ACT-12-1755Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 178792
Scheduled Inspection Date: November 01, 2012
Inspector: Rodriguez, Jorge
Owner: CHURCH, ST ROSE OF LIMA CATHOLIC
Job Address: 418 NE 105 Street
Miami Shores, FL
Project: <NONE>
Permit Number: ACT -9 -12 -1755
Permit Type: Awnings /Canopies/Tents
Inspection Type: Final
Work Classification: Miscellaneous
Contractor: ALEXANDER & JOHNSON PROJECT MANAGEMENT AND DE
Phone Number (305)758 -0539
Parcel Number 1122310150060
Phone: (954)309 -6567
Building Department Comments
INSTALL NEW SHADE STRUCTURE REPLACE OLD ONE
IN PLAYGROUND
Infractio Passed Comments
INSPECTOR COMMENTS
False
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
November 01, 2012
For Inspections please call: (305)762 -4949
Page 5 of 15
PERMIT #
CONTRACTOR: f' An�4-3 '` ` ` ` "" "
SUBMITTAL DATE: q 01-4 L
ADDRESS: Li l' 10s
mo^t___
NAME: o onresc c,,,- nAn 1
RESUBMITAL DATES:
PROJECT TYP : A DY e-
f i -d { -ii - ^
V#1 NG' '" -
FIRE
STRUCTURAL
IMPACT FEES
ELECTRICAL
HRSIDERM
PLUMBING
NOC
MECHANICAL
BLDG
r
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
lo
ll11V G
PERMIT APPLICATION
Permit Type: BUILDING
)j 165°' gfi�L
JOB ADDRESS:
tp-7- 7, EiVED
SEP 2 1 2012
FBC20LO
Permit No.
Master Permit No. °" � a--11
Zip:
ROOFING
City: Miami �Shores County: Miami Dade
Folio/Parcel #: 1nACl A skelir of iLod 1154 III^ CFI'S llmsr`11
Is the Building Historically Designated: Yes NO
33i
Pu4� �tm► 5F�Qrta,� i7
Pl T t ..4�rq3 KT
AK
Phone#: , `� v Jdl' CJ / �1
el I
Zip.
33 /
Flood Zone:
OWNER: N e (Fee Simp Titlehhollder):M12e`1 1 /O�; W. d 4.04
Address: (1/4) / Oly '�'I �L vim()
City: 1�l �-Yp L �4•6 34•644^S I state: rid, -1 ,671'
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Of ev i i £ LS ..7-Atit... /VI •D/ Phone#:
Address: 3 (� f"/ ..5 ,e4"
City: ,e)//4,/,..„„,,J,,),-1 State: /2_,
Qualifier Name: ' 44v-t2 -S fr! !J( -I d `l
Zip: 73e) ZL
Phone#: %S �/ jL�
State Certification or Registration #: C' C I S ep, 6. `t Certificate of Competency #:
Contact Phone #: 1-47/, Sec Email Address: Al PM. b
DESIGNER: Architect/Engineer: Phone #:
0 <`
c Value of Work for this Permit: $ 3�e Square/Linear Footage of Work: � 36
Type of Work: ❑Addition ❑Alteration
Descriptio' f Work: i / � l l ilJ �PiV
A
New ❑Repair/Repl e ❑Demolition
14046- ®U)
Color thru tile:
*,+* *** *,** ** * * * ** *** ******* * ******'*** es********************************************
CA,
Submittal Fee $56 s..D Permit Fee $
rs
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ 1 13 Pe
f
1
ti
r •
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
Own ' or Agent
The foregoing instrument was acknowled before mmee thi
day of Sr,20a,by2STCI l�bQh Q/
who is all known to me or who has produced �,
pe y o
As identification and who did take an oath.
1
NOTARY PUBLIC:
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of , 20 Al, by ^�LC.l N eC ,
who is personally known to me or who has produced
'I L - as identification and who did take an oath.
My fission Expires:
Comm# EE095931
Expires 5/28/2015
NOTARY PUBLIC:
Sign:
Print: 11/711 t`2
My Conunission Expires:
* ***** *ffi, h*******+ U**+ k**dN*** *d+**, N, NsH*, k***, H+ N***, k**+ k+ k*, N, k*, k* ****+ U+ k*****9+Y***+k ***,A*** bah* ******* *�s,N�,RoH+h�6�%�h+h�kk,UM+kf ***
APPROVED BY
Plans Examiner
Structural Review
(Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 0611 0 /20 0 9)(Revised 3/15109)
7/i/P Zoning
Clerk
ELMS
Nam Pick - of Rondo
My Comm. Expk.s Osa 15, 101
Commission OK WW1
Bonged Through National Notary It.
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That the most Reverend Thomas Wenski, as Archbishop of the Archdiocese of Miami, his successors in
office, a corporation sole, has made, constituted and appointed, and by these presents does hereby make,
constitute and appoint Sister Elizabeth A. Worley, C.O.O., his true and lawful attorney for him and in his
name, place, and stead
Giving and granting unto Sister Elizabeth A. Worley, C.O.O., his said attomey full power and authority to
do and perform all and every act and thing whatsoever requisite an necessary to be done in and about the
premises as fully, to all intents and purposes, as he might or could do if personally present, with full
power of substitution and revocation, hereby ratifying and confirming all that Sister Elizabeth A. Worley,
C.O.O., his said attorney or his substitute shall lawfully do or cause to be done by virtue hereof.
In Witness Whereof, I have hereunto set my hand and seal this 1 % day of K ,v
A.D., 2011
Signed, sealed and delivered
in presence of:
Witness:
rfcA.wa�4
Witness Signature
NA-g4 ■R
Printed Na ,
W +4/
ess /CL�I e �cP //(1(cW)
ted Name
STATE OF FLORIDA
) SS:
COUNTY OF DADE
The Most Reverend Thomas Wenski
as Archbishop of the Archdiocese of Miami his
successors in office, a corporation sole
I hereby certify that on this day, before me, an officer duly authorized to administer oaths and
take acknowledgements, personally appeared The Most Reverend Thomas Wenski, as Archbishop of the
Archdiocese of Miami, his successors in office, a corporation sole, known to me to be the person
described in and who executed the forgoing instrument, who acknowledged before me that he executed
the same, and an oath was not taken. )C Said person is personally known to me Said person
provided the following type of identification:
Witness my hand and official seal in the County and State last aforesaid this 19 day of _
A.D. 2011.
My Commission Expires:
MAYRA NEUUNA ROWEL
Wary Publo, Mob
Commis don MINN
My Ciwei 1*. 21, 111
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000
VALID OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012
DBA:
Business Name: ALEXANDER & JOHNSON PROJECT
MANAGEMENT & DEVELOPMENT INC
Owner Name: JAMES EDWARD ALEXANDER
Business Location: 2306 SCOTT ST
HOLLYWOOD
Business Phone: 954-309-6567
Rooms
Seats
Employees
2
Receipt #:18 0 - 6214
Business Type:G' CONTRACTOR (GENE -
CONTRACTOR)
Business Opened:o5 /09/2005
State /County /Cert/Reg:CGC150 8 864
Exemption Code:
Machines
Professionals
For Vending Business Only
Number of Machines:
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 an 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:
JAMES EDWARD ALEXANDER
2306 SCOTT ST
HOLLYWOOD, FL 33020
2011 - 2012
Receipt *05A -10- 00009805
Paid 08/03/2011 27.00
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399 -0783
ALEXANDER, JAMES EDWARD
ALEXANDER & JOHNSON PROJECT MANAGEMENT AND DEVELOPMENT INC
2306 SCOTT STREET
HOLLYWOOD FL 33020
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 i
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
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 team more about the
Department's 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!
DETACH HERE
STATE of FLORIDA AC# 6 I a 9.3 8 7
DEPARTMENT OF BUSINESS AND
PROVES SION •< REGULATION
akF
CGC1508864 ' 1j412 120015714
CERTIFIED ERAL_ CONTRACTOR
ALEXANDERI k 0:;?'
AL NDER PROJECT MANA
IS CERTIFIED under the - provisions of .Ch.489 is
S+ttiratioa date, AUG 31, 2014 L12070600973
L - r-
THIS DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING • LINEMARK'':PATENTED PAPER
C# 6189387 STATE OF FLORIDA
DEPARTMENT_ Q.7 CT RM1SING °N REGULATION
UION BUSINESS AND INDUSTRY SEA L12070600973
BATCH NUMBER
LICENSE NBR
07/06/2012 120015714 CGC1508864
The GENERAL CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter:4
Expiration date: AUG 31, 2014
ALEXANDER, JAMES EDWARD
ALEXANDER & JOHNSON PROJECT MANAGEMENT
2306 SCOTT STREET
HOLLYWOOD FL 33020
.SCOTT
GOVERNOR
DEVELOPMENT INC
DISPLAY AS REQUIRED BY LAW
KEN LAWSON
SECRETARY
•
08 -10 -2011
JEFF ATWATER 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:
08/10/2011 EXPIRATION DATE: 08/09/2013
ALEXANDER
JAMES
FEIN: 202390227
BUSINESS NAME AND ADDRESS:
ALEXANDER & JOHNSON PROJECT MANAGEMENT AND DEVELOPMENT INC
2308 SCOTT ST
HOLLYWOOD FL 33020
SCOPES OF BUSINESS OR TRADE:
1— GENERAL CONTRACTOR
*
IMPORTANT: Pursuant to Chapter 440 . 05114), 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 440.06112), 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 440.06(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.
OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
QUESTIONS? (850) 413 -160
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
EFFECTIVE 08/10/2011 EXPIRATION DATE: 08/09/2013
PERSON: JAMES ALEXANDER
FEIN: 202390227
BUSINESS NAME AND ADDRESS:
ALEXANDER & JOHNSON PROJECT MANAGEMENT AND DEVELOPMENT INC
2306 SCOTT ST
HOLLYWOOD, FL 33020
SCOPE OF BUSINESS OR TRADE
1• GENERAL CONTRACTOR
IMPORTANT
FO 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
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
11111111111111111111111111111111111111101111
CFN 2012R0725633
NOTICE OF COMMENCEMENT OR Bk 28309 Ps 2430 tips)
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION RECORDED 1� if 1112412 14:28342
HARVEY RUVIN, CLERK OF COURT
MIAMI -DADE COUNTY FLORIDA
PERMIT NO. M-7 °% ` 03-5.-- TAX FOLIO NO. LAST PAGE
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.
1. Legal description of property and street ! address:
1s- Ade f= o" S?'
1V' /L1 d�
2. Description of im•r ve ent:
3. Owner(s) name and
Interest in property:
Name and address of fee simple titleholder:
l "-f 0 625/. aF
A �1 wzazyriiim
iiirannw
Al I
4. Conti actor's nam and address: P
5. Surety: (Payment bond required by owner from contractor, if any)
Name and Address:
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.
Name and Address:
8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided
in Section 713.13(1)(b), Florida Statutes.
,Name and Addr=
1 • /�
e
.s-
9. Expiration date of this Notice of Comme -ment: (the expiration date is 1 year from the date of recording unless a
different date is specified)
Signatu''+ er
Pnnt Owner's Name S is �e(' Cl, ,6ei -h W®i le>t Prepared by
Swom to and subscribed before me this day of ° 20 12.
Notary Public.
Print Note
My commi
s
Na
e•
NOTARY PUBLIC
STATE OF FLORIDA
Comm# EE095931
Expires 5/28!2015
I
►.
WITNESS m ' ® mot
County
OP ID: KM
ACORO"
`._...- CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
09/26/12
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 pollcy(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 561 -391 -4661
Sena & Whitney Corp Office 561- 338 -6551
Sena & Whitney, LLC
190 Glades Rd Suite C
Boca Raton, FL 33432
CONTACT N
PHONE FAX
INC. No. Ext: INC. No):
EMAIL
ADDRESS:
CUSTOMER ID t: ALEXA -C
INSURER(S) AFFORDING COVERAGE
NAIL
INSURED Alexander &Johnson Project
Management & Development Inc.
2306 Scott Street
Hollywood, FL 33020
INSURER A: Mid - Continent Casualty Company
23418
INSURERS:
04GL000837212
INSURER c
12/11/12
INSURER D :
$ 1,000,000
INSURER E :
$ 100,000
INSURER F:
CLAIMS-MADE I X
•
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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
TYPE OF INSURANCE
INSR
VNO
POLICY NUMBER
(MMN�DIWYY)
1MMIIDDNYYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
OCCUR
04GL000837212
12111/11
12/11/12
EACH OCCURRENCE
$ 1,000,000
[PREMISES RENTED
PREMISES (Ea occurrence)
$ 100,000
CLAIMS-MADE I X
MED EXP Any one person)
$ EXCLUDED
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L
X
AGGREGATE UMIT
APPLIES PER
LOC
PRODUCTS- COMP /OP AGO
$ 2,000,000
PO-
POLICY . E T
$
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 LIAB
EXCESS LUIS
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
_
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Yl N
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
I
ER
I TORY LIMITS LIMITS 1 I —
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY UMIT
$
DESCRIPTION OF OPERATION 1 LOCATIONS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
MIAMIS4
MIAMI SHORES VILLAGE
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
I
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
SiligWi
ACORD 25 (2009/09)
0) 1988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD