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RC-10-2034Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 153315 Permit Number: RC -11 -10 -2034 Scheduled Inspection Date: April 28, 2011 Inspector: Rodriguez, Jorge Owner: BURNSIDE, JEFFREY Job Address: 290 NE 98 Street Miami Shores, FL 33138- Project: <NONE> Contractor: RHINO CONSTRUCTION Permit Type: Residential Construction Inspection Type: Final Work Classification: Kitchen Cabinets Phone Number (305)757 -4955 Parcel Number 1132060134150 Phone: (305)206 -6761 Building Department Comments TWO BATHROOM REMODEL Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. April 27, 2011 For Inspections please call: (305)762 -4949 Page 2 of 22 i Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 290 NE 98 Street Miami Shores, FL 33138- 1132060134150 Block: Lot: JEFFREY BURNSIDE Owner Information Address Phone Cell JEFFREY BURNSIDE 124 NE 110 ST MIAMI SHORES FL 33161 -7046 (305)757 -4955 Contractor(s) RHINO CONSTRUCTION Phone (305)206 -6761 Cell Phone Valuation: Total Sq Feet: $ 3,500.00 0 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: two bathroom remodel Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: _Bond Retum : Occupancy: Single Family Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $2.40 $2.00 $2.00 $0.80 $105.00 $12.00 $3.20 $127.40 Pay Date Pay Type Amt Paid Amt Due Invoice # RC -11 -10 -39435 11/24/2010 Check #: 1009 $ 127.40 $ 0.00 Available Inspections: Inspection Type: Drywall Final Framing Insulation 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. November 24, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date November 24, 2010 1 This Document Prepared By and Return to: RICHARD A. GOLDEN, P.A. KRAMER AND GOLDEN P.A. 1175 NE 125TH STREET SUITE 512 NORTH MIAMI, FLORIDA 33181 RTSC FILE NO. 141 -10o Parcel ID Number. 11-3206 - 013 -4150 Warranty Deed This Indenture, Made this 3rd day of November Jeffrey Burnside and Elaine Burnside, his wife 111111111111111111111111111111111111111111111 CFN 2'D10R0779106 OR Bk 27492 Pss 4762 - 47631 (bas) RECORDED 11/17/2010 09:32:17 DEED DOC TAX 3x720.00 HARVEY RUVIH: CLERK OF COURT MIAMI -DADE COUNTY, FLORIDA , 2010 A.D. , Between of the County of MIAMI -DADE , State of Florida Giselle L. Kovac Trustee of the Giselle L. Kovac Revocable Agreement dated May 19, 1998, with the full power and authority to protect, conserve and to sell, or lease or to encumber or otherwise manage and dispose of the real property described herein. whose address is: 290 NE 98 Street, Miami Shores, FL 33138 , grantors, and Trust of the County of Miami -Dade , State of Florida ,grantee. Witnesseth that the GRANTORS, for and in consideration of the sum of TEN DOLLARS ($10) DOLLARS, and other good and valuable consideration to GRANTORS in hand paid by GRANTEE, the receipt whereof is hereby acknowledged, have granted, bargained and sold to the said GRANTEE and GRANTEE'S heirs, successors and assigns forever, the following described land, situate, lying and being in the County of Miami -Dade State of Florida to wit: Lots 1 and 2, Block 31, An Amended Plat of Miami Shores Section No. 1, according to the map or plat thereof, as recorded in Plat Book 10, (Continued on Attached) and the grantors do hereby fully warrant the title to s aid land, and will defend the same against lawful claims of all persons whomsoever. In Witness Whereof, the grantors have hereunto set their hands seals the day and year first above written. Signe d delivered in our presence: e+y B :100 rnside P Wi • ame : �(j a i ,,„ Elaine Burns/ mr us � P.O. Address: 100 Kings Point Dr #1604, NORTH MIAMI, FL 33169 (Seal) Dr #1604, NORTH MIAMI, FL 33169 (Seal) STATE OF Florida COUNTY OF MIAMI —DADE The foregoing instrument was acknowledged before me this 3rd day of November Jeffrey Burnside and Elaine Burnside, his wife who are personally known to me or who have produced their Florida driver r s licens 1.41 -1Op =MS Aleithl Mai RI Wag BlOZ'C LaW:S3SIdX3 St8999001NOISEIYMOO >ADY1S q";;;;;;;70 'dentification. ,2010 by Printed _ a °w;:'°t MACYmiimm Notary M 4 016114661091 B 0/)855946 My Commission rs: ayg•ar EXPIRES: May 23, 2013 'Ra,�.o'�` Boded ant Bu�ef Bergs Laser Generated by C Display Systems, Inc., 2010 (S63) 763 -5555 Form awn-I Book27492 /Page4762 CFN #20100779106 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 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: BUILDING OWNER: Name (Fee Simple Titleholder): /r ti Address: 7Po lo r Permit No. I Master Permit No. Phone #: City: U“ ( A'1/4—"( YL Late: Zip: S Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: City: Folio/Parcel #: act° mow- Miami Shores County: Miami Dade Zip: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: T\ 1 t-k 3 Address: ` ((a `-`-- City: tkit c k I1nn l Qualifier Name: P U J .A acYL65TrlAC...7 � ®a \� Ste: Phone #: O.� 2 L`�C� Ca>2 G State Certification or Registration #: cote2 Certificate of Competency #: Contact Phone #: S CD S Cep 7 C ,\ Email Address: PI aki C 0.-K Pe fv\ i_ D c r C DESIGNER: Architect/Engineer: Phone #: `- Zip: 33 121 Value of Work for this Permit: $ Type of Wort: DAddress Description o Work: Phone #: Square/Linear Footage of Work: ONew ORepair/Replace COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: ********* *** **** *** * * **** *** *x * ** * * * *** Fees * * * *** * * * ***** ter** ** * *** **** * * * ***** * **** *** 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, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection w'. +t !e approve an 3h ;.e tion fee will be charged. Signature J` ' ! ' v�� Signa re Ow = or Agent nn '/ae//` The foregoing instrument was acknowledged before me this /v�• day of j / Q by ee It .01/4 C . , Contractor The foregoing instrument was acknowledged before me this )•;- �7 day of � ��' i ID by 11', / Of or who has produced W =ersonally kno> to ni,e or who has produced w is As identification and who did take an oath. As identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: ** * * * * * * * * * * * * * * * * * * * * * * * ** *****************,***************** * * * * ** * * * * *, * ** * * * * * * * * * * * * * * ** * * * *** * * * ** APPROVED BY �€ //> �� D . Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)(rev6/4/10) Cl R= 25.00' L= 39.29' Tan = 25.02' A=90°03`00" CH= 35.37' CHB =N44 °58'30 "W S00 °03'00 "W 115.00'(R) &(M) 75.00' es FLOOD ZONE: X PROPERTY OF: GISELLE LESLIE KOVAC 290 NORTHEAST 98th STREET MIAMI SHORES, FLORIDA 33138 NOT VALID Amour THE FL RI ORIGINAL RAISED SEAL OF A FLORI . SURVEYOR AND MATE MAP & PANEL= 12086C0302 COMMUNITY No.: 120652 SUFFIX :: L DATE OF FIRM: 9 -11 -09 BASE ELEV. = N/A • tYlan \k . • •• rgevDVA c (L; .-.=.. s...:* N &-w 'F'xTV s C�' ` 'F es . s5 • ' • 1 EMou1 Ne- `F'� -�r - �N acv_ • • (•REPLACI I h DL. 'T? 1E 4'C`.4 U4li�S • • • • . • ••.. • • • ; • • • • • • • • • • • • • •. .• (PAINT? N� •••••• • .... • • .•.. per I� LCA 11 - `SON FuoaeLAN r7z 2d t3-31-31-7 Am l 94" FxtanQo T--1\\D\IASPON INC-WM5 Neit4 'Fix:11)12E3 (TOILET, ''FAUC.,E-f Y--)- ENJrnL€) 7AdNili\b- ••• ••: : . • . : : . •• L455-1Atialata- s' •• ••• •• • • • •• • • 000 • ••• ••• It•• • • • • • • • • • • • • • • • 0 •• • • • • • • • •• SO •• • • •• • • ••• • • • • ••• • • • • ••• • • • • • • • • • • • • • ••• • • • • • • • • • • • • • fb 55 •• • • • S. •• 555 • • • ••• i • r-VRIP-cui,it 2_ Tem) 29D NE X) mom stoces • CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNY) 021/10 PRODUCER Southern United Inc. 2544 N.W. 7th St. Miami, FL 33125 Phone (305)642 -4344 Fax (305) 541.8269 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 # q INSURED Rhino Conshtotion & Development Inc 1865 Bricked' Ave A909 Miami, FL 33131- INSURER A: AMERICAN SAFETY INDEMNITY CO /APPU INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR NERD INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/1YYY) DATE MIDDIYYYYI LIMITS A • GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY rY 158AUI83019 -00 12/08/2009 12/08/2010 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 100,000 u • CLAIMS MADE :2 OCCUR IVIED EXP (Any one person) 5,000 PERSONAL 8 ADV INJURY 1,000,000 li • GENERAL AGGREGATE 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: ❑ POLICY • PROJECT • LOC PRODUCTS - COMP/OP AGG 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) • ANY AUTO • ALL OWNED AUTOS BODILY INJURY (Per person) • • SCHEDULED AUTOS • HIRED AUTOS BODILY INJURY (Per accident) • NON OWNED AUTOS • PROPERTY DAMAGE (Per accident) • GARAGE LIABILITY • ANY AUTO • AUTO ONLY - EA ACCIDENT • OTHER THAN EA ACC AUTO ONLY: AGG U EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE • OCCUR • CLAIMS MADE • DEDUCTIBLE • RETENTION $ AGGREGATE WORKERS COMPENSATION AND EMPLAYERS' LIABILITY Y/N ANY PROPRIETOR / PARTNER i EXECUTIVE OFFICER / MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under SPECIAL PROVISIONS below U WC STATU- U OTH- TORY LIMITS ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES, CITY OF/ BUILDING DEPT 10050 NE 2nd AVENUE MIAMI SHORES, FL 33138 F: 305-756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 26 (2009/01) QF 1111313-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTICE OF COMMENCEMENT 1111111 11�11l f1I1 1t1'f��l��l�1f1'1i"11l A RECORDED COPY MFf BE POSTED ON THE JOB SITE AT TIME OF FIRST NEFECICN FB AT NO. 1049 Ig TM FOLIO NO. ` 3 20�o `- 4 1,3- 7/ — STALE CF FLORIDA COLR•ITYCJF MIAMI -DADE: TFE UNDERSIGNED hereby gees notice that k rpo ements wine made to certain real property, and in accordance with Chapter 713, Florida S`ilur es, the foolowing Information is provided h this Notice of Cornmenoerrnt. CFN 2010R0796191 OR P,i< 27501 Ps 1087; (1P9) RECORDED 11/24/2010 13:59:56 HARVEY RUVIN, CLERK OF COURT MIAMI -DADE COUNTY, FLORIDA LAST PAGE c7n, Legal description of property and street/address: Z t {C) , i ail- 1. °2 l l— 3 2-Q Co —C. 1 3— 4 5 a t w-v� c Sfi(�S S r- L 2. Description of improvement: 3. Owner(s) name and address: v4 �.q c....L. v Pie._ 2 CAC) t J Interest in property: Name and address of fee simple titleholder. 4. Contractor's name and address: 0._,\-\ \ lJL 0 o W.:ru L3-1= `C1 NS. Jt2 5. Surety: (Payment bond required by owner from contractor, If any)a-ATE OF 1 Name and address: t HEREBY C IFY ►: Amount of bond $ 6. Lender's name and address: 7. Persons within the state of Florida designated by Owner upon provided by Section ;l:;. i A.1 ;1.. Florida Statutes, Name and address* 8. in addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Name and address* 9. Expiration date of this Notice of Commencement (the expiration date is 1 year from the date of recording unless a different date is specified) i� ft, / Signature of Own _, / ✓ , Owner's Na � .1 Print Name Sworn to and subscribedfore me this Notary Public Print Notary's Name My commission expires: 113)149 8104 PAGE3 Prepared by "rd`9 Address: l gzo,5 e itk,q- t r \ t--( '23! 29 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 290 NE 98 Street Miami Shores, FL 33138- 1132060134150 Block: Lot: JEFFREY BURNSIDE i Owner Information Address Phone Cell JEFFREY BURNSIDE 124 NE 110 ST MIAMI SHORES FL 33161 -7046 (305)757 -4955 Contractor(s) CHARLES CULPEPPER Phone 305 -759 -8255 Cell Phone Valuation: Total Sq Feet: $ 800.00 0 Type of Work: ELECTRICAL Additional Info: BATHROOMS REMODEL Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $2.25 $2.25 $0.20 $225.00 $3.00 $0.80 $234.10 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -11 -10 -39436 12/14/2010 Check #: 1018 $ 234.10 $ 0.00 Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Underground W. W. In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. December 14, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date December 14, 2010 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. I 10-94765 Master Permit No. a'a. O 4- Permit Type: ELECTRICAL Owner's Name (Fee Simple Titleholder) UM C. Phone # Owner's Address 09 ‘78Y--n S Jq City ( 1 S State FA_, Zip Tenant/Lessee Name Phone # � '- D - 5 39 Email G/sell-e • kavq ca4>'r / /* 6 Job Address (where the work is being done) 2q ! Y-11 (S'YY-6- T • City Miami Shores Villa • e County Miami -Dade FOLIO / PARCEL # Zip Is Building Historically Designated YES Flood Zone ntractor's Company Nam _ _ P Y + Lr4 ' ,lone # �D.� /Pe 676/ Contractor's Address a3e/6,1'1/f «v' City Ni dj x-41 State_ . Zip j, , Qualifier Name 6000/%45 (4,‘11/6/2-€/e--- ,e / Phone #�� O f �� S', 9 State Certificate or Registration No. 'V" i Certificate of Competency No. P Y Contact Phone( 3) r"13-7C9 �"j )1 E -mail erl #AV c!/r /19%-a- 10 #0/ e Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 1110 1 Type of Work: DAddition DAlteration ONew Repair/Replace elm? Describe W Square / Linear Footage Of Work: ***************************************Fees******************* *** * * * * ** * ******* * *, *** r Submittal Fee $ Permit Fee $ P �® 3 f/6/' CCF $ CO /CC $ Notary $ Training/Education Fee $ Scanning $ Radon $ DPBR $ Double Fee $ Violation date: Technology Fee $ Bond $ Structural Review. $ Total Fee Now Due $ Y4-10 See Reverse side -4 Bonding Company's Name (if applicable) Bonding Company's Address Y City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address /11. City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection 5,;, t b approv ' °c �'on fee will be charged. i !%ih.1 ; O 8ro'Ag t The foregoing instrument was acknowledged before me this day of D K 20 ID , by t i iW //e ki4"LC to me or who has produced identification and who did take an oath. NOTARY PUBLIC: * * * * * * * * * * * * * * * * * * ** APPROVED BY Signature Contractor The foregoing instrument was acknowledged before me this iO2 day of I.._ .:vd�r: !.'0 4 by a/ atekl tv/ e/" wh i . ersonall o me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ************************************************ **************************** *** //. J.—jj'vl4? Plans Examiner Zoning Engineer Clerk checked (Revised 07 /10 /07)(Revised 06/10/2009) Nov 12 2010 4:58PM ACORL P HP LASERJET FAX p.2 Policy Number DADLYN -A Date Entered: 9/9/2006 CERTIFICATE OF LIABILITY INSURANCE I DATE $,INVDDJYYVY) 11/12/2010 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INF CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGI BELOW. THIS CERTIFICATE OF INSURANCE DOES REPRESENTATIVE OR PRODUCER. AND THE CERT ORMATION ONLY AND CONFERS NO RIGHTS UPON TH 1TIVELY AMEND, EXTEND OR ALTER THE COVERAGE NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUIM FICATE HOLDER. CERTIFICATE HOLDER. THIS FORDED BY THE POLICIES INSURER(S), AUTHORIZED IMPORTANT; If the certificate holder is an ADDITIOI the terms and conditions of the policy, certain polio certificate holder in lieu of such endorsement(s). (AL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to as may require an endorsement. A statement on this certificate does not confer rights to the PRODUCER INSURED The World Of Insurance, Inc. 13155 SW 134 ST suite 209 MIAMI, FL 33186 CHARLES B. CULPEPPER 801 BRICK:ELL BAT DRIVE BOX #7 MIAMI, FL 33131 k Ef1E4EZL: (796) 573 -2221 t � (7861573 -2224 ADDRass: Jilletheworldofinsuancs. cam PRODUCER INBURER(5 ) AFFORDING COVERAGE INSURER A :WESTERN MELD INSURANCE C01 ANT INSURER B : INSURER C : INSURER O : INSURER E : INSURER F TSACe COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 HEREPI IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. A L BR POICY EFF POUCY EXP POLICY NURSER IaN11IDOV L 10mt1 1MMIDDtYVYYt UNITS I GENERAL LIABILITY bACH OCCURRENCE s300,000 A \ ! DAMAGE TO RENTED /C GOMMERCIALGENERAL_W8ILITY Tc'NARC-3 $ /7j2010 9/7/2011 pReMlca e(faa =„�) x100,000 CLAIMS -MADE /� OCCUR MED EXP (Any ore person) $55 , 000 iron! LTR TYPE OF INSURANCE GEN'L AGGREGATE I MIT APPLIES PER: --I 77 ( POLICY : FRO- L LOC AUTOMOBKE LIABILRY ANY AUTO 1, ALL OWNED AUTOS SC I* DU LED AUTOS hIREC AUTOS NON- CWNEOAUTOS PERSONALaADV ■hJURY $300, 000 GENERAL AGGREGATE $300,000 PROD jOTS - COMP/OP ADD $300,000 $ N/A COMBWED SINGLE LIMIT (Ea ea+dem) 8001LY INJURY (Per person) S 80D1LY INJURY (Per eeddent) t$ PROPER TY DAMAGE {Per =dent) UMBRELLA LUIS OCC:1R ~. EXCESS LIAR [.. -...1 CIA161S -MACU DEDUCTIBLE RETENTION $ N/A EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFF10ERIMEMBEREXCLUDED? U IN/A (Mandatory In NH) It yes. orscnee under DESCRIPTION OF OPERATIONS endow N/A I WC r *RYL$TATU- R:S lM i E.L. EACH ACCIDENT S I$ is OTH -' EST_ E L DISEASE -EA EMPLOYEE E I.. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES IAtteCE ACORD lot. AddItMeal Remarks Sehedul, I/ more epee, Is required) PLUMBING ELECTRICAL, AND MECHANICAL CONTRACTOR. CERTIFICATE HOLDER CITY OF MIA!!2 SHORES 10050 NE 2ND AVE ZiA+ML SE ES, FL 33138 ,:" 'N • AN •' E ABOVE • THE EXPIRATION DATE THERE • _h t: ,., u. I., .. - T• - • ICIE$ BE CANOE r3• B ORE , NOT E WILL BE DELIVERED IN n A• i.' •,�: AUTNORRED REPRESENTATIVE MLA ACORD 25 (2009/09) 111986.2009 A ORD ORPORATION. Alt rights reserved. The ACORD name and logo are registered marks of ACOR Produced LIMO Forms Boss PITS ect ware. w•r,.Fdrnlsfoaacorn: Imp:easies Publishing 800.:08 -1977 1Z?14/10 01:46pm P. 001 to, ,----- --, AL coicrry. • t CERTIFICATE OF LIABILITY INSURANCE- . , , . . s‘z * Da (rtuniddiyy) 1 /20/2010 .....--- Producer Advanced • Risk Solutions 12980 Metcalf, Suite 490 Overland Park, KS 66213 913.385.2455 www.advantedrisksolutions.com 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. T.:41BM:ADEMIEEMSZE INSURER Lumberme4 Underwriting Alliance A ., INSURER • B • . INSURER C 'Insured Tri-State Employment Services, Inc. 160 Broadway, 15th F New York NY 10038 INSURER D • -. INSURER E ,.... . . . . COVERAGES ''.' ..... .. . .. • THE POLICIES CIF 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ' POLICY NUMBER POLICY EFFECTIVE DATE • II/IM/DD/YY POLICY EXPIRATION DATE MNI/L2D/YY LIMITS GENERAL LIABILITY col...sal:cum. GENERAI. MS . 1CLAIMS MADE DOCCUR • I •• ' EACH OCCURRENCE FIRE DAMAGE (Any one Ere) $ MO EXP (Any one person) $ PERSONAL & ADV INJURY ,j GENERAL AGGREGATE PRODUCTS-COMP/OP AGG MC, AGO LIMIT APPLIES PER 1POLICV F1PROJECT fl 1.0 . AUTOMOBILE LIABILITY _ ANY AUTO ALL OWNED AUTOS _ _ SCHEDULED AUTOS _ HIRED AUTOS — NON-OWNED AUTOS • COMBINED SINGLE LIM IT RODIIN INJURY (Per parson) s Ii0DILY INJURY (Per accIdent) PROPERTY DAMAGE (Par accident) GARAGE UABILITY RAW AUTO .!. j AUTO ONLY • EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS LIABILITY OCCUR CI CLAIMS MADE DEDUCTIBLE RETENTION $ • ' ' 1 ' . EACH OCCURRENCE $ AGGREGATE $ , S S $ A WORKERS COMPENSATION & EMPLOYERS' LIABILITY . 298001 1/1/2010 ' 1/1/2011 . : LISTATUTORY UMIT f lOTHER . EL EACH ACCIDENT 5 1,000,000 $ 1,0Q0,000 1.000.000 EL DISEASE • EA EMPLOYEE EL DISEASE - POLICY LIMIT • • DESCRIPTION OF OPERATIONS/LOCAT THIS CERTIFICATE CONFERS NO Covers all employees of the insured Tri-State Employment Services, Inc employees ONS/VEHICLES/EXCLUSIONS ADDED ENDORSEMENT73PECiALI5IMISIONS ADDITIONAL INSURED RIGHTS UPON THE CERTIFICATE HOLDER. as respects the employers agreemen (PEO) with while assigned to Charles Culpepper Company. . .. , . .., .. CERTIFICATE HOLDER • '''. ' ...'. ".5CANCELLATI&I..' • ' ' .''' City of Miami Shores 10050 N.E. 2nd Avenue Miami Shores, FL 33138 • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRE- SENTATIVES. • AUTHORIZED REPRESENTATIVE Robert M Gagne ACORD.25-S (7/97)* ''' — — ' ' ... ..:77.... -". -- . " ' ea ACORO CORPORATION 1988 CERT NO.: 612048R CLIRNT owe, TM Dane emarcrocchi 1/20/2010 8,12,53 AM PARR ot Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 10 --1,09 Inspection Number: INSP- 153323 Permit Number: EL -11 -10 -2035 Scheduled Inspection Date: April 27, 2011 Inspector: Devaney, Michael Owner: BURNSIDE, JEFFREY Job Address: 290 NE 98 Street Miami Shores, FL 33138- Project: <NONE> Contractor: CHARLES CULPEPPER Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)757 -4955 Parcel Number 1132060134150 Phone: 305 - 759 -8255 Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments a /eta ;,a9/7 April 26, 2011 For Inspections please call: (305)762 -4949 Page 5 of 36 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 290 NE 98 Street Miami Shores, FL 33138- 1132060134150 Block: Lot: JEFFREY BURNSIDE Owner Information Address Phone Cell i JEFFREY BURNSIDE 124 NE 110 ST MIAMI SHORES FL 33161 -7046 (305)757 -4955 Contractor(s) RHINO CONSTRUCTION Phone (305)206 -6761 Cell Phone Type of Work: PLUMBING Type of Piping: BATHROOMS REMODEL Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.25 $0.40 $150.00 $3.00 $1.60 $160.70 Pay Date Pay Type Invoice # PL -11 -10 -39437 12/14/2010 Check #: 1018 $ 160.70 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Top Out Final Underground 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. December 14, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date December 14, 2010 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 Type: PLUMBING OWNER: Name (Fee Simple Simple itleholder): Address: . q6 9 le'" l r� City: raZW31 Permit No. V1 ``O LQ /OA Master Permit No. "et w�C.f�.� Phone #: M / State: Zip: /3 Tenant/Lessee essee Name: Phone#: 871- Email: b./44011-6 •ray -1 /J' Lew) JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes NO �,/ Flood Zo CONTRACTOR: Company Name: Ohs, Ac1 GU //at pirz. Address:, ! I �tc,l 1 ba- D. ol� s 7 City: (9-11-4 , n State: Zip: 63P)1 Qualifier Name: t ; �-✓ ac /�,. �-( 2. Phone# State Certification or Registration #: l T C:U Certificate of Competency #: Contact Phone #:. �� ' 51 a S 1 ) Email Address: / 1 ( Phone #:17� I rr t DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ ➢ 50,9 • OD Square/Linear Footage of Work: Type ' CQAd ditei ONew Desc !p ,4 k ', ei mo, Lk 1n illETIPZIMMIIIIL WALMITA 11111r='af *** **** ** **** x+ x* ******* ********+xa: ****** Fees ***** *x:**x: ********* : ******** ***u: **** * *** **** Submittal Fee $ Permit Fee $ 22S Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ R:D4-40 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 Ill Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approves einsp will be charged. Si natur: 07I / ;�� A Owner . r Agent The foregoing instrument was acknowledged before me this /°°' The foregoing instill ent was acknowl- • ged before me this , day of r. 11 �' ` i , by %J'IsSeC/' -e Mr e.0 , day of _ !z !! 0, by e or ho has produced who is • e ° : :.. _ o �� .: a or who has produced as identification and who did take an oath. NOTARY PUBLIC: Contractor w As identification and who did take an oath. NOTARY PUBLIC: .J ANIL Sig • Pri r" ' '2 ' L.1i.tu f s . .'��rtf' '^ ;.,�` C.orntrriselon 00 O ` My o on Exr ess:�_� � notary ; lc • state of Florida Sign: Print: My Co A a a _ • PICA I4IERIN0 i pir 4M134trl ElpS Wit Florida Act 2, 2013 ****** ** *x:****** ** x * **** x** ********:x*x::*x:x * ** * * *** **** **** **** **> K** **+ x**** **x: **** **x: ******* ******x:**** ***** APPROVED BY 11-17 — /61 Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 lo Inspection Number: INSP - 153325 Permit Number: PL -11 -10 -2036 Scheduled Inspection Date: April 27, 2011 Inspector: Hernandez, Rafael Owner: BURNSIDE, JEFFREY Job Address: 290 NE 98 Street Miami Shores, FL 33138- Project: <NONE> Contractor: CHARLES E CULPEPPER JR Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)757 -4955 Parcel Number 1132060134150 Phone: (305)372 -5189 Building Department Comments PL WORK FOR BATHROOM REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comme is April 26, 2011 For Inspections please call: (305)762 -4949 Page 6 of 36