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RC-11-1573Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 165281 Permit Number: RC -8 -11 -1573 Scheduled Inspection Date: November 17, 2011 Inspector: Bruhn, Norman Owner: MARSHALL, JENNIFER Job Address: 180 NW 101 Street Miami Shores, FL Project: <NONE> Contractor: HOME OWNER Permit Type: Residential Construction Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1131010230180 Building Department Comments BATHROOM REMODEL 9/12/2011 - NOC 9/20/2011 - NOC SUBMITTED. passeV1/7/11 Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 163752. MISSING ELECTRIC AND PLUMB FINALS. JR November 16, 2011 For Inspections please call: (305)762 -4949 Page 3 of 17 MATE OF FLC'fU A, COUNTY OF DADE 1 HEREBY CER77FYthrit f #fit3 campy ofdaa cried KW in t r . ( L day of 1 A U 36_ NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO.g0I 1 _ 1 J13 TAX FOLJO 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. 1101111111111111111111111 CFN 2011R0611351 OR Mt 27523 Ps 08S9f (.1ps ) RECORDED 09/13/2011 11:57 :15 HARVEY RIJV'II4r CLERK:. OF COURT MAUI-DADE C :OUHTYp FLORIDA LAST F'AGE -/ �c I'✓ S7 Space above reserved for use of recording office Legal deic�ription of propertyAnd street/address: / NIA / I 2 Description of improvement: I -3 .411.2 t c3 IA 1 I Owner(s) name and address: ✓ .G In r L. n mr /IA �f'A i 1 } &A/Li Iry v 5.7 Interest in property: �� �- J rt i t { e_rat-,3 _ 0,3 I y- Name and address of fee simple titleholder: 9 Contractor's name, address and phone number. O s -'7* j 1 $ Q ( U _ f3vi l t' 5. Surety: (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, Name, address and phone number. 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, address and phone number. 9. Expiration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a different date Is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER Al- i EH 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 INSPECT' N. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK • `1R CORDI YOUR NOTICE j F �,OMMENENT. % emu/ q k/`^ s) or Owner(s)' Authorized Officer/Director /Partner /Manager repared Print Nam Title/Office STATE OF FLORIDA COUNTY OF MIAMI -DADE The foregoing instrument was acknowledged before me this By S+-t 41,1- ❑ Individually, or ❑ as for ❑ Personally known, or produced the following type of identficatioj. Signature of Notary Public: Print Name: (SEAL) VERIFICATION PURSUANT TO SECTION 92.525. FLORIDA STATUTES Under penalties of perjury, 1 declare that I have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. amercartmenram . 4 Prepared By r Itle /Office One day of // ,��'�i . \N ra L ,, S TAi ® \N`Ns Signature(s) of Owner(s) or Owner(s)'s Authorized Officer/Director /Partner/Manager who si6rii#1 live: By By 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 T g: BUILDING OOFING OWNER: Name (Fee Simple Titleholder): "s=-1 10 ‘( 41A9bLI)N Phone #i Ce U Address: l,S,® ITAJ ( ( City: ll Q V\A, k t p `i b res, State: Zip: Tenant/Lessee Name: / Phone #: Email: -1) Permit No. I t H LJ 0. / Master Permit No. JOB ADDRESS: l'iC) / ©( -- City: Miami Shores County: Miami Dade Zip: 33/ S---b Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Company Name: c›:4 NO t- Flood Zone: Phone #: Address: City: State: Zip: Qualifier Name: Phone #: 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: Addition UAlteration UNew dRepair/Replace Description of Work: 171 l Q. t"JOkco r. ODemolition ******* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** *Fee *********** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *: Submittal Fee $ Permit Fee $ 76 y' 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 `114,10,C1 Signature The fo ; :oing.i day of iI`jl_n who Contractor e regoing instrument was acknowledged before me this • ,20,by is personally known to me or who has produced as identification and who did take an oath. o me or who has produced identification and who did take an oath. NO l ' Y PUBLIC: - Sign: Print: My Commission Expires: • APPROVED BY I 405 ��i' /07 Plans Examiner Zoning NOTARY PUBLIC: Sign: Print: My Commission Expires: Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NAME: �Pir� :+ . , -hall( fN DATE: VS- ADDRESS: 1 • fJ (0 (� 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 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 2. I understand that building permits are not required to be signed by a property owner unless he or she i 'responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initia i�" c 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand tha ' 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 1'- se numbers on permits and contracts. Initial 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I ma 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 substanti Ily improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I buil : ubstantially improved it for sale or lease, which violates the exemption. 5. I understand that, as the owner- builder, I must provide direct, onsite supervision of the construction. Initial Initial 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons workitlg 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. 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 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who i!. 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 abi 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 by all applicable 4, 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.mvfloridalicense.com/dbpr/pro/cilb/inde 1 Initial 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I 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 info 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 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 AS day of /\ B lk personally known to me or who has P Y Produced there License orl 0 (Q')%'D, J ` L+ - ) OI _ as identlfic.tion. ,201) NOTARY 0� � , 111.‘‘ � '165' 011 ADD SMOKE/CARBON MONOXIDE DETECT RS. ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLAcD. 1 /-lcl(a. 9-0 04 1 1VcOL BATHROOM RECEPTACLE OH 20 CITY AHD G.F.1 PR .y.e r v\x ilea ozo \N\coxvn, c, `Ink wt vvcYou1 J Ozir 4---vcOvri t,%0 A-"- Y\1\1,Cs.. k %-\&S3 (CS 410-\ WI in 40L-1 CJA,440,ry RA YMORE COMMISSION EXPIRES: June - 3 OMMI 8SSION DD 88914 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 163776 Permit Number: PL -8 -11 -1574 Scheduled Inspection Date: October 07, 2011 Inspector: Hernandez, Rafael Owner: MARSHALL, JENNIFER Job Address: 180 NW 101 Street Miami Shores, FL Project: <NONE> Contractor: HOME OWNER Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1131010230180 Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comme October 06, 2011 For Inspections please call: (305)762 -4949 Page 2 of 15 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PRONE NUMBER: (305) 762.4949 BUILDING Permit N . --)21( PERMIT APPLICATION Master Permit No. ,C i 15-1 FBC 20 Permit Type: PLUMBING OWNER: N e (Fee Simple Titleholder): 4AXC Address: V6 Lb ! Q'‘-k Pr.-1,01,V c Phone #: Tee 2,1c -`f o Co City: V\M C, W\ k `v\0\ctC State: Zip: J C-+ Tenant/Lessee Name: f W Phone #: Email: JOB ADDRESS: L 0 )\11,0 City: Miami Shores County: Miami Dade Zip: Z' (`73 Folio/Parcel #: Is the Building Historically Designated: Yes NO ,e'" Flood Zone: CONTRACTOR: Company Name: 1' . Phone #: Address: City: State: Zip: Qualifier Name: Phone #: State Certification or Registration #: Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect /Engineer: Phone#: Value of Work for this Permit: $ aOO ' 60 r Square/Linear Footage of Work :, , Type of Work: Address UAlteration ONew41Replace `,.CIDemolition Description of Work: 0.C. 73—Ab cod e-c+- ***: x***** ******. x*****+xx::x** ** ********* ** Fees********* *** ****+ x*+ x**** ********************* Submittal Fee $ Permit Fee $ r° — 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 CONDMONERS, 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 Ada" Signature Contractor I e foregoing instrument was acknowledged before me this to me or who has produced ho is personally known to me or who has produced identification and w o did take an oath. as identification and who did take an oath. NO UBLIC: NOtARY PUBLIC: * * * * * * * * * **+x* *x� �x.x mix «_ ..:<****** **+x**** *** * * * * * * * * * * * * * ** **** *****+ x* ** **** ************ ** ** APPROVED BY Plans Examiner (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Structural Review 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: Jam- fR It.. Fe, fin a 1( Alb; DATE: ADDRESS: iccO 4J Ai f 0/51r / /14 i / 7a. 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; l 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 1, as the owner of the property listed, ma act as my own contractor with certain restrictions even though I do not have a license. Initial W/l 2. I understand that building permits are not required to be signed by a property owner unless he or she is construction and is not hiring a licensed contractor to assume responsibility. Initial sible for the 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I +'ay 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 e numbers on permits and contracts. li il . Initial z 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may all. 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 subst. -tially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I b t substantially improved it for sale or lease, which violates the exemption. Initial is 5. I understand that, as the owner- builder, I must provide direct, onsite supervision of the-construction. Initial 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working oh my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law an y county or municipal ordinance. Initial W// " w 624 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 will ly 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 ot 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 'y 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 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.myforidalicense.com /dbpr /pro /cilbf ex.html Initial 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 infor 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 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 6' day of 20 l� \Y\who was personally known to me or who has Produced there License or Zn s-12-L i.entifi «:tion. WNER u TTS' 0 NoT b '• .:. 3 : seams 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 180 NW 101 Street Miami Shores, FL 1131010230180 Block: Lot: JENNIFER MARSHALL Owner Information Address Phone Ceti JENNIFER MARSHALL 180 NW 101 ST MIAMI SHORES FL 33150 -1214 Contractor(s) Phone Cell Phone RAYS ELECTRICAL SUPPLY INC (786)236 -2777 Valuation: Total Sq Feet: $ 900.00 0 1 Type of Work: ELECTRICAL Additional Info: SERVICE REPAIR Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $2.25 $2.25 $0.20 $150.00 $3.00 $0.80 $159.10 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -10 -11 -42261 10/31/2011 Credit Card $ 159.10 $ 0.00 Available Inspections: 1 Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Underground W. W. 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. October 31, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date October 31, 2011 1 A�C9Rti CERTIFICATE OF LIABILITY INSURANCE �--�'" DATE(MIVDDNYYY) 10/26/2011 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(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 cerdficate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER KOSKI & COMPANY INC. 9875 SUNSET DRIVE MIAMI, FLORIDA 33173 CMTACT GINGER YOUNG LAIC No SM. 305.5952127 1 a No, 305.596.9780 A SS: GINGER @MYKOSKI.COM INSURERS) AFFORDING COVERAGE NAIC # INSURER A: LANDMARK AMERICAN INS. CO. LIABILITY COMMERCIAL GENERAL usury INSURED RAY'S ELECTRICAL SUPPLIES INC. 2023 OPA LOCKA BLVD. OPA LOCKA, FLORIDA 33054 INSURER B I TECHNOLOGY INSURANCE CO. LBA133270 INSURER C: 10/20/2012 INSURER D: Si 1,000,000 INSURER E: $ 100,000 INSURER F : $ 5,000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 POUCIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN TYPE OF INSURANCE ADDL Y�NVD POLICY NUM$ER NMMIDDY/1'i f DD�IY�YY► VAS A GENERAL X LIABILITY COMMERCIAL GENERAL usury LBA133270 10/20/2011 10/20/2012 EACH OCCURRENCE Si 1,000,000 PREMISES (Ea accwmnce) $ 100,000 MED EXP (Any one person) $ 5,000 ( CLAIMS -MADE X OCCUR PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 1,000,000 GEN'L AGGREGATE LIMIT APPUESPER: POLICY n n LOC $ AUTOMOBILE __-_ LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS AUTOS SINGLE LIMIT BODILY INJURY (Per pew) $ BODILY INJURY (Per amt) $ P�RO)OANAGE $ $ UMBRELLA IJAB EXCESS UAB + OCCUR CLAIMS.MADE EACH OCCURRENCE $ AGGREGATE $ $ DED 1 1 RETENTION$ B WORXERSCOMPENSATION AND EMPLOYERS' LABILITY Y o FFICERIMEMBER CL Y XUDEE (Myyaens,datory, In NH) IIdescribe under MRIP110N OF OPERATIONS below NIA TWC3265193 01/31/2011 01/31/2012 X 1 OCRYSLAibe -81 1 ° R E.L. ACCIDENT $ 1�' EJ.. DISEASE - EA EMPLOYEE $ 500,000 EJ.. DISEASE - POUCY UMIT $ 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I more space Is repaired) ELECTRICAL. CONTRACTORS & SALE OF ELECTRICAL EQUIPMENT. ALL TERMS, CONDITIONS, LIMITATIONS & EXCLUSIONS OF THE POLICY & THE INSURED'S WARRANTIES TO THE COMPANY APPLY. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 N.E. 2 AVENUE MIAMI SHORES, FL 33138 -2382 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE AI KOSKI & COMPANY INC. i' ACORD 25 (2010/05) ®1988.2010 ACORD C�RORATION. All rights r The ACORD name and logo are registered marks of ACORD l d. 663630-3 BUSINESS NAME / LOCATION RAYS ELECTRICAL SUPPLIES INC 2015 OPA LOCKA BLVD 33054 OPA LOCKA THIS IS NOT A BILL — DO NOT PAY RENEWAL RECEIPT NO. 240067-9 STATE* EC13002844 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 OWNER RAYS ELECTRICAL SUPPLIES INC Sec. Type of Business WORKER/S 19 ELECTRICAL CONTRACTOR 10 THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF 114E COUNTY OR CMES. NOR DO NOT FORWARD DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF RAYS ELECTRICAL SUPPLIES INC THE HOLDERS GUALIFICA- 110148. 2015 OPA LOCKA BLVD OPA LOCKA FL 33054 PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/27/2011 02290031003 000045.00 SEE OTHER SIDE 177 • 10)2411-- art" BUILDING 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 Permit Type: Electrical Permit No. 11 t Master Permit No. RC' - V 1 -/ 1 f OWNER: Name (Fee Simple Titleholder): Phon : Address: City: \.p■o re__ State: F k Tenant/Lessee Name: //44 Email: Zip: r-q`f IP Phone #T %.C..`"-2-1W 1.4Y ()Co JOB ADDRESS: City: Folio/Parcel #: vv® Lk) l0 %t- Miami Shores County: Miami Dade 1 x (0 1 to -2.- [ Zip: 3 -61 6 Is the Building Historically Designated: Yes NO ' Flood Zone: CONTRACTOR: Company Name: aL A e@'� Q_Q ` Address: ZO /,.S ' i9" l pl h.Q at. . (f City: 6 /4- L cje f G A State: /"- [ / � n Qualifier Name: Pit i.0410 JA) 2- State Certification or Registration #: OG G/ 36161 Zic Certificate of Competency #: Contact Phone #: 14.'236 Z 77,7 Email Address: DESIGNER: Architect/Engineer: Phone#: Phone #: 3es (D, ?. 7/ 3) zip: .3)o Phone #: 565 t gz 7/ Value of Work for this Pe4rmit: $ e) Square/Linear Footage of Work: Type of Work: DAddress UAlteration ONew 121 ot� pair/Replace Description of Work: ODemolition ** ******** **************+x ******+x******* Fees** ****** ****a: *********** ****** ************** Submittal Fee $ Permit Fee $ Pc"-®^ a de, 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 FT.ECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOIT .FRS, 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 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: ********* ******* APPROVED BY Signature �-- Contractor The foregoing instrument was acknowledged before me this/ day of , 20 ff , by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUB C: Sign: Print: My Commission E VALTY RAYMORE MY COMMISSION # DD8138914 E}II'IRL: } -Mz l9, 2013 ***: g**+ k*+ k** *+ k******** *********+ k+ k********* N= *+ k****** **N= *N=# Ni= k +k*M+*N3****:ksk** ** * ***N *** C9-4"/ Plans Examiner Structural Review (Revised 07 /10 /07XRevised 06 /10 /2009)(Revised 3/15/09) Zoning Clerk AY'S ilGECTRICAL 0UPPLIES. INC. at? of tA7 kw ST NJAijI' ShippiF ill 5c 2023 Opa -Locka Boulevard, Miami, Florida 33054 Phone: (305) 688 -7133 • (305) 688 -6334 • Fax: (305) 687 -2235 3 41 Ke5i Ced5Do iz 1 Cot) u,; t d49 . icx Com&) — (99 Miami S h c;b'es l' lace APPROVED BY DATE ZONING DEPT BLDG DEPT 41/1 417e/ l SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS 6w' 1'4 'J91., d �! LL Gr12cwc ► g. - ; o are- ?few ALTY RAYMORE OMbIISSION # DD888914 EXPIRES. Jame 19, 2013 Discount &sop. Co. AY'S LECTR(CAL EPPLIES, (NC. Mr au tai ST /1-611/1 .S7 nc3/5' 2023 Opa -Locka Boulevard, Miami, Florida 33054 Phone: (305) 688 -7133 • (305) 688 -6334 • Fax: (305) 687 -2235 Miarni Shores Village APPROVED BY DATE RZON NG DEPT BLDG DEPT /01-r--7,/, FEDERAL I IllrCT TO COMPLIANCE WITH ALL 1 A 11 AND COUNTY RULES AND REGULATIONS a., 5-, Wiz;° 2A ?eitt CtGwti F- . &a� e- la &Ew Nod_ �eU'St�r caJ17u i � eq/(/1/o ALTY RAYMORE OR9ISSION # DD888914 EXPIRES* June 19, 2013 is:nuat Asoa. Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)7564972 Inspection Number: INSP - 165321 Permit Number: EL -9 -11 -1644 Scheduled Inspection Date: November 16, 2011 Inspector: Devaney, Michael Owner: MARSHALL, JENNIFER Job Address: 180 NW 101 Street Miami Shores, FL Project: <NONE> Contractor: RAYS ELECTRICAL SUPPLY INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1131010230180 Phone: (786)236 -2777 Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 164216. Service not to code .Bathroom is O. K. and will be finaled when a permit to repair service is submited. r--- // (ecV( November 15, 2011 For Inspections please call: (305)762 -4949 Page 12 of 43 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 Type: Electrical OWNER: Name e (Fee Simple Titleholder): Address: i' I�° N W ` / 30M19 CEP 0 7, 2011 Ali Permit No. Fl l 1 l . Kati Master Permit No. 11 '` Phone #: 21% 1414°67 City: INIVtrow 'U1Jo c. State: - zip: tb Tenant/Lessee Name: I v f Phone #: Email: JOB ADDRESS: V® ()Ai cp:k- City: Miami Shores County: Miami Dade zip: 33 t Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Compan Name: NO Flood Zone: Address: - AtQ1 G/ City: / State: �� Qualifier Name: , r/I /�9 /LJ State Certification or Registration #: , gen, ZcP Certificate of Compe Email Address: Contact Phone #: 7d c,Z ; e e, 777 DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ i 00 Square/Linear Footage of Work: Type of Work: Address DAlteration CD l� Replacee ®� ,ryODemoliti/on� Description of Work: �� k�-u -. 0' & C) C� ` r O 1L 13")44\k' ******** * * * * ** * * * * * * * * * * * * * * * * * * * * * * * ** gees*** a:***** ***:x********a:*** ***** * * ** ::x*x:****** Submittal Fee $ Permit Fee $ /-4-70 Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ 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: 1 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 wil of be approved and a reinspection fee will be charged. Signatur�i�„ / lA er or Agent The foregoing instrument was acknowledged before me this day of Spoi., 20 /L , by who is personally known to me or who has kAAjeAAJ:2— As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commissidn Exp. * * * * * * * * * * * * * ** APPROVED BY VALTY RAYMORE MY C0M J3SION 0 DDS 138914 EXPIRES: Juoe 19, 2013A ttcc * *H!�a'�'.n11o0.'(:0 2 96'P/7 Signature (O Contractor The foregoing instrument was acknowledged before me this 6 day of ' , 20// , by who is personally known to me or who has produced as ident i ^ cation and who did take an oath. NOTARY PUBLI : Sign: Print: My Commis wow EXPIRES: June 19 nig Not,, y Ike: Aseafl. Ga, oksksk�Is********** * ** * * * * * * * * * * * * * * ** ** * * * * *** * ** Sk** `, * * * * * * ** Zoning Plans Examiner Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)