DS-13-2236 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
nspection Number: INSP-202655 Permit Number: DS-10-13-2236
Inspection Date: November 08, 2013 Permit Type: Driveways/Sidewalks/Siabs
Inspector: Rodriguez,Jorge Inspection Type: Final
Owner: EVERETT, HENRY AND FRANCES Work Classification: Addition/Alteration
Job Address:9636 NE 2 Avenue
Miami Shores, FL 33138- Phone Number (727)461-4370
Parcel Number 1132060132500
Project: <NONE>
Contractor: M&J KUSTOM Phone: (754)581-6344
Building Department Comments
OVERLAY PARKING AREA 1'TYPE S III ASPHATT RE- Infractio Passed Comments
STRIPE AS PREVIOUSLY EXISTING INSPECTOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-202579. CREATED AS
REINSPECTION FOR INSP-200397. No work/permit on site
Missing handicap sign
Failed El
Correction
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
For Inspections please call: (305)762-4949
November 08,2013 Page 1 of 1
- ORR
tKG 19aa L
x1511 n.,.� Miami shores Village
'k �� Building Department
1pR1pA 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305)756.8972
RECEIPT
PERMIT#: m5/®/jaq 3& DATE: /o s
1,14:21 10"le
I,
ml&ntractor
o Owner
o Archite
Picked up 2 sets of plans and (other) ply S
Address: L44Y
From the building department on this date in order to have corrections done to plans
And/or get County stamps. I understand that the plans need to be brought back to Miami
Shores Village Building Department to continue permitting process.
Acknowledged by:
PERMIT CLERK I L:
RESUBMITTED DATE:
PERMIT CLERK INITIAL:
Miami Shores Village c
Building Department OCT 0 3 2913
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
1 - Tel: (305)795.2204 Fag:(305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
V FBC 20
BUILDING Permit No.
PERMIT APPLICATION Master Permit NODS A 3
Permit Type: BUOLDING ROOFING
JOB ADDRESS: 0 (' �-- 22 , �
4
City: Miami Shores County: Miami Dade
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder) -11-9 L le s � � Phone#:17>
Address:
City: Z��State' �_ Zip: 7
Tenant/Lessee Name: Phone#:
Email'
CONTRACTOR-Company Name: ��� �!i�-� _Phone#: Z i V V
Address:
City: o ui a,W 0 Ob 4 State: Zip: e c)
m
Qualifier Name: � E° g:c q o u A— Lcc- uj 1 Phone#: s U
State Certification or Registration 511 .1 J 6 Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer Phone#:
Value of Work for this Permit:0 ® ® SquarelLinear Footage of Work-
Type of Work: ❑Addition OAlteration ❑New _IRepair/Replace ODemolition
o�
Description of Work:e Arm l ® 79 n e- L-- A sOA-+,4�
Color thru fik:
Submittal Fee$ LT 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$
r •
Bonding Company's Name(if applicable)
Bonding Company's Address
City State zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT:'
Notice to Applicant. As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law1b'rpchure will be delivered to the person
whose property is subject to attachment. Also, a ceri#iied copy of the recorded notice of commencement must be posted at the job site
for the farst inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signa �'�'`� gn
Si afore
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was ac owledged before me this
day of �t.rnbt/,20 I ,by 6e LnCe S day of
who is personally known to me or who has producedft4 1 � who is personally known to me or who has pp.
I/ey U-4-, As identification and who did take an oath. �a-o zn� as ide � e� th.
NOTARY PUBLIC: NOTARY
Sign: u kr`¢ btb�q Sign:
Print: w w e bVtn Q Print: 4o77,v1
My Commission Expires: TR tMy Public.S KATHERINE BISHOP
oary My Commission Expires:
tate� ..
*Comm.Expires Oct:48,2015
N .EE 134015
APPROVED BY J Plans Examiner 3 Zoning
Structural Review Clerk
(Revised 3/12=12)(Revised 07 110/07)(Revised 06(10/2(Mf9)(Revised 3/15/09)
n
Miami shores Village
Building Department
Rte' 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LICENCES
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 JETTHER CERTIFICATE OR EXCEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
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 WORKERS 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: Q ���� �e 1 �
BUSINESS ADDRESS: CITY h ��Y�
STATE ZIP CODE 33a
BUSINESS PHONE: ( I— 4,3qY FAX NUMBER�)
CELL PHONE ( ������� QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER: f c 15-1// ( �
E-MAIL ADDRESS (IF APPLICABLE): d ys P `e ° e"ift
Created on 3119109 BY MLDV I RV 3126109 MLDV I RV 6127111 AS
2013-09-26 16:22 9547313312 9547313312 >> 1 800 685 7530 P 1/3
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The GEMRA*L CONTRACTOR
N&Med below XS CERTIFXM
Under the
,provisions of Chapt :.,
00
Expiration date: Auc n4
31, 20141f
LMqXs, JVFFERSON A
Mfct7 KUSTOM 3BTyjLDEj:tS LLC
2107 RODMW ST
HOLLYWOOD
M 33020-19se ;
•
•RICK SCOTT
GOVERNOR ZEN LAWSON
DISPLAY AS REQUIRED BY LAW SECRETARY
2013-09-26 16:23 9547313312 9547313312 >> 1 800 685 7530 P 2/3
`4C Q� CERTIFICATE OF LIABILITY INSURANCE F OA'Mj;
1 1211312012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THts
CERTIFICATE DOES NOT AFFIRMATIVE16Y OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED gy THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE 00I:3 NOT CONSTnVTE A CONTRACT BETWEEN THE ISSUING INSUReMS), AUTHORIZED
REPRESENTAYWE OR PRODUCER,AND THE CE"PICATE HOLDER.
IMPOWrANT: if the cerilfieate hetdor Is an ADDITIONAL INSURED,the policy(eS)must be endorsed, If SLISROGATION IS WAIVED,subJoct to
the terns and conditions of tha policy,pertain politics may requim an er dare mortt. A statement an this cortNieato does not confer rights to the
cortlficath holder in lieu of such oodoraomen s1.
PROQVaa DAMEL ROIS1N30N
:SIMPLIFIED MORTGAGE AND INSURANCE -- DA �.__�__. 'FM -- -
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954 583.1500 _�ltyc,ALo. 8S3 593-6987
065 S.W.27TH AVENUE,SUITE 02 "L
FT.LAUDERDALE, FLORIDA 33312
...'. •......... .._... 89rfLIReRLS)AFFGR4>rrG GOVeaAGO ..__,_.�-NAIC!!•-
INSlIIIPJ) At AC�IDENT INSURANCE-COMPANY
MMQ KUSTOM BUILDERS,INC. INSUaeaa.
210RODMANSTREET � "L�Egc: - - �_. -•__ _
MOLLYWOOD,FLORIDA 33020 U!lu y I - -
COVERAGES CERTIFICATE NUMSER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW FUUI@ BEEN ISSU15D TO M INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIRCMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHdt DOCUMENT WITH RESPECT Tp WHICH TMG
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES 06SCRISEO HEREIN IS SUBJECT TO ALL THE TERMS,
VCLUSION3 AND GONUMONS OF SUCH POLICIES,LIMITS SHOWN MAY NAVE BEEN REDUCER BY PAID CLAIM$.
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GENERAL CONTRACTOR
CERTIFICATE HOLDt? CANCELLATION
CITY 01*NORTH LAUDERDALE BUILDING DEPT. SHOULD ANY OF THE ABOVE�O PO��P PC CAi�ILCD tlCl`tIQC
ROCK ISLAND ROAD THE t%PMA'IRON DATe TMMC.OF, NOTICZ WILL Be ORUVS Mn 1%
NORTH LAUDERDALE FL ACCORDANCE write TM POucv IxRo"10148,
wtJTNapi2>Ip a11+'Retstrsrellva
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2013-09-26 16:23 9547313312 9547313312 >> 1 800 685 7530 P 3/3
JEFF ATWATER •^wa..«,a�'.
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
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: 4/26/2013 EXPIRATION DATE: 4/2612015
PERSON: LEWIS JEFFERSON A
FEIN: 201491607
BUSINESS NAME AND ADDRESS;
M&J KUSTOM BUILDERS LLC
2107 RODMAN STREET
HOLLYWOOD FL 33020
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL
CONTRACTOR
Purdivant to cnapter 44o.05(l4),F.S an officer of a eorporiyflon Who alochr oxomptiOn from this Crtapter by fiting 8 COnIficute of olocfion undor .thilt secs may
not rocovor ben�sfits or compensation under this chaptor.Pursuant to Chapter 440.0502),F.S.,CortNleatos of elnctivn to be axentgt••,apply only within the scope,
Of Inc ausfncrss or trade listod on the notice of olaction to by exempt.Pursuant to Chaptor 440,05(73),F.S.,NoticeS of election to be exempt anrf Corftfic. of
olection to ho oxompt shin be subject to rovocation if,at any time after the filin0 of the notice or the issuanca of the certificate,the ponson neared on the notice or
cprtHlCata no longer meets tno roquiramont5 of this section for issunnce of,a cortilicaie.7'110 tlr!panrnant shall revoke a Cortftwo at any time for flnurc of the
Parton namod on the cortifiCato to moat rho roquirorrionts of this yaGion.
OFS•F2-0WC-252 CERTIFICATE-OF ELECTION TO Wii EXEMPT REVISED 07.12
QUESTIONS?(850)413-1609
c
RO
11 S.Andrews Ave., Rm.A-100. Ft. Lauderdale, FL 33301-1895-954-831-4000
VALID OCTOBER 1,2013 THROUGH SEPTELIBER 3o,2014
Dm: M&JKUSTOMBUILDERS Receipt#;susIN2, ss7FnmNcIAL/C0N
B tlessi Name: U.S.PAVE,INC Susie s Type:(CONSULTING)
OWMrNaime« 2107 RODMAN STREET Business Opened:oS/21/2013
Business Locad i HOLLYWOOD,FL 33020 SwWiotlntylCert(ft:
Exemption Code:
Business Phortie 88 8-15 81-9355
ROOM 1, Iwo+> Professionals,y����
' y/� r
Fbr V6nd1118%Wn"$only
Nor of t#sddnW kV Tyt'w.
TaX AMoun Transfer Fee S fl eas CoileG n Gcsrt Total flair!
•.lhti .s4">.en.nfrrf,•2;k"7lXS%��z9.'<.... . !n... %vi t;d of,c:• ...,.r.,:nF,»vr.
33.130 0.00 i�'g�,�'��r 1�s�l�Y ,1 ' fk� �x a�',` Q 0.00 33-00
/ +>rGyi�. �
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT TNs tax is levied for the privilege of doing business within Broward County ands
non-regulatory in nature.You must meet all County and/or Municipality Ping
and zone requirements.`This Business Tax Recd must be trans%rf+ed when
Vi�lEN VAl'Wit'73ATEE3 9 �
the (business is sold, business name has dmw*ed or you have moved the
business motion.This receipt does not indicate that the business is legal,or thet
It is in compliance with State or local taws and regulations.
Melling Address.
M&J KUSTOM BUILDERS
Receipt #3QA�#30A-12-00010570 U.S.PAVE,INC
2107 RODMAN STREET OB/21/2L313 33 OQ
HOLLYWOOD,FL 33020
2013 - 2014