUMBER THIS IS TO CERTIFY THAT 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CAMS. INSR __ TYPE ADDLSUBR MR WISE POUCY NUMBER POLICY EFF IMMADDIYYYYI POLICY EXP iMMIDD/YYYYI LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY JC LAIMS•MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE EMI SO RENTED PRE]4IISESIEaamrtartoe) $ MED EXP (Anyone person) $ PERSONAL & MW INJURY $ GENERALAGGRKTATE $ GENL —I AGGREGATE LIMIT APPLIES PER: POUcY n n LOC PRODUCTS - COMP/OP AGO $ $ AUTOMOBILE - LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea occident) $ BODILY INJURY (Per person) $ — BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peremldard) $ — _ $ _ UMBRELLA EXCESS LIAO OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ — DEDUCIBLE RETENTION $ $ 5 A VIORKERS COMPENSATION AND�LOVERS LIABILITY ANYPiOPRIETORJPARiNEWEXECUTNE OFFI�AMEJBER OCCLUDED? (Mandatory, In NH) If yes. describe under DESC WPTICNN OF OPERATIONS YIN N I A TWC3249169 09123/10 09123111 WC STATU- OTH- TORY UM= X I ER EL EACH AIX DENT $ 500,000 EL. DISEASE -EA EMPLOYEE $ 500,000 below EL. DISEASE - POLICY LIMIT $ 800,000 DESCRIPTION OFOPEWT�NSI TIONSfVEIICXES(AttachACORO1091 AdditionalRemaH ® Schedule. BmaeSpateisrequired) Pool construction is A spas). 6761 W. Sunrise Blvd #16, Plantation, FL 33313 *Except 0 days notice for non - payment of premhun. CERTIFICATE HOLDER I MIAMISH Miami Shoresdillage 10050 NE 2nd Avenue M lam I Shores, FL33139 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISION&, Paul Applegate AUTHORIZED REPRESENTATIVE �� ACORD 25 (2009109) ®1988 -2009 ACORD CORPORATION. Ail rights reserved. The ACORD name and logo are registered marks of ACORD AW RD' LJa IC.OIL'ML.v IU J.0 1.JO r 111 raUG.c UI .3 PARKPOO-01 MARTIND CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/24/2010 PRODUCER International Assurance Inc. P 0 Box 9635 Mobile, AL 36691 (251) 344 -5530 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. INSURERS AFFORDING COVERAGE NAIC 5 INSURED Parkwood Pools Inc 6761 W Sunrise Blvd Ste 16 Plantation, FL 33313 INSURER A: Landmark American 33138 INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDTHE F ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUANY REC MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF MAY PEF POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADM NSRD TYPE OF INSURANCE POUCY NUMBER POLICY EFFECTIVE DATE (MMIDD/YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY1 LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY LBA082354 7/10/2010 7/10/2011 EACH OCCURRENCE $ 500,000 P SES RENTED ► $ 50,000 CLAIMS MADE X OCCUR MED EXP (My one person) $ 5,000 GENI. PERSONAL ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY n J& n LOC PRODUCTS - COMPIOP AGG $ 1,000,000 AUTOMOBILE 1 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) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS —1 / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS AND MPPLOYERS' ANYPROPRETOTPARTNEWEXECUTIVE OFFICERIMEMBER (Mtmdatruy B yes, describe SPECIAL PROVISIONS LIABILITY YIN TORY LIMITS I ER EL. EACH ACCIDENT $ EXCLUDED? M NH) under below E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS A 30 day notice of cancellation applies except 10 days for nonpayment of premium. CATE HOLDER Miami Shores Village 1 N E 2nd Avenue _ IMMiami !Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAD. 30 DAYS WRITTEN NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. atXTHORI2ED REPRESENTATIVE 01988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OUC UIRE FTAIN 1 U-1 - J *1 • I A7NI■•■— *YYAMS JULV1r��V- iW'.'�• ∎./ �i' ■11�• ■ v .o • • 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954 - 831 -4000 VALID OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011 DBA: Business Name: PARKWOOD POOLS INC Receipt #:188 -1217 Business Type: POOL /MARINE CONTRACTOR (COMMERCIAL POOL /SPA nps*Tn.n % /Tn1r n 1 Owner Name: DAVID W ADAMS /QUAL Business Opened:o3 /12/2009 Business Location: 6761 W SUNRISE BLVD 16 State /County /CertlReg:CPC1457879 PLANTATION Exemption Code:NONEXEMPT Business Phone: Rooms Seats Employees 2 Machines Professionals For Vending Business Only • Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: DAVID W ADAMS /QUAL 6761 W SUNRISE BLVD STE 16 PLANTATION, FL 33313 2010 - 2011 Receipt #03A -09- 00021775 Paid 09/02/2010 27.00 • ','7F:142 "3644 : •" •• °d. 1T55339 WARRANTY DEED This Indenture, made this 2. 6, day of March, 1997, Between ARTHUR P. WARD and KRISTEN L. WARD, husband and wife, of 11810 NE 19 Drive, Miami. Florida 33138, he inaft r_c4eLtike ors, to PATRICIA A. CALANDRA, a single woman, ct, Miami Shores,ortida 33138, hereinafter called grantees: (Wherever used herein the terms °grantor° and "grantees" include all the parties to this instrument and their heirs, legal representatives and assigns of individual, and the successors and assigns of the corporation) WITNESSETH, that the grantor, for and in consideration of the sum of TEN ($10.00) Dollars, and other good and valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens and remises, releases conveys and confimts unto the grantees. all that certain land situate in Dade County, Florida, to -wit: Lot 20, and E h of Lot 19, Block 68, of MIAMI SHORES SECTION 3, according to the Plat thereof, as recorded In Plat Book 10, at Page 37, of the Public Records of Dade County, Florida, a1Wa 795 NE 95 Street, Miami Shores, Florida 33138. SUBJECT TO: Conditions, restrictions, reservations, limitations, and easements of record. Vasty, applicable zoning ordinances, taxes for the year 1997 which are not due and payable and subsequent years. (Grantee) Arthur P. Ward S.S. (Grantee) Kristen L. Ward S S. Tax Polio Number. 3206-014-2180 TOGETHER with all tenements, hereditament) and appurtenances thereto belonging or in anywise appertaining. TO HAVE AND TO HOLD, the same in fee sample for ever. Harvey Ruvin Clerk of the Circuit and County Courts Miami -Dade County, Florida 11111111111111111111111111111111111111111111111111111111 Application 1998 - 010716 Official Record Date: JUL-08 -1998 Bk/Pg: 389/2965 Certificate of Marriage Marriage License Bureau 140 W. Flagler Street R1503 Miami, Fl 33130 Phone: 305-375-3019 1, Harvey Ruvin, Clerk of the Circuit and County Courts of Miami -Dade County, State of Florida, do hereby certify that KENNETH R DUBOFF Resident of the City of MIAMI SHORES County of DADE State or Foreign Country of FLORIDA , and who was bom on MAR -18 -1951 in the State or Foreign Country of NEW YORK and PATRICIA A CALANDRA Maiden Name: GIBBEMEYER Resident of the City of MIAMI County of DADE State or Foreign Country of FLORIDA , and who was bom on MAY -18 -1953 in the State or Foreign Country of PROVIDENCE RI were married on JUL-04 -1998 by • 0GUILLERMINA WRIGHT.- ....._ in KEY WEST, FL who-is ..a-.... NOTARY .._........._....... _ ................._ .....; WITNESS my hand and Official Seal this 18 day of October , 2010 . Harvey Ruvin, Clerk Circuit 47 Courts