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DEMO-11-835Miami 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) 7614949 BUILDING PERMIT APPLICATION I JUL I' 9 201 U O a00AACi9PE'Ge"c'H °C^P57° Y+BC20 Permit No. -6 -I 1 Master Permit No. AID Permit Type: BUILDING ROOFING JOB ADDRESS: /2 A) £ q)l 4e e I City: Miami Shores County: Mipmi Dade Folio/Parcel#: /13 Z (6 0/3 02 q a7/ Is the Building Historically Designated: Yes NO 64 OWNER: Name (Fee Simple Titleholder): OsCa i 22/ Phonek3PS 733 6937 Address: ' 6 P E /0'7 0 77.e. t° City: 1-fl07,7 1 < Jd? Ores State: r/ Tenant/Lessee Name: / / / Email: E L tJq" O yGApe51 Zip: 33138 Flood Zone: CONTRACTOR: Company Name: Address: City: Qualifier Name: ■' State Certification or Registration #: f10. T@ H 111 Phone#: Zip: 33 I ` State: Contact phone#: is& 1 Z Email Address: Certificate of Competency #: 1lf i,ra<��.;P�L 11 Zip: DESIGNER: Architect/Engineer: .{ one#: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddition OAlteration ONew D e s c r i p t i o n o f W o r k : , i n s ex ORepair/Replace i olition Color thru tile: ******* * * * * * * * * * * *** * * * * *** * * * * * *** * ** ************* * * * *** ** * * * * *** * * * * * * ** * * * * * * ** Submittal Fee $ Permit Fee $ 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, BEATERS, TANKS and AIR CONDTITONERS, 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 inspe 'on will no = ' ' proved and a rer n fee will be charged. Si Owner or Agent The foregoing instrument was acknowledged before me this day of 1,4 , 20 by 06001.. € > DU- 1111 . who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: C The foregoing instrument was acknowledged before me this i day of `l , 20 33_, by 1. 04.0 CV.air 11-1°A 1A who is personally known to me or who has produced, it Diki LXd 9c y'V20°113 -`l11°a identification and who did take an oath. NOTARY PUBLIC: My Commission Expires: 11 43\ NOTARY PUBLIC STATE OF FLORIDA �,,_ _ Comm# EE135383 • `' QE 1 Expires 10/3/2015 **************** * * * * * * ******** ** * * * * * *** ****** M* ****i*************** * * * * ******** ***R**** *** ***** *** ****** ** APPROVED BY s1:41:::) % �� Plans Examiner Sign: C Print: oPciLths (3 o� VA CARLOS J. NdiLA ; My Commission Expires.o�� qs ' 0 NOTARY PUBLIC 3 XA C STATE OF FLORIDA `�li4J �' s Comm# EE135383 NCE 18 Expires 10/3/2015 Zoning Structural Review Clerk (Revised 3n2/2012)(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) CERTIFICATE OF LIABILITY INSURANCE Date 7/8/2013 Producer: Lion Insurance Company 2739 U.S. Highway 19 N. Holiday, FL 34691 (727) 938 -5562 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 policies below. Insurers Affording Coverage NAIC # Insured: South East Personnel Leasing, Inc. & Subsidiarie 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Uon Insurance Company 11075 - Insurer B: Instuerc: Insurer D: Insurer E: Coverages _.. «es. rsuuanceI- r_.. =;ow aye . <.nissu =, . I=rsuu= -.nam :..:.ove.ri:p.1cype .. W" F1; .1 ng any requre = =rm or ... . Ion . any o.,,= «orol,r.ocum. ■ respe to 1. this certificate may be issued or may pertain, the insurance afforded by the poll des described hen is subject to all the terns, exdusiors, and c ondltions of such poGdes. Aggregate limits shown may have been reduced by paid claims. INSR LTR ADDL wsRD Type of Insurance Policy Number Policy Effective Date (MM/DD/YY) Policy Expiration Date (MM/DD/Yl') ENERAL LIABILRY Commercial General Liability Claims Made ® Occur Each Occurrence Damage to rented premises (EA occurrence) Med Expr rsonal Adv Injury eneral r. aggregate Emit applies pen Policy ® Project ❑ LOC General Aggregate, ■ Products - Comp /Op Agg UTOMOBILE LIABILITY Any Auto All Owned Autos Scheduled Autos I-Gred Autos Non Owned Autos Combined Single Umit (EA Acddent) ■ ■ . ■ ■ ■ Bodily hj�Y (Per Person) Bodily hju ry (Per Accident) �k Property Damage (Per Acddent) �{ -` EXCESS/UMBRELLA ■Occur `■ LIABILITY Each Occurrence Claims Made Aggregate Deductible A Workers Compensation and Employers' Liability Any proprietor /partner /executive officer /member excluded? NO If Yes, describe under special provisions below. WC 71949 01/01/2013 01/01/2014 x WC Statu- tory Limits , OTH- ER E.L. Each Accident $1,000,000 E.L. Disease - Ea Employee $1,000,000 t E.L. Disease - Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations /LocationsNehicleslExclusions added by Endorsement/Special Provisions: Client ID: 81 -65 -696 Coverage only applies to active employee(s) of South East Employee Leasing Services, Inc. that are leased to the following "Client Company": Morlah Construction Company Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s) , while working in: FL Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937 -2138 or by calling (727) 938 -5562. re Project Name: FAX: 305 - 756 -8972 / ISSUE 07 -08 -13 (TLD) =,in Data: 6 /12/2011 CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES VILLAGE, FL 33138 Should any of the above described polides be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named tote left, but failure to do so shall impose no obligation or liability of any kind upon the Insurer, Its agents or representatives. Ac9Rii. CERTIFICATE OF LIABILITY INSURANCE 461...i DATE(MMIDDIYYYY) 07/08/2013 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 Insurance To Go Inc 10651 W Okeechobee Rd ste#201 Hialeah Gardens Fl 33018 -1911 CONTACT NAME: Lisandra Gonzalez rPxH�O N • Ext1: (305) 826 -0224 to No): (305) 819 -0062 ADDREss: lisandra @instogous.com INSURER(S) AFFORDING COVERAGE NAIL # INSURERA :AMERICAN SAFETY INDEMNITY COMPANY LIABILITY COMMERCIAL GENERAL LIABILITY INSURED MORIAH CONSTRUCTION COMPANY 5865 SW 89TH AVE MIAMI FL 33173 -1675 INSURER B: PROGRESSIVE EXPRESS INSURANCE 156AU 162358 -00 INSURER MOUNT VERNON FIRE INSURANCE COMPANY 10/19/13 INSURERD: $ 2,000.000 INSURER E: $ 100,000 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUER WW1 POLICY NUMBER POLICY EFF (MMVDD/YYYY) POLICY EXP (MMIDDNYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY 156AU 162358 -00 10/19/12 10/19/13 EACH OCCURRENCE $ 2,000.000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR ME) EXP (My one person) $ 2,000,000 PERSONAL & ADV INJURY $ 2,000.000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE POUCY LIMIT APPLIES j�a PER LOC PRODUCTS - COMP /OP AGG $ $ B AUTOMOBILE LIABILITY ANY AUTO AAUUT ED HIRED AUTOS X AUTOS ED NON -OWNED AUTOS 0594025-0 05/08/13 05/08/14 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) $ 100,000 BODILY INJURY (Per accident) $ 300,000 PROPERTY BDAMAGE $ 50,000 $ C UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE XL2551183 04/24/13 04/24/14 EACH OCCURRENCE $ 2,000.000 AGGREGATE $ 2,000.000 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Alt ch ACORD 101, Additional Remarks Schedule If more space Is required) As Provided for in section 320.02 (5) (E)Florida Statutes, The listed insurance policy(S) or surety bond (S) may not be canceled on Tess than 30 days written notice by the insurer to the department of highway safety and motor vehicles, such 30 days notice to commerce from the date notice is received by the dept CERTIFICATE HOLDER CANCELLATION Phone: 305-795-2204 Fax: 305-756-8972 CITY OF MIAMI SHORES, BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES FL 33138 -2304 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE /%_ ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t� THIS is NOT A BILL - DO NOT PAY RENEWAL 588455 —E LOCATION RECEIPT NO. 613800 -2 SUSINFSS NAME / MORIAH CONSTRUCTION COMPANY STATE* C8C1511870 5865' SW 89 AVE 33173 UNIN DADE COUNTY FIRST -CLASS U.S. POSTAGE I PAID MIAMI, FL PERMIT NO. 231 uW QR1 T MORIAH�aCoNSTRUCTION COMPANY WORKER'S s 7,TJ6 L BUILDING CONTRACTOR 1 O HOLDER E Y nL � TO VIOLATE _ANY EXISTING REGULATORY OR ZONDIG OP COUNTY OR NOR DOES IF EXEMPT THE PERMIT HOLDER PROM ANY OR UC SE REQUIRED EY LAW. THE IS THHO 1)0N PAYMENT RECEIVE! g=gCOtERYTAX 09/28/2012 09010767001 000075.00 SEE OTHER SIDE DO NOT FORWARD MORIAH CONSTRUCTION COMPANY JACQUALIN RODRIGUEZ PRES 5865 SW 89 AVE MIAMI FL 33173 it1I1 *11111,11I1it lilt 1 111111 '11111111111111/11'i1111f1 Z1 April 19, 2011 Miami Shores Village 10050 NE 2nd Avenue Miami, Florida -33138 Attn. Building Inspector Ref.: Property located at: 128 NE 94th Street Miami Shores, F1. -33138 To whom it may concern: This is to inform that I, Oscar del Valle owner of the above - mentioned residence, grant permission to Moriah construction to demolish my two story CBS residence. According to all local and municipal codes. If any more information is needed, please do not hesitate to contact me. Sincerely, Oscar d' -1 alle Signature: Title Print Name: 0&c_ cl" STATE OF FLORIDA} COUNTY OF } SS: Sworn to who subscribed b ore me this before me this 6 April 28,2011 MOriah Construction Co, PO EiGX 831V2 Fl 33283-1622 Re; 125 NE 94 EtTedtive 04/2812011, FPL has removed the meter and disconnected the *FM...service wire to the 1 above referenced address. However, before demolishing the structure, you should bays the prerniSes Checked by .a qualified individual to assure that electricity is. not being supplied to the structure from any possible source. If. there are any questions., or if J may be of flatlet assistance in this matter, please contact me at the telephone number bekm. Sincerely, . H Associate Engineer 305-770-7979 04/19/Z011 0823 moot IAA April 1.9, 2011 Morin Construction Company P.O. 8ox 831622 Miami Fl. 33283 Proposed Demo: 126 NE 94th Street, Miami Shores. After a review of our facilities) wi that Teco Peoples Gas has no U i�AAX) P.001/001 the a b o v e c a d areas, we would like io inform you natural gas service at said property. However, if you are p to excavate the surrounding area of the work site, please contact Sunshine State One Call of Florida by ' • at lam 48 hours in advance, there might be other undergo ,+ , utilities. By contacting SSOCOF, the risk of personal injury property damage can be reduced. You can get the latest , ,f> r1{ +° x. on SSOCOF by visiting their web site at www.caisunshina.com. Should you have any additional questions concerning the - z ve, please contact me at 305 -987 - 3857, extension 77247. Sincerely, ij4I."'°49 Yolande Hong ling for Jesus Vega Division Manager North Miami Division PEOPLES GAS 16778 W DNB Hwy NORTH MIAMI, FL 33162 AN BOUAL OPPORTUNITY COMPANY Prepared by : Yolanda Hong Ting. FAX 305 -687 -3804 j+' 1W nt GV.Cflri Prepared by: • GUARANTY TRUST & TITLE, INC. 1915 Hollywood Blvd. Hollywood, Florida 33020 File Number 260941 WARRANTY DEED THIS INDENTURE, made this 8th day of July 2005 between: Steve Lawson and Michelle Lawson, husband and wife 11111111111111111 1111111111 111111111111111111 CF I4 2005R07 5692 DR Bk 23552 Pas 0866 - 8674 (lass) RECORDED 07/20/2005 15:27:43 DEED DOC TAX 4,950.00 HARVEY MIN, CLERK OF COURT MIAMI -DADE COUNTY: FLORIDA los as Grantor*, whose address is: 54 NE 07th Street, Miami Shores, Florida 3310, and Oscar E. Del Valle, a single man, as Grantee *, whose address is: 200 East 32nd Street, New York , New York 10016. * Singular and plural are Interchangeable as context requires. WITNESSETH: That the Grantor, for and in consideration of the sum of TEN DOLLARS (310.00) and other valuable considerations to said Grantors in hand paid by said Grantee, the receipt whereof is hereby acknowledged, has granted, bargained and sold to the grantee and grantee's heirs forever the following described land located In the County of Miami -Dade, State of Florida , to-wit Lot 10, 11, and 12, Block 22, Amended Plat of Miami Shores, Section No. 1, as per plat thereof, recorded in Plat Book 10, Page 70, of the Public Records of Miami -Dade County, Florida. Parcel ID Number: 11-3206-013-2980 SUBJECT TO easements, restrictions and reservations of record, if any, and taxes for current year and subsequent years. Said grantor does hereby fully warrant the title to said land, and will defend the game against the lawful claims of all persons whomsoever. IN WITNESS WHEREOF, Grantor has hereunto set grantor's hand and seal the day and year first above written. State of Florida County of Broward The foregoing instrument was acknowledged before me on 07108/2005, . - teve Lawson and Michelle Lawson, who is/are personally known to m: who has produced d�7 ,40 as identifi . : nd ..,take an oath. Notary le Print Name: V My FLORIDA: DEED INDIVIDUAL WARRANTY DEED- Orr JO. 4, ERIC M. IIMJ.ER aiit,4`o"taty Public- Slot$ of Ronda iii, .01ytConent�Jonb Feb9.2Ib6 c ` BondedOyNatona1WotaryAssn. • Book23592/Page866 CFN#20050755692 Page 1 of 2 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 CONT TOR 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 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: de A---/ 4-174 01)SZet d'') BUSINESS ADDRESS: STATE , s , (3/6z1--- ZIP CODE 3..21-3---422,- _At/ 4 CITY 4%// BUSINESS PHONE: (-7S Co. 7-2-/J 2— FAX NUMBER (3 ) -9•�ZY b CELL PHONE ( 6) -J 2---)) 2— QUALIFIER'S NAME: 3/ c..1r4-14 J /444,6W--1- QUALIFIER'S LIC NUMBER: C EG� % 7/'7D E -MAIL ADDRESS (IF APPLICABLE): "� '-e G� o�i.9�,�� .�5/ i �C, a. _L C'o Created on 3119109 BY 6QLDV 1 RV 3116109 MLDV r ■ SEE OTHER SIDE DO NOT FORWARD MORIAH CONSTRUCTION COMPANY JACQUALIN RODRIGUEZ PRES 5865 SW 89 AVE MIAMI FL 33173 ildh" lunilh“hdi>> idhiiHisui,hh.lhuhhaild .4"--: -11 ,•,, A4CC A RV r CERTIFICATE OF LIABILITY .11%..I''i DATE (MINDDITYYY) INSURANCE 1 04/12/11 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 i BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED i I REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Witte certificate holder Is an RODMoNitt. INSURED, the poi:W(RM) must be endoglietL It SUBROGATION is WAIVED, subject to the tent and conallions of the pont% certain porkies may require an endorsement A statement on this cenlilcate does not confer rights to the certificate holder in Ills, of mid) endomement(s). PRODUCER, USA General Insurance/USA Insurance Agency 5841 SAN,137th Ave. MEIMI, FL.33183 Phone (305) 386-3305 Fax (305) 386-6778 =MGT Nouse Victoria Ferramcke PHoNE ate. (305) 386-3305- 1 ra ma (305) 386-6778 ADDRESM PRODUCER CURIO/MR ID* INSUREIMS)*FFORDRIG CO'VER*GE MC* INSURED :! Oath Construction Company ;• 5865 S.W, 89th Avenue Miami, FL:33173- (786) 217012 INSURER A : United Specialty Insurance Company 10/0612010 INSURER Et : EACH OCCURRENCE INSURER C • DAMAGE TO RENTED PREMISES fEa occurrence) INSURER D : MED DP (Any one person) INSURER E : PERSONAL & ADV INJURY insURER P : 0 : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 PERTNN THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDMONS OF SUCH POLICIES. UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,. VW' ' TYPE OF INSURANCE FMDL /INSR SUBIC MD POUCY NUMBER POLICY Of ItassOWTYYYI iet,.4 .4 ,''' - LIMITS A GENERAL LIABIIEY COMMERCIAL GISVERAL UABILITY 0 0 CLAMS-WOE 0 OCCUR 0 . NS1207473 10/0612010 10/03/2011 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PREMISES fEa occurrence) s 100,000 MED DP (Any one person) S 5,000 PERSONAL & ADV INJURY s 1,000,000 0 : GENERAL AGGREGATE s 1,000,000 GENLAGGREGATE UNIT APPLIES PER: 0 POUCY El FIER& 0 LOC PRODUCTS - COMP/OP AGO s 1,000,000 S AUTOMOBILE minim El ANY AUTO 0 ALL OWNED AUTeS COMBINED SINGLE UNIT s (Ea sccideM) BODILY INJURY (per poison) S BODILY INJURY (Per =ideal S • SCHEDULED AUTOS PROPEFOY DAMAGE (Ferzdaaas $ • HIRED AuTos Li r_., Now-cwNED Amos s Il UMBRELLA LIAO III occur 1=1 EXCESS LAB n CLAIMS-MADE EACH OCCURROICE $ AGGREGATE $ 0 DEDUCTIBLE 0 RETEIVTION $ S S WORKERS COMPENSATION AND EMPLOYERS' LIAINUTY Y / N NIA 1-1 WC STAID- r-i 07}4- /. I TORY LIMITS I 1 ER Et EACH ACCIDENT $ ANY PliOPRIETCMPARTNER/DIECUTIVE OFFICER/MEMBER OCCLUDED? E.L DISEASE - EA EMPLOYE S (Mandstoty In NH) IMIPTIONescribe OF OPERATIONS below EL.. DISEASE - POLICY LINT $ DESCRIPTION OP OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD tOt „ Additional Remarks Schedule, It more space Is required) GENERAL CONTRACTOR 4 . CERTIFICATE HOLDER CANCELLATION .1 Verge Of Miami Shams ald9- DePt- 10050 N.E. 2rid Avenue Ward Shores, FL 33138 1 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 88 DELIVERED IN ACCORDANCE WITH THE - • • • ,'• • ,• . / AUTHORIZED REPRESENT* • . .--,. , 0 - - .. -.........-- AO ACORD 25(2009109) QF 1988-2009 ACORD CORPORATION. AU rights reserved. The ACORD none and logo are registered marks of ACORD TRANSMISSION VERIFICATION REPORT TIME : 04/12/2011 09:03 NAME FAX TEL SER.# : F8N291B50 DATE, TIME FAX NO. /NAME DURATION MG RRESUl T} P MDE 04/12 09.02 3057568972 00.00:30 01� OK STANDARD ECM 09-14-2010 ALEX SINK 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: 10/25/2010 EXPIRATION DATE: 10/24/2012 PERSON: RODRIGUEZ JACCIUALIN FEIN: 204841064 BUSINESS NAME AND ADDRESS: MORIAH CONSTRUCTION COMPANY P 0 BOX 831822 MIAMI FL 33283 SCOPES OF BUSINESS OR TRADE: 1— CERTIFIED GENERAL CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 06(14), 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 440.05(121, 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. QUESTIONS? (850) 413 -1609 DWG-262 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 128 NE 94 Street Miami Shores, FL 33138- Owner Information Address Parcel Number 1132060132980 Block: Lot: Applicant OSCAR DEL VALLE Phone Ceti OSCAR DEL VALLE 128 NE 94 Street MIAMI SHORES FL 33138 -2822 1 Contractor(s) Phone Cell Phone MORIAH CONSTRUCTION COMPANY (786)217 -2112 Valuation: Total Sq Feet: $ 10,000.00 3025 1 Type of Demo: Building Additional Info: ENTIRE HOUSE Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $6.00 $4.50 $6.00 $2.00 $400.00 $9.00 $8.00 $435.50 Pay Date Pay Type Amt Paid Amt Due Invoice # DEMO -5-11 -40892 05/10/2011 Check #: 1663 $ 50.00 $ 385.50 05/26/2011 Check* 1673 $ 385.50 $ 0.00 Available Inspections: Inspection Type: Final 1 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. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy May 26, 2011 Date May 26, 2011 1 50 sill_ t-iLei 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 No.y✓E 9 11 155 Master Permit No. Permit Type: BUILDING rr� OWNER: Name (Fee Simple Titleholder): b ®® Vb"J� Phone #: Address: /� �" g City: 4 f �� % State: {° ( Zip: 3 V Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 12, Imo' 16 14' City: Miami Shores County: Miami Dade y p /' Zip: I �8 Fo1io/Parcel #: I I° 3 g (6 — O L r. 1 o ` L- r j to � Q �� i-K 2L/ rig Is the Building Historically Designated: Yes Flood Zone: ' Gb T 0--TrOlt) Phone #: CONTRACTOR: Company Name: "b ial Address: ?? 0. " ES (b 2- City: (,Ui NIA 1 • 247°2112- State: Zip: 32'13° Qualifier Name: J4c, 04444 PoOP-- 145 ' Phone #: 7 (� State Certification or Registration #: 1 ' ( r 1 ° Certificate of Competency Z #: Contact Phone #:7 f 1 Email Address: M o P( 'CO «ir4f�Y I - DESIGNER: Architect/Engineer: � ' Phone #: 7 44 � ` 236), ZoZ- Value of Work for this Permit: $ t 0®000 Square/Linear Footage of Work: Type of Work: OAddress UAlteration ONew ORepair/Replace ) emolition Description of Work: t) om O 4 `i 1Oo ® F' /41A-1 E (- 1 COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * * * * * * * * * *** **** r * ***** *** * * **** r******* Submittal Fee $ Permit Fee $Q ©0d CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Double Fee $ Structural Review $ Training/Education Fee $ 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: 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 in ection which occurs s .ays after t e .u' .ermit is issued. In the absence of such posted notice, the inspection w j be appro Signature The forego day of acknowledged before me this The foregoing instrument was acknowledged before me this 20 6 , by r e, 1 V'i. j le • , day of 4 ` , 2014 , by e✓ ye1/441A& F200 who is personally kn wn to me or who has produced NOTARY P Si nt: Jo As identification and who did take an oath. A My Commission Expir APPROVED BY JORGE E. LASTAYO ;t MY COMMISSION # DD - 12 :5 EXPIRES: March 10, 2014 Bonded Tin Notary Pub9C Umiet vdtBrs who is personally known to me or who has produced * * * * * * * * * *k , Y**** * *,Y,Y,t*rrAr,k9rde,Y4r,Y,Y*** NOT Sign: P as identification and who did take an oath. Y PUBLI nt: JO aal '.mss My Commis * * * * * * * ** MY COMMISSION # 00989812 EXPIRES: March 10, 2014 Thru Kan Palk Und s * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6/4/10) Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 159579 Permit Number: DEMO -5 -11 -837 Scheduled Inspection Date: June 17, 2011 Inspector: Hernandez, Rafael Owner: DEL VALLE, OSCAR Job Address: 128 NE 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: B&S SEPTIC TANK COMP Permit Type: Demolition Inspection Type: Final Work Classification: Plumbing Phone Number Parcel Number 1132060132980 Phone: (786)217 -2112 Building Department Comments PUMP AND ABANDONMENT OF EXISTING SEPTIC TANK Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments June 16, 2011 For Inspections please call: (305)762 -4949 Page 3 of 12 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 128 NE 94 Street Miami Shores, FL 33138- 1132060132980 Block: Lot: OSCAR DEL VALLE Owner Information Address Phone Cell OSCAR DEL VALLE 128 NE 94 Street MIAMI SHORES FL 33138 -2822 Contractor(s) B&S SEPTIC TANK COMP Phone CeII Phone (786)217 -2112 Valuation: Total Sq Feet: $ 325.00 3025 1 Type of Demo: Plumbing Additional Info: SEPTIC TANK ABANDONMENT Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $3.00 $0.80 $108.60 Pay Date Pay Type Amt Paid Amt Due Invoice # DEMO -5- 1140894 05/26/2011 Check #: 1673 $ 58.60 $ 50.00 05/10/2011 Check #: 1663 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final 1 1 In consideration of the issuance to me of this permit, 1 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, 1 authorize the above -named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy May 26, 2011 Date May 26, 2011 1 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 No. Master Permit No MAY �� E) 2i11 LJ Permit Type: PLUMBING Q OWNER: Name (Fee Simple Titleholder): V P i Phone#: Address: 12b e"°_ q4 City: tdi t 1 e5 State: PL--, Zip: -r8 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 128 PE 91 -eerr City: Miami Shores County: Miami Dade Folio/Parcel #: 1 `"'" •6 ' 0 (3 2166 Is the Building Historically Designated: Yes Zip: 33138 Flood Zone: CONTRACTOR: Company Name: J EX` /1"1C �Caf ---, ilp. Phone #: l l�?tO- 2,n—al 1? Address: 3424 ioe._. -1- 4 (vie- l City: - 1f"I Cah State: Zip: ©; O Z... Qualifier Name: �..�1 i 1 drer� y--)0,y- ber; � Phone #: 1©i0'"2..f -21 12, State Certification or Registration #: 21 0 (.0''-j Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ 22.G Square/Linear Footage of Work: Type of Work: Address UAlteration UNew ORepair/Replace Description of Work: Demolition * * * * * * * ***** ****** *** * **** x****a:******* Fees***** ****** ********* ** *** * *** *a::x********* *** i Submittal Fee $ Permit Fee $ /° 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 promise in good faith that a copy of whose prope • subject to atta for the first nspe.tion which inspection ill not e appro Signature uance of a building permit with notice of commencement a ent. Also, a certified curs seven (7 and a re opy of th he buil harge estimated value exceeding $2500, the applicant must construction lien law brochure will be delivered to the person orded no ice of commencement must be posted at the job site permit is 'ssued. In the absence of such posted notice, the 0 The foregoing instrument was acknowledged before me this day of 1 , 20 I, by ►r e t � V(9 l }e . who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUB C: Sign: E I itros Bonded EXPIRES: March ut& Uedetwriteis y Commission Exp ** * * * * * * * * * * * ** - ** * ** d2a/A1/5411.A.14-6C ontractor The foregoing instrument was acknowledged before me this O , 20 AL, by P1 tAred ibarberi s , day of or who has produced as identification and who did take an oath. NOTARY PUBLIC: APPROVED BY Plans Examiner (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Structural Review Sign: Print: My Commission Expires AT 1 Jacqualin Rodriguez Commission 00674693 Expires 07/15/2011 da Zoning Clerk The Florida Department ofilealth herebyvertifies the business or entity named below has satisfied the requirements of Part 111, Chapter 489, Florida Statutes, for septic tank contracting and has been duly authorized by the department to provide septic tank-contracting services under the name of: e STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: Oscar Del Valle PROPERTY ADDRESS: 128 NE 94 St Miami, FL 33133 PERMIT #:13 -SC- 1315278 APPLICATION #: API003221 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR843168 LOT: 10 -11 -12 BLOCK: 22 PROPERTY ID #: 11- 3206- 013 -2980 SUBDIVISION: E Liberty City Sec A [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ ] GALLONS / GPD CAPACITY A [ ] GALLONS / GPD CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D R A I N F I L D O T H E R [ ] SQUARE FEET SYSTEM [ ] SQUARE FEET SYSTEM TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] CONFIGURATION: [ ] TRENCH [ ] BED [ ] LOCATION OF BENCHMARK: ELEVATION OF PROPOSED SYSTEM SITE BOTTOM OF DRAINFIELD TO BE FILL REQUIRED: 1 0.00 ] INCHES [ ][ / ][ABOVE/ BELOW ] BENCHMARK/REFERENCE POINT I ][ / ]I ABOVE/BELOW ]BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ ] INCHES Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The tank shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected by the health department after it has been pumped and ruptured but before it is filled with sand and covered. SPECIFICATIONS Y: PEDRO N OSPINA APPROVED BY: �1 -- Petit, N Ospina DATE ISSUED: 04/28/2011 TIT TITLE: Dade CHD EXPIRATION DATE: 07/27/2011 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E- 6.003, FAC v 1.1.4 A1,1003221 SE -1 Page 1 of 3 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28 -106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty -one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN # A02, Tallahassee, Florida 32399 -1703. The Agency Clerk's facsimile number is 850 -410 -1448. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. STATE OF :FLOR!DA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT PART II - SITE PLAN Scale: Each block represents 5 feet and 1 inch = 50 feet. 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U 5515 enan Site Mari submitted byr Plan Approved BY� Date t '` ALL CHANGES MUST BE APPROVED -`BY THE COUNTY HEALTH DEPARTME 4015. 10196 (Fteplaces HRS•H Form 4015 vetch may -be used) (Stock Number 87444)02 40158} 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 $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT), D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTIONI IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT1 D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: TD4 1011)(--% Orryl nfn BUSINESS ADDRESS: M� [1r) )4 (Ale_ CITY -\\C1 NeCtIt STATE AA, a ZIP CODE ? )� BUSINESS PHONE: (M L9 ) 2-11-23, FAX NUMBER (' ) 6 Z4 9 CELL PHONE (7 6(0 )2-11-7,1 1 ? QUALIFIER'S NAME: . 22:16. !rt QUALIFIER'S LIC NUMBER: 002.1 OLo E -MAIL ADDRESS (IF APPLICABLE): Created on 3119/09 BY ALDV / RV 3126109 MLDV N The Florida Department of Health hereby certifies the business or entity named below has satisfied the requirements of Part IA Chapter 489, Florida Stmutes, for septic tank contracting and has been duly authorized by the department to provide septic tank contracting services under the name of MAR-28-2011 22:22 F : ausamtba TAX C USCTOR - -1n FLOOR • 2010. LOCAL DURD4013 TAIL DECEDIT : 2011 • MIAMR.0ADE COUNTY - STATE.F FLORIDA - tagiT. 2011 MUST OD DISPLAYED AT PLACDOP UUU$IN 00 NT •. • PURSUANT TO t Y t30M CRAFT1EA QA --•ART". 9 a 1ti This is WV A BILL KOT PAY TO:305596245B P.3'6 tamenacam - •P.RWAL 669712 -3 PUM wit- 8 B S SEPTIC TANK CO - OPERATINO IN DADE COUNTY t, R IERIS CORD at euthmon Sta. OO�ur.�ii tea# � M name soommunv am MONO rLOAM Of • MUM -WM . MEW Mk UMW ;. t1 traia swami i =W■claanr TAY 09/23/2910 40000090267 000075.00 0E£ anO=R SIDE EMOVEE/S ADCONNTTRAC x TORS RECEIPT 60 NOT FORWARD Y $ S SEPTIC TANK CO NILDRED DAROERI PRES 3424 W 14 AVE NIALEAH FL 33012 t, JIIull.11 lr+rirr�irrr f�l►rrr�I gtl�Nr�r►iNwi� f"AR -28- 2011 22:22 FROM: TO:3055962458 P.5/6 08 ■03 -2010 ALEX SINK STATE OR FLORIDA FmmiCift DEFER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION e• * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW 1r lib CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida WurkcYs' Compensation law, EFFECTIVE DATE 00/03/2010 EXPIRATION DATE: 08/0212012 PERSON: BARBER'S MILDRED C FEIN 943431877 BUSINESS NAME AND ADDRESS: MILDRED WARIER =S CORPORATION DBA B&B SEPTIC TANK CO 3424 W 10TH AVE , HIALEAH !L 33012 SCOPES OF BUSINESS OR TRADE 1- SERVICE CONTRACTOR 2- SEPTIC TAWS IMPORTANT: Poloot to Molar 440. 00t14), F.S.. su ottIcor 111 1 etaporailoe iiba Neeti lumptles bola toil choler ay flibta a certificate at ele ilas maw ate + *victim riy eoi rateoa ye,efl a sr capeesstlea miter Mb ekpt*r. Persusa is CAptu 440.001121. • teetttkat*. el 014 41104 tS is esmmpt... *WY malt' vial* the /septa of tfa beetmas o► 1,Ns ittlel m ills napes 61 el.alsu e IN *rime!. Porsont to Chilli,' 440.001101, F.9.. Melees ei *lesion to 01 exempt sad animal of Mediae to be ems Mill be subject to revectltas 11, H suy lima ester Bra NNnO of Oa notice Um linnet al as callflni,, me peraoe aimed am Iba oak* er certill.aa se Wager meal air ntptkemsste of Ibis aectio* ler luaus of a ce/littete. The depsroeia 0111 ravels a c ridtcah s1 say tins far fatlare el Mu poles aimed as ma colllicm ra seat Ilia ngairs aaa at tali sealant. aUESYIONst OHM 413 -18 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 0906 .a ACICORBCP- thisampao''''' CERTIFICATE OF LIABILITY INSURANCE OATE(MMIOD/YYYY) 03/28/2011 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 prolicy(iies) must be endorsed. if SUBROGATION 1S WANED, subject to the terms and conditions of the pol icy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder MI lieu of such endorsement(s). PRODUCER AX BdotoTS ktsurestce 1524W49St Hialeah, R 33012 Phone (305) 362 -5830 Fax (3(15)826 -4734 CONTACT CLARIBEL OR ROBBIN PHONE (305) 362 I IP FAX NO: (305) 826 -4734 ADORN CGORT@aflmgton¢ir nce.com INSURER(S) AFFORD= COVERAGE NAIC 0 INSURER A: ASCENDENT COMMERCIAL INSURANCE INSURED MILDRED BARBERIS CORP B&S SEPTIC CO. 3424 WEST 14 AVE HIALEAH, FL 33012 INSURER El: INSURER C : INSURER 0: INSURER E: INSURER F: COVERAGES CERTIRCATE NUMBER: REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 11-E INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR COiNDFTION OF ANY CONTRACT OR OTHER OOCUM ENT \MTh RESPECT TO AM-HCH TI-IS CERTIFICATE KAY 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. UMITS SHOY144 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD1 SUEN INSR WVD POLICY NUNr36R POLICY EFF POLICY EXP LTS GENERAL LIABILnY X 1 COMMERCIAL GENERAL LIABILITY Ic ANAS -MADE OCCUR GENtt AGGREGATE LMT APPLEES PER: In PRO- JET 1-1 1 ! n GL-35526-0 02129/2011 04/29/2012 EACH OCCURRENCE DAMAGE TO RENTED PRE3NSES (Ea occurrence) MED EXP (Anyone parson) $ 1,000,000.00 $ 100,000.00 $ 5,0.00 PERSONAL & ADV INJURY GENERAL A cN EGATE $ 1,000,000.00 $ 2,000,000.00 PRODUCTS- COMP/OP AGO $ 1.000.000.00 $ AUTOBBI ILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS INNED RH1AUTOS N HIRED AUTOS n COM a SINGLE LIMIT (Ea BODILY INJURY (Per person) BODILY INJURY (Per a=ddend) PROPERTY (Per DAMAGE $ $ $ $ LEAB EXCESS LAB OCCUR fl CLAIMSMADE DED I 1 RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS* LIABILITY ANY PROARIETON7/PiUi &aCECUTNE O'FICEAR nBE2 EXCLUDED? NH) II yes, ((maitre under DESCRIPTION OF OPERATION) beim YIN it NIA INC TORY L I Iet E.L EACH ACCIDENT EL DISEASE - EA EMPLOYEE $ EL DISEASE - POLICY UNIT $ 1 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEINCLES (ACachACORD 101, Additional Remarks Schedule I more space Is requhed) SEPTIC TANK CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES BLDG. DEPT. 10050 N.E. 2ND AVENUE MIAMI SHORES FL 33136 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 88 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESRTATEVE ACORD 25 (2010 ®1 OA The ACORD name and logo are registered marks of ACORD A11 rights reserved. Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: I NSP- 159578 Permit Number: DEMO -5 -11 -836 Scheduled Inspection Date: June 16, 2011 Inspector: Devaney, Michael Owner: DEL VALLE, OSCAR Job Address: 128 NE 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: MED ELECTRICAL CONTRACTOR INC Permit Type: Demolition Inspection Type: Final Work Classification: Electric Phone Number Parcel Number 1132060132980 Phone: (305)226 -0095 Building Department Comments TOTAL DEMOLITION AND DISCONNECTION OF POWER SERVICE. FPL HAS REMOVED METER AND CUT CABLE TO THE MAIN Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. )--676L- e June 15, 2011 For Inspections please call: (305)762 -4949 Page 11 of 24 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 128 NE 94 Street Miami Shores, FL 33138- 1132060132980 Block: Lot: OSCAR DEL VALLE Owner Information Address 128 NE 94 Street MIAMI SHORES FL 33138 -2822 Phone Ceti Contractor(s) Phone Cell Phone MED ELECTRICAL CONTRACTOR INC (305)226 -0095 Type of Demo: Electric Additional Info: SERVICE DISCONNECTION Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $3.00 $0.80 $108.60 Pay Date Pay Type Amt Paid Amt Due Invoice # DEMO -5-11 -40893 05/26/2011 Check #: 1673 $ 58.60 $ 50.00 05/10/2011 Check #: 1663 $ 50.00 $ 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. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy May 26, 2011 Date May 26, 2011 1 MAY /25/2011/WED 10:03 AM FAX No, P, 002/002 A ° CERTIFICATE OF LIABILITY INSURANCE DA'�(MM'° °"""' 06/25n 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO BIGHTS 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: Nth. ea tif1c$te holder is an ADDITIONAL INSURED, the poiicy(Iea) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condltlons of the policy, Certain policies may require an endorsement. A statement on this certiflcata does not Confer rights to the certificate holder In Ilea of such endorsement(s). PRODUCER Discovery En(r, Insurance Agenoy 10733 N.W. 58th Street Miami, FL 331713 Phone (305) 718 -8919 Fax (305) 718 -3584 _ CONTACT MARIA DWZ NAME: p Na p„f); (305) 718 -8919 ITAILedoil (305) 718 -3584 able: marilu@disoodoralina.com INSURER(S) AFFORDING COVERAGE NAIC $ INSURER A : NOVA CASUALTY CO. INSURED MED ELECTRICAL CONTRACTORS, INC. 1421 S. W. 107 AVENUE, STE. #175 MIAMI, FL 33174 (305) 228.0095 _ _..__ - _ _ INSURER B ; BRIDGEFIELD EMPLOYERS INS. CO. pE/ACCHH PREAAI3ES Ewa t aneet . INSURER C: MEDEXP(Anyoneperson) INSURER V ; ® P.D. DED. $250.40 INSURER Et 3 1,000,000.00 INSURER P I INS GENERAL AGGREGATE SIO 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 MAYBE 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. INSR 1.Ili A TYPE OF INSURANCE ADDLSUBR ImAn %Wu, POLICY NUMEER PpQ GY EFF (BAI6/DDIYYYYI 05121/2011 POLIC�Yy EXP rM6f1017/YYYY1 05/21/2012 LIMITS OCCURRENCE $ 1,000,000.00 GENERAL. LIABILITY 0 COMMERCIAL GENERAL LIAB1LIIY • • CLANS-MADE !j OCCUR 09AL049995 pE/ACCHH PREAAI3ES Ewa t aneet $ 100.000.00 MEDEXP(Anyoneperson) $ 5,000.00 ® P.D. DED. $250.40 PERSONAL &ADV INJURY 3 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 $ 2,000,000,00 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP/OP AGG • POLICY • !' a • LOC 3 AUTOMOBILE LIASILJTY El ANY AUTO AUT03 NED • SACS L1LED CQMBIINetS1NGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ • HIRED AUTOS AUTOS © a�Y AMA3E $ ❑ . $ El UMBRELLA UAB ❑ OCCUR • EXCESS LIB • CLAIMS -MADE EACH OCCuRRENCe $ AGGREGATE $ • DED • RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPR tP In P}1RT)J�itE(FD,?XECUTNEa OFFICE sM riiClV (Mendatory In NH) N/A 830 - 47132 01/28/2011 01/28/2012 WC STATU- r t OTH- TORY IMITS 1 . J ER E.L EACH ACCDENT $ 100,000.00 E.L. DISEASE -EA EMPLOYE $ 100,000.00 DISCRIPTION under OERATIONS below el. DISEASE - POL1CYLmrtn' ffi 500,000.00 .m- DESORIPTiON OF OPERATIONS / LOCATIONS /VEHICLES ELECTRICAL CONTRACTORS (Attach ACORD 1111, Additional Remarks Schedule, if more apace is required) CELLATION MIAMI SHORES VILLAGE FAX 305 -758 -8972 ATTN: VIVIANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORI2ED REPRESENTATIVE ACORD 25 (2010/05) OF CO 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 No. Master Permit No. 11-05 Permit Type: Electrical ^�, / OWNER: Name (Fee Simple Titleholder):,, DMi C be\ \ le, Phone #: Address: \2 E K\.& _ (14- City: 1 � (l€ 1 ��j State: iTiOri c Ci . Zip: \kB Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 12_25 kN1 "_ 04 • , City: Miami Shores County: Miami Dade Zip: 2 / \ c,- - 10- t —12_ -bW- 2Z [ e 10-1 0 Is the Building Historically Designated: Yes Flood Zone: CONTRACTOR: Company Name: met) 6:19.-c-4 9.' it. XL I colt' roe, 44' I PG Phone #: 3 ( 2:1 6 o O 9 Address: i y Z I &(14) (o Z 4 U€ Li l mil' City: Mt Gt &d ( State: Pt Zip: 3 3 1-7 y Qualifier Name: / 4 It e l &Eildi4 Phone #: 3a'` 2 2-6, O 0 ga.. State Certification or Registration #: -se. tg b 0Z92-0 Certificate of Competency #: Contact Phone #: 3 043 2.1- co co 9 r Email Address: ii E t M t CP (= el 7e- l(S b CI N• Met, DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ =,00 . Square/Linear Footage of Work: Type of Work: Address OAlteration ONew ORepair/Replace `demolition Description of Work: TO tt1 t ' \,t-ii on CA 'T . , t-1 4Ji C cOok \o e main . ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************** * * * * * * * * * *,x * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ f Q6Nef® CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ vf0 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 bui promise in good faith that a copy of the notice of . eommencemen whose property is subject to attachment. Also, a certified copy o for the first inspection which occur: : ays : er th b inspection of be approved a be ar ' t Signature j /1t Owner or Agent The foregoing instrument was acknowledged before me thi day of , 20 _11, by e, V \ke who is personally known to me or who has produced As identific NOTARY PUBLIC: unit with an estimated value exceeding $2500, the applicant must and the ildi ed ruction lien law brochure will be delivered to the person notice of commencement must be posted at the job site is issued. In the absence of such posted notice, the b,1_ an o•th. The foregoing day of Contractor trument was acknowledged before me this t , 20 i., by e E\ Fes\ ioc . , who is personally known to me or who has produced b, L 1 1'. ('' Print: a,. My Commission Expires: * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY stagy ° u . is State of Florida Jacquelin Rodriguez My Commission 00674693 Expires 07/15/2011 as identificaf oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: o Jacquelin c State of Florida Rodriguez My Commission Q Exrrres 07/15/2011 b674693 ************************************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** l/ / /AFa-PP1ans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10 /2009XRevised 3/15/09) 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 COMPLETE CONTRACTOR'S INFORMATION, BUSINESS NAME: Diet ,e'jco.\ Q *or BUSINESS ADDRESS: 14-2_1 S(51 c\y( fii1Q.rn1 STATE ZIP CODE )3 f BUSINESS PHONE: (h25._) 2.19°OQS FAX NUMBER ( ) CELL PHONE (b0.5) 221Q-00 c15 QUALIFIER'S NAME: 14 ue.\ _\ t O� QUALIFIER'S LIC NUMBER: EC, ooD2daZO E -MAIL ADDRESS (IF APPLICABLE): Icc.X\it.vr% Created on 3119100 BY Et LDV I RV 3126109 IILDV AC RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDNYYY) 04/26/2011 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(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 Discovery Eftits. insurance Agency 10733 N.W. 58th Street Miami, F133178 Phone (305) 718 -8919 Fax (305) 718 -3584 NAME: MARIA L. DIAZ ((AIC No. Extk (305) 718 -8919 FAX No): (305) 718 -3584 E-MAIL SS: mariat discodoralins.com INSURER(S) AFFORDING COVERAGE NAICS INSURER A : NOVA CASUALTY CO. LIABILITY COMMERCIAL GENERAL LIABILITY INSURED MED ELECTRICAL CONTRACTORS, INC 1421 S.W. 107 AVENUE, STE #175 MIAMI, FL 33174 (305) 226 -0095 INSURER B: BRIDGEFIELD EMPOYERS INS. CO. 09AL049995 INSURER c 05/21/2011 INSURER D: $ 1 000 000.00 INSURER E: $ 100,000.00 $ 5,000.00 $ 1,000,000.00 INSURER F : MED EXP (Any one person) 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WYD POLICY NUMBER POLICY EFF (MNWDNYYY) POLICY EXP (MMWDDIYYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY 171 09AL049995 05/21/2010 05/21/2011 EACH OCCURRENCE $ 1 000 000.00 DAMAGE TO PREMISES (Ea occurrence) $ 100,000.00 $ 5,000.00 $ 1,000,000.00 1 MED EXP (Any one person) CLAIMS -MADE X OCCUR PERSONAL &ADVINJURY X P.D. DED. $ 250.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMPIOP AGG $ 2,000,000.00 GEM_ AGGREGATE LIMIT APPLIES 7 POLICY n PST ~— PER: LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED NON-OWNED AUTOS �r : (Es accident) SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA IJAB EXCESS LIAR OCCUR CLAIMS -MADE ! J ! J EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRU.RRJETORIPARTAIEA!€XECUTIVE OFFICE/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPEj2ATIONS below YIN N / A 83047192 01/28/2011 01/28/2011 X WC STATU- TORY LIMITS OTH- ER EL EACH ACCIDENT $ 100.000.00 EL DISEASE - EA EMPLOYEE $ 100,000.00 EL DISEASE- POLICY LIMIT $ 500,000.00 EP t DESCRIPTION OF OPERATIONS f LOCATW NS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) ELECRICAL CONTRACTORS VILLAGE OF MIAMI SHORES BLDG. DEPT. 10050 N.E. 2ND 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. HORIZED REPRESENTATIVE O ACORD 25 (2010105) ©1 0 ACORD CO TION. All rights reserved. The ACORD name and logo are reglste marks of ACORD ,+�`� iLVti.�� `• a� i��i''at� -s"�"� G'� 'h� ii3�}.'.� fti: Ll3W Dd 9t C.1 1.�M1 G: . 4 I 4 �Q: AY THIS IS NOT A BILL — DO NOT PAY 234523 -9. RENEWAL BUSINESS NAME / LOCATION RECEIPT NO 24'6458 - 44 MED ELECTRICAL CONTRACTORS INC ° STATE# EC0002920 FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 23' 220 NW ' 124 AVE 33182 UNIN DADE COUNTY, OWNER MED ELECTRICAL CONTRACTORS INC Sec. Type of Business WORKER/S r r6A F ECTRICAL CONTRACTOR . 2 TAX E DOE NOT PERMIT RECEIPT. HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITTE &. NOR DOES IT EXEMPT THE HOLDER FROM 'ANY OTHER PERMIT OR LICENSE REQUIRED;BY LAW. THIS Is NOT A CERTIFICATION OF 714E HOLDER'S QUALIFICA- TION PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 09/01/2010 09010097001 000075..00 SEE OTHER SIDE DO NOT FORWARD MED ELECTRICAL CONTRACTORS INC MIGUEL ELIAS PRES 1421. SW 107 AVE #175 MIAMI FL 33174 Dr� tet�`fltot sta t tt' tl tb ► .ttthhfltah till“ tt