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RC-12-2047Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 185761 Permit Number: RC -10 -12 -2047 Scheduled Inspection Date: February 12, 2013 Inspector: Bruhn, Norman Owner: MORSELLO, VINCENT Job Address: 78 NW 95 Street Miami Shores, FL 33138- Project: Contractor: <NONE> ELITE RESTORATION INC Permit Type: Residential Construction Inspection Type: Work Classification: Repair Phone Number (754)246 -7940 Parcel Number 1131010340080 Phone: (954)964 -2906 Building Department Comments BACKSPLASH AND COUNTER TOP GRANITE REPLACEMENT 11/21/2012 - PENDING LIC AND INS FOR PLUMBING CONTRACTOR. Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. February 11, 2013 For Inspections please call: (305)762 -4949 Page 31 of 31 PERMIT # P-.) I -1 CONTRACTOR: ) ;/ ijv' � SUBMITTAL DATE: 1 O 29 l ADDRESS: IS AO sl - NAME: RESUBMITAL DATES: PROJECT TYPE: irlin ZONING FIRE STRUCTURAL IMPACT FEES \AO ELECTRICAL HRSIDERM olc A Eq-1-/-2.-- PLUMBING NOC MECHANI CAL l jS BL L 1 ulZOl�z Datvet BUILDING Miami Shores Village Building epartment 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 No. NOV 0.7 2012 BY: 00000000am0000e_�me= FitC 20 1.7-0-04-7 PERMIT APPLICATION Master Permit No. Permit Type: BUILDING JOB ADDRESS: 1t• N V3 ` J 0 City: Miami Shores Folio/Parcel #: Is the Building Historically Designated: Yes NO Y Flood Zone: ROOFING County: Miami Dade ebrb 1 5° OWNER: Name (Fee Simple Titleholder): ‘ tizArr MCCI-6(14,0 Address:, A t 14\A _ 15 City: 1"' l.) MAI SiltoW5 State: Tenant/Lessee Name: 1111 Email: Phone#: S4 '--14410 (MO Zip: libt6 Phone #: CONTRACTOR: Company Name: '° rf1-' 4-sKtgurf\tAs Address: r2—r b 413 ° (f)30 Ain NJ G, Phone #: L "1*404 City: X761. AP �P9 y�%5tate: 1- Qualifier Name: 6 (AQ S 1 e State Certification or Registration #: C GC '0 1.1 45 Contact Phone #: i i q )O' Peke Email Address: DESIGNER: Architect/Engineer: FA A ip e)Sb ®2,0 Phone #: p 1 910Li aciote Certificate of Competency #: Phone #: Value of Work for this Permit: $ I �^� 1 Type of Work: DAddition OAlteration Description of ork: g a i - 6u-st +tm. -4ce Square/Linear Footage of Work: ONew epair/Replace OD molition tINis Color thru tile: * ******* ********w*+x+x+x***4* * ** *** ** * ee w *�xa�� *** *** ** x+ x�x+ xa�a:** **a��x+x�x+��x *�x�x�xa�� *** Submittal Fee $ Permit Fee $ 1�� 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 ce of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit su In the absence of such posted notice, the inspection will not be appro ed and a re' pection fee will be charged. Owner or Agent The foregoing instrument was acknowledged before me this day of 20 _, by who is_p_ersonalLyknot to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: „...2-4,s- /2 ifnze2As-,e, 7.42 * * * * * * * * * * * * * * * * * * * ** cro No, Notary Public State of Florida ; Jason F Morsello c My Commission D0907781 * * *Wir gIil 4kk * * * * * * ** Signature Contractor The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced 1106405'e as identification and who did take an oath. NOTARY PUBLIC: Sign: //% Print: a%i430/7 //0 My Commission Expires: * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY 6 Planstiamine Structural Review 10 /07)(Revised 06 /10/2009)(Revised 3/15/09) :oS►9r °% � Notary Public State of Florida Jason F Morsello At My Commission 00907761 Zoning Clerk 11/07/2012 16:43 9543409540 It+CVATIVE 1 • CERTIFICATE OF LIABILITY INSURANCE PAGE 01/01 OP ID; 812 EMI EINIEW(YYYI 11!07112 74:68 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON6Y AND CONMRS NO MMEITS UPON THE OEITITACATE HOLM MS OERIVICATE DOES POT AFFIRMATIVELY OR NEGATIVELY AMMO. EXTEND OR ALTER THE cavEniman WORM BY THE POLICIES TES ClEtTIPICATE OF EMAIRANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INNURENI8), ALIMOREED REPRESENTATIVE OR PRODUCEII, ANOMIE CWWWICATE IMPORTANT: If Um oestEleate helaar Is en ADINTIONAL INSURED, the pe1 moot endorsed. 0 SUBROGATION IS W to the towns am! comakele et may requite an endemenlenL A ettemarit NA this eadifizate dote not sonfor Oita to the eartMeete holder In ��u PRMILIMIR INNOVATIVE INSURANCE CONSULTANTS I. CORAL te■ I J 5100 � FL BRIAN J. IMMO MRS ELITE E RES 1 ORA INC. 1213 scum SON AVENUE HOLLYWOOD, !I.33020 a IVIMINEM INSURANCE COMPANY maw s IM I 18832 NIZURNR Ns NINNIM MS IS TO CERTWY THAT THE POWER OP INSURANCE MED Maw HAVE SEEN ISSUED TO THE MUM NAMED ABOVE FOR NE POLICY PERIOD INDICATED. NOW4THSTANCING ANY RECUMBENT, TERM OR CoNomcm OF ANY CONTRACT OR OTHER IXESIMENT WITH RESPECT TO WWCH THIS CERTIFICATE MAY 08 ISSUED OR MAY PERTALN, 705 INSURANCE AFFORDED SY THE POLICES MIMED HEREIN 1S SUBJECT TO AU. THE EXCWSIONS AND CONDITIONS OF SUCH MUM WETS SHIM WYNANE BEEMREDUCED AYPNDCLMM TIPS EP INEEPANOB UNNERAL t Y C CLAINIMADE =CM x417.1* G8 4 AGGREGATE LJMI4 APPLES "ER i OLIgV El MHOWINNAUMMAY *'AUr° ALL OWNS) AUTOS SCIMEUM AUTOS HIRECIALITO8 A TOS • OCOINIRENCE 8 P PERSONAL & i1V(iIA $ 8 ONUOMOMMMAUMM eaddenE #i;v MAST o +I SWAY WNW (P PRWERTY DAMAGE 8 $ ANIMA 1MN Ot3bLIL,; HAD CIAIIMMME oISUCISLE FRTENTION e ANA EMPLOYM LANEUIT WCV0104891-01 07/01/12 07101113 t+ c Ii 99 rmiu 4334 om mssve AimmEm w 1Uuaelawwal uls,No e.pecerwqueee CERTIFFATIA HOLDJEFt MIAMI SHORES VILLAGE 10050 NE 2 AVENUE MIAMI 9HORESI EL 33132 ACORO 25 (MOM MIAMI4 CA A TAI MACH MOURNS= a ASERECATE X - x EL. UCH iticatimar E.4. .EA EA, DISEASE -PMACY MET • 1 WIN 1,f;0Q Allt AH? OP THE ACME MASOREED POMMES EIS CANCEL= BEFORE THE ISAPIRATION DATE . NOTICE WILL SE DELDERRLI 01 annonnance WITH THE POLICY AumeNcloItImioNENYMINE TION. All tights reserved. The ACORD name and logo are rantetwed marks *IACONO AE /O► CERTIFICATE OF LIABILITY INSURANCE was ontoomrml 8/17/2012 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFRR11ATIVELY 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(2), AUTHORIZED REPRESENTATIVE OR PRODUCER, ANOMIE CERTIFICATE HOLDER. IMPORTANT: IT the certificate holder is an ADDITIONAL INSURED, the po1ky(les) must be enthused. If SUBROGATION 13 WAIVED, subject to the terms and conditions of the policy, certain >olides may metre an endorsement A statessint on this certificate does not confer tights to the certificate holder In lieu of such endorseoa»ge). PRODUCER Corporate Inauranese Advisors 100 RE 3rd Avenue Suite 1000 rt. Lauderdale INSURED Elite Restorations, Ina. 1213 S 30th Avenue TA 33301 Felice Trinarub (954) 315 -5000 EVivarob8aiafl.net ollyWood COVERAGES Ma A»: os4)sis -soso 15MUMIEDINA COVERAGE WSURER A Aockhill InsilLranee Co. INSURER B: NAM 28053 MERRIER ROMP : ROIIRMIRE XL 33020 INSURER CERTIFICATE NUMBER:CL1281609472 REVISION THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED-TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REGUIREMINT, TERM 03 COMMON OF M Y CONTRACT OR OTHER WITH RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAM, THE COMMON WSURANCE 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 CLAWS. TYPE of BBERAI. LIABILRY COMMERCLPL GENEIALL LIPSIUTY OCCUR AGGREGATE LOST APPLIES PER: POLICY .f :t 1 7E4 fl Loc AUTOMOBILE LI SSLITY • e nowasse444402 0/18/2012 0/118/2013 EAcm OCCURRENCE DAMAti TO Utna 4r R1�s fEe a�aureuel - MED EXP (Any one 6 6 PERSONAL & ADY UAWARv GENERAL AGGREGATE 6 PRODUCTS- cOMP/OP AGO 2,000,000 50,000 5,000 2,000,000 2,000,000 2,000,000 ANY AUTO MINED ALL AUTOS AtiTOS HIREDAlTOS puT UMBRELLA LfA0 OCCUR EXCESS MS CLANSMACE DEDI I RETENTLBN$ S9VGLE UNIT BODILY MORT per won) 6 6 6 10ZoLy 0 RY per =WWI DAMAGE (PerPROPERTYenD 6 6 MOMS C NPENeATION AND DAB1UT OFFI�PR� am� MIA Ryes, M DESCRIPTION • F OPERATIONS baow A Coutraestors Pollution Liability EACH OCCURRENCE 6 AGGREGATE 6 I TWIZA I FM 6 on aP86600044402 p/10/2012 0/18/2013 d LEESCRIPTION OF OPERATIONS I LOCATIONS IIMOIMS (AtlaeNAc0589101, MOWN Row*. soluglor, VANN Om b EL EACH ACCIDENT 6 Et DSEASE EAEMPLOYI ' 6 E.L. DISEASE - POLICY LIMIT 5 $2.000.000 62.000000 Per Claim Aggregate 11FICATE HOLDER village of Mini Stores 100E0 R 5 2nd Avenue Miami Shores, 8L 33138 CANCELLATION SHOULD ANY 0P 1f.G ABOVE OEMS= POLICES BE CANOELLINI BEFORE TEE TIO�N,�O P DATE , N0003 WILL, 03 0l Tree Mark Sohwart.2s ';, +.J i - •.r +., r'+ 1'j ACORD 25 (2010105) INS025 mom ot 111811.21)10 ACORD CORPORATION. AU rialto The ACORD name and logo are rivistmed matins of ACORD "., • CITY OF HOLLYWOOD .TREASURY SERVICES DIVI LOCAL BUSINESS TAX RECEIPTING 2600 HOLLYWOOD BLVD, ROOM 103 �� : • HOLLYWOOD, FL 33020 ELITE RESTORATIONS, INC. 1213 S 30 AVE HOLLYWOOD FL 33020 E CITY OF HOLLYWOOD LOCAL BUSINESS TAX RECEIPT 1572 30717 PRINT DATE: 9/20/12 THIS IS YOUR LOCAL BUSINESS TAX RECEIPT, PLEASE DETACH AND POST IN A CONSPICUOUS PLACE AT THE BUSINESS LOCATION. PLEASE DO NOT REMIT ANY PAYMENT. THIS IS NOT A BILL, Business Name: Business Location: Business Class: Tax Basis: Receipt Number: Receipt Year. Expiration Date: ELITE RESTORATIONS, 1213 S 30 AVE CONTRACTOR /GENERAL 5 - 25 WORKERS 13 00018556 10/01/12 09/30/13 INC. NEW CHARGES: (Itemized Below) Base Fee Additional Charges: ♦r 316.00 Comments- 316.00 TOTAL NEW CHARGES: Penalty Amount: Previous Balance Due: TOTAL AMOUNT PAID: 316.00 .00 .00 316.00 PURSUANT TO STATE LAW, THE LOCAL BUSINESS TAX IS LEVIED ON THE PRIVILEGE OF DOING BUSINESS WITHIN A CITY'S LIMITS, AND IS NON - REGULATORY IN NATURE. ISSUANCE OF A LOCAL BUSINESS TAX RECEIPT BY THE CITY OF HOLLYWOOD DOES NOT MEAN THAT THE CITY HAS DETERMINED THAT THE EXISTING OR PROPOSED USE OF A LOCATION IS LAWFUL. ISSUANCE OF A LOCAL BUSINESS TAX RECEIPT DOES NOT LEGALIZE OR CONDONE THE NATURE OF THE BUSINESS BEING CONDUCTED IF CONTRARY TO ANY LOCAL, STATE OR FEDERAL LAWS OR REGULATIONS. STATE OF FLORIDA DEPARTMENT OF BIISS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH ROE STREET (850) 487 -1395 TALLAHASSEE FL 32399 -0783 EREST O S ELITE INC 1213 S 30 AVE ELITE O HOLLYWOOD OR#TIONS L 33020 one p o Department of "� .. , egu a boxers to barb que r nants, and they keep Florida's � from Eeksf� we do in to serve you Setter.; onto wwwartylterldelicense.cont, There you can find more information about our divhdons and the regulations impact you, to and team more about the that Department's initlat ves. Our mission at lire Department is: Ucertse Efliclently, R constantly skive b you so brat you can serve your cu to. mers. Thank you for doing business in Florida, and ormgratulatIons on your new licensel ' under Um provisions or ca.489 rs Ib t esaa !MUM *AUG 31, 2014 212072200115 STATE OF FLORIDA AC# 6 2& ti 8 2? DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CGC057725 07/22/12 110434324 CERTIFIED GENERAL CONTRACTOR KELLER, CHARLES W ELITE RESTORATIONS INC AC# 6214827 DETACH HERE 1£:> OO Utv7�[3'; i?.�',S :: ^vL Q 1 r);OAL.KCRO�a�: €� • lvt�,. ?C)i'R':? z G l: 'z£: -941 6h TION SEQ0 r uo722oo11s The GENERAL CONTRACTOR-'. Named below I8 CERTIFIED Under the provisions of-Chapter 489 FS. Expiration date: AUG 31, 2014 KELLER, CHARLES 1W2. ELITE RESTORATIONS MC', 1213 3 30 an HOLLYWOOD FL 33020 RICK :SCOTT KEN LAWSON STATE OF FLORIDA di DEPARTMENT OF BtYSInSS AND PROFESSIONAL REGULATION MOLD- RELATED SERVICES LICENSING PROGRAM (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 • KELLER, CHARLES W 1213 S 30 AVE ELITE RESTORATIONS INC HOLLYWOOD FL 33020 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myflarldaJcense.com. There you can find more information about our divisions and the regulations that Impact you, subscribe to department newsletters and team more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! AC# 61.33921 DEPAR DETACH HERE STATE OF FLORIDA AC# 6333921 DEPARTMENT OF .BUSINESS AND `:.PROFESSIONAL .PHOULATION MR5R1864 , 2 110389216 MOLD TELLER; ZB CERTIFIED nad r the provisions of cd.468 vs 6+PLt'tto°' dater JUL 31, 2014. L12051400869 t,ihlE.Ank PL: r Rfd'frzD PAU'R STATE OF FLORIDA- PR DATE BATCH NUMBER ILENSE NER 05/18/2012.110389216' MRSR1864 The MOLD REMEDIATOR Nested :below IS CERTIFIED Under the provisions of Chapter Expiration date: JUL 31, 2014 REGULATION ROGRAM SEQ#L12051800869 TELLER,. CHARLES :W 1213 S. 30 AVE ELITE RESTORATIONS INC HOLLYWOOD 'RICK SCOTT GOVERNOR FL 33020 DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY 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 No. 'c )V..204-1 Master Permit No. BUILDING PERMIT APPLICATION FBC 20 /0 � I Permit Type: — OWNER: Name (Fee Simple Titleholder): ti 8A1(10 ' I 1 O Phone #: l Address: 4�^ v�t_t) £35Y h City: 1 4r�y. ✓►` ace . State: FL Zip: Tenant/Lessee Name: Phone#: Email: V (:)(re fib e c 0'' OCT mom-gym] At 2 ''3 2012. II BY: JOB ADDRESS: —755 i0 City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Company ame: - - – A S `i: _ ' ,1 ` �l/, Address: 1 , a, S City: 11E1 Qualifier Name: I. Ea MI/ i State Certification or Registration . - -- Contact Phone#: , 11.11r DESIGNER: Architect/Engineer: If ficate of Flood Zone: Phone #: Zip: Phone #: ompetency #: Address; Phone #: Value of Work for this Permit: $ Type of Work: °Address °Alteration Description of Work: °New near Footage of Work: °Repair/Replace °Demolition ***** *** ********* ** * *** ******* *******Fees****** * * ******** * *** ***,x+s**** * * ** x*s:**a * ** 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 EL PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONE _ , 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 app ed and a reins ection 'e wilJte charged Signature Ay Signature Owner or Agent Contractor The fo :o ins n� as a owledged efo e 3 s The foregoing instrument was acknowledged before me this day o .f ' , , 20 Id , by � t I A , A ` . U d of 20 _, by who is p rsonally known to me or who has produced & who is personally kncx"wn to me or who has produced identification and who did take an oath. s identification and who did take an oath. NOTARY PUBLIC: 90 NOTA ' .Y PUBLIC: Sign: Print: pv. LOS t �� Ck/ a e 2015 'Pl'A Notail Pe Eyves ..12$50 EE pss�. * • CO h oo9N2i�ona� • ee�aa My Commission Expires: Sign: Print: My Commission Expires: ** ****** **** **** **** ** **** ************************************************** *** ***** * **** ****** ******** ** ** APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) 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: \ t'Or& — O e tiO DATE: t O / ,Qct 4a ADDRESS: /6 11)qi (t S 4' ' `1X11 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 °Meese, 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 o 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 is r: aonsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may .rotect myself from potential financial risk by hiring a licensed contractor and tfaving the permit filed in his or her name instead of name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license 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 may !so 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 substantially i .ved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built o s tially 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 working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law and my 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 a 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 not licenses to perform the work being done. Any person working on my building who is not licensed must work under my ect 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 compensatiop#gr 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 by 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, orclinances, 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 050:48T.1395 or htto : //www.mvfloridalicense.com/dbpr /pro /cilbfindex.ht Initial 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I m the party legally and financially responsible for the proposed construction activity at the following address: %'6 0 9 ict.Am 4 510ce, Initial 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information 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 retumed 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 orl day o who was personally known to me or who has Produced there Lice 199020 as identification. CLAUDIA V. CUBILLDS s•�PS1Y PVe i�'i Notary Public - State of Florida My Comm. Expires Sep 23, 2015 Commission # EE 128810 °',`,yo-•` Bonded Through National Notary Assn. Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 185071 Permit Number: EL -11 -12 -2142 Scheduled Inspection Date: February 04, 2013 Inspector: Devaney, Michael Owner: MORSELLO, VINCENT Job Address: 78 NW 95 Street Miami Shores, FL 33138- Project: <NONE> Contractor: RICKYS ELECTRIC COMPANY Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number (754)246 -7940 Parcel Number 1131010340080 Building Department Comments REMOVE EXISTING BACK SPLASH AND COUNTER TOP REPLACE 2 GFI OUTLETS IN KITCHEN Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments February 01, 2013 For Inspections please call: (305)762 -4949 Page 44 of 45 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 Permit Type: Electrical JOB ADDRESS: -74 /'J LO O r - kil City: Miami Shores Folio/Parcel #: ECEI NOV 142Q2 FBC2010 Permit No. ' LIP2- ,-,2) I 42 Master Permit No fZG i2 — L - County: Miami Dade Zip: 33 /5 0 Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): V Its r Ce 1 M 0 `- ( 1 0 Phone#: 75' 4 Address: - t7 1ickp.4C�, �ao cX City: State: L— Zip: 3 3 3Q (• Tenant/Lessee Name: ��,-11 ,^ Phone #: Email: " /Yv1 o rye- (("® "`K✓ 'e �l no . Civet CONTRACTOR: Company Name: ' � i $ 2u `4"4 L.- Phone #: q4-44-- I OF- 054 2" Address: t!OFO Y 1414-) (0� �.ei*"r*c.* , City: Vox.% fav^ei State: Qualifier Name: 54.42".1A - State Certification or Registration #: £C 1306)444k Certificate of Competency #: Contact Phone#: �7 J� r"'?)) ' P Email Address: DESIGNER: Architect/Engineer: Phone #: Zip: r'3(7 Phone #: Value of Work for this Permit: $ � 09 Square/Linear Footage of Work: Type of Work: DAddress p UAlteration ONew XRepair/Replacc Description of Work:' : 1j 1ti L ` L c :. L - NJ Iii ODemolition 9 ***************************************F *****: r***** **+ x**+ x****+ x**+ x*************+x***** Submittal Fee $ Permit Fee $ /i D / ep 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, BOII.FRS, HEATERS, TANKS and AIR CONDMONERS, ETC OWNER'S AFI+IDAVIT: 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 app ' ved and . einspection ' ( ill be charged. Signature ` /!/ % /'�` Signature Owner or Agent The foregoing instrument was acknowl ged before me this day of /©s , 20 J , by ,t ra,t6/Ylprs//0 Contractor The foregoing instrument was acknowledged before me this , day of f , 20 ha, by e , &CC who is personally known to me or who has produced / l Ii ',G✓L° As identification and who did take an oath. NOTARY ' UBLI Sign: Print My C • ssion Expires: *b ************N:***Ns*** APPROVED BY ROBERT JOSEPH ROTH MY COMMISSION QEE199753 FIRES May 17.2018 ��0l� 133 ice:: xa% �k�x�sx�roMro�.R�t.m.- AiT'r(Tl'�i .. I.....,. N***************N ++k**ik:kHnk* who is personally known to me or who has produced / (C't,° 11° as identification and who did take an oath. NOTARY P ; t LIC: My Commission E iva /3 Plans Examiner Zoning Structural Review Clerk (Revised 3 ✓42/20112)(RMvised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) 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 No. g 12-1/39t) PERMIT APPLICATION Master Permit No. i 1 2,-/M1 FBC 20 NOV mi)l-amaYmi la 0 5 2012. BY: Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): (),;t"--) t"--) 2_e_ Acr-S-e_1\ e, Addr e " �� r s: s City: l -CLtip 4.\ Cc- Phone#:75 2 7q 2 State: Zip: Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: ' \ L e CT"; City: Miami Shores Folio/Parcel# A County: Miami Dade Zip: Is the Building Historically Designated: Yes NO Flood Zone: ())14e-CI CONTRA~~C�TPPOR: Company Name: VK�J rik.; ✓� Address: c7-.lfa t-D . 0 . City:ee A add- State: Qualifier Name: Vc (/ 'L Phone #: State Certification or Registration #: C_.Ec_.. q 92,C ] (4 Certificate of Competency #: Contact Phone #: �,t lc, �.(l t -?j- S� Email Address: X .�N` iC b O1�Q.1?(1/i- elf -s e i4 f c e e_014-1. - DESIGNER: Architect/Engineer: Phone #: 7`' nut . ocfc ` art is a :$ f "D t 'dress RAl itit af Work. 16 {`4. e.� r ' Square/Linear Footaage a� of Work: �� ation ONew a r/Replace ODemolition **+ + x******* **** **+x+x+a ********* **+x******* Fees** ** * *** : ****** ** *+ x+ s**** *********+xw*+x+x *+x**** Submittal Fee $ Permit Fee $ lI CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ 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 CONDmONE'RS, 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 is ued. In the abence of such posted notice, the inspection will not be app oved and a, einspection ee will be ,, ged. Owner or Agent The for g ing instrumt was ar(lcowledged efore ne day of who is pers Sign: Print: My Commission Expires: known to me or who has produced l 1 entification and who did take an oath. ccUBtLLOS to of Florida . Sep 23, 2015 Commission #. EE °tar Assn. Signature ontractor The foregoing instrument was acknowledged before me this% ( day of ,20`S .,byck r(\ia who is personally known to me or who has produced, as identification and who did take an oath. ************************** s<* *************** *************** *********s<***** *s<******* ** * * ** *** * * * * * * * **** * * ** APPROVED BY 4. w, 1 3 11° Plans Examiner Zoning Structural Review (Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) Clerk DBPR - YANES, ROBERTO; Doing Business As: AMERICAN DRAIN CLEANERS & ... Page 1 of 1 Licensee Details Licensee Information Name: Main Address: County: License Mailing: LicenseLocation: License Information License Type: Rank: License Number: Status: Licensure Date: Expires: Special Qualifications Construction Business 10:38:05 AM 11/5/2012 PANES, ROBERTO (Primary Name) AMERICAN DRAIN CLEANERS & PLUMBING, INC. (DBA Name) 5229 W 26TH AVENUE HIALEAH Florida 33016 DADE Certified Plumbing Contractor Cert Plumbing CFC1428514 Current,Active 11/10/2011 08/31/2014 Qualification Effective 11/10/2011 View Related License Information View License Complaint 1940 North Monroe Street, Tallahassee FL 32399 :: Email: Customer C.ntact Center :: Customer Contact Center: 850.487.1395 The State of Florida Is an AA /EE0 employer. Copyright 2007 -201, tate of Florida, privacy Statement Under Florida law, email addresses are public records. If you do not want your email address released in response to a public- records request, do not send electronic mail to this entity. Instead, contact the office by phone or by traditional mall. If you have any questions, please contact 850.487.1395. *Pursuant to Section 455.275(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one. The emails provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish to supply a personal address, please provide the Department with an email address which can be made available to the public. Please see our Chapter 455 page to determine if you are affected by this change. https:// www. myfloridalicense .com/LicenseDetail. asp ?SID= &id= 3690CC88C50D3D36B4... 11/5/2012 } w w. +w +...ww • As A .. \r • w ,a• ww ,• \•., w. ♦ . a i • •R,w .t• r� Lion. OM STATE OF FLORIDA DEPARTMENT OF BUSINESS MID PROFESSIONAL REGULATIO. t � FC14 8514;t " 06/29/4 116012914 . •. w•••••••••• AC#F?fl3t3' bfferi_ cam, s • ; CERTIFIED. A4,. MINE :CONTRACTOR that TEES , ROBERT 4 : f = ' ° : + • AMERICAN I1 GENE •.• IJNI ense! X 'C R:TIFI D under: the pTovi. ie ' of v 489 is L12.062900485 t It • a l • • ' •Y• \•f • of j• t -0' 0 Y-I 0C X tT �a�J„t) >r},' ), yr; rili ft .Y•<iy`Py.: ^w•sv.Y.Sa r {•rifwlyl .q••• ♦•w N,i'• ",fir a • Y•r •Y • . I. ' I-DAD COUNTY • ,TAX COLLECTOR '1410 W. FINAGLER ST. lst FLOOR i M FL 33130 • • f^< es . av ';c!. .z;;;;T:11: .••try -Z.: ,i /�St Y4. uy} S•s..("i<.'•'S•� 3eh ?= )54.. �r t•: ,�..y,f :r?� �f`�'�;i�✓ sf.,� %Xjp+CGh:,'% .,µt yr, y'y�%.•i f,;f�'•f ieiC :a%l�.• 14;1- it sr%i'i✓-yrS,'�J•�j; •>i.>•yyr ..y••• M.• I ": }•. .. �✓ . I:.. 1,'1. •r rs•.•• <•••A >••• •nn , . .. • •. •• 6r. 2012 • LOCAL ONES T. RECEIPT 2013 • , • MI PM D� COUNTY - STATE KOWA. MBEs SEPT. 30, 2013 MUST OE DISPLAYED AT PLACE OF BUSINESS • PURSUANT TO mum CODE CHAPTER ► = ART. 9 -10 • FIRST-CLASS U.S. POSTAGE PAID IIAMI; FL PE IM' NO. 231 ./FrAsivYMgl�fA. r. ekM•. y. :.eK�+A•fWiiSr4J�•wo•w.wscwsv,✓ i*,•aei hw,�..ti:w.�wO•."x.... y..ry ri . ".v., qks dr THIS IS NOT A BILL DO NOT PAY memo, RENEWAL ,1 E i Hof 120112.2 STATE* CFC142 514 692532' 6 • BUSINESS �E . LOCATION AM .1yJyCAt DRAIN CLEANERS & .AMERICAN PLUMb I & INC 2630 W 60 ST 33016 HIAtEAH O'ER AMERICAN DRAIN LEA ER .PLUHBI Se0% Type t sin ` 196 PLUMBING H CONTRACTOR 1$ ONLYrs�A .AL SURM TAX R ain IT WINS NOT PEWIT THE M f V VIOLATE ANT EXISTING tWU Tt ' OR 20/M40 LAWS O INN. =NW �X NO COO ft /NOWT THE fOR MOM ANT OMR PEI3M ' OR LOME t#E UIRE�73��N7 NT LAW. MIS N A Cflify! WICA TON OF ' t' E. ROWER'S OUA A MOM t�sstrita,�i=�i.lyd�E" ijay[�y� �yi�y`3.tr�7Nw�+t TAX VXKLEOTOOt 10/01/2012 09010250001 000049.50 ac i tv t itiftP WORKER/S 2 DO NOT FORWARD AMERICAN DRAIN GLEANERS PLUMBING INC RO ERTO VANES 2630 W 60 ST HIAL AH FL 33016 gitee Pt 4' et< g s,s �O E/CARBON MONOXIDE DETECTORS. IVY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED. NO POINT ALONG COUNTER TO BE MORE THAN 2 FEET FROM G.EI PROTECTED RECEPTACLE. PUT D/W RECEPTACLE UNDER SINK. ALL FIXED APPLIANCES ON DEDICATED CKTS, CITY COPY SUBJECT TO COMPLIANCE WITH STATE AND CO( ! �.L FEDERAL. ATE A NTY RULES AND REGULATIONS Ffr */.00 30e3)--r /V /` /7- COQ -.