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RC-13-2372Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 211034 Permit Number: RC -10 -13 -2372 Scheduled Inspection Date: April 18, 2014 Permit Type: Residential Construction Inspector: Rodriguez, Jorge Inspection Type: Final Building Owner: ERIC DIAZ, ROBERT BAKER Work Classification: Alteration Job Address: 260 NW 112 Terrace Miami Shores, FL 31368 -3332 Phone Number Parcel Number 1121360010280 Project: <NONE> Contractor: MDIAZ CORP Phone: (305)303 -0206 comments KITCHEN REMODEL INSPECTOR COMMENTS False April 17, 2014 For Inspections please call: (305)762 -4949 Page 24 of 24 Inspector Comments Passed Failed Correction Needed ❑ Re- inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. April 17, 2014 For Inspections please call: (305)762 -4949 Page 24 of 24 Miami Shores Village ,Building Department age10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �f� Tel: (305) 795.2204 Fax: (305) 756.8972 C$ J' S tjj INSPECTION'S PHONE NUMBER: (305) 762.4949 UILAING Permit No. PERMIT APPLICATION OCT 19 2013 9 FBC 20(3 Master Permit No. R C-11 11,20 — A51;� Permit Type: BUILDING ROOFING JOB ADDRESS: 1-60 re VA c k City: Miami Shores County: Miami Dade Zip: 3 316 F Folio/Parcel #: Is the Building Historically Designated: Yes NO >9 Flood Zone: OWNER: Name (Fee Simple Titleholder): a r�` `,� 4e ✓ Phone #: (11 Address: 6. .7(�-i SC. 73(,44 , S4, (o 3 -- 'LS` City: Atom State: FL Zip: 3 7 (3 47 Tenantlessee Name: Phone#: Email: � o"!2,00- . c...,% CONTRACTOR: Company Name: Qjd A-t6' Sao ck S ej4t:,A `• kZO !kr 4— &Iry Phone #( off -) i C r - 19,71 Address: �r(`s 1 tSc4N,tit '41J t03- 2S� City: Ak State: F L Zip: 33 % ?r Qualifier Name: Phone #: State Certification or Registration #: Certificate of Competency #: Contact Phone #: & 10 g i r- 93'} ( Email Address: 6616L, DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ �� Square/Linear Footage of Work: �i� S g ll� Jk, Type of Work: DAddition OAlteration ONew *Repair/Replace ODemolition Description of Work: (e$to,Ak eh,;4,, j c,, a..d W4 f6ce 44.: f► aew C`+ t; . �jj r/ � �i2A.6s�fL t�X! �m C(k4—*!J@ Y <� zL. u S S rhlti , L�is•�w� l�z�a -�ir`i 6`A, StwC. , kki CrI ware 4' J P'C10(4'�� v 1 �1-Nd to Color thru tt'le. 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 $ / %1. 6A Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City t AA-1 State 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 roust be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature F Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Signature Contractor The foregoing instrument was acknowledged before me this day of .20 _, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: My Commission Expires: APPROVED BY Plans Examiner Structural Review (Revised 5/2 /2012)(Revised 3/12/2012) )(Revised 06/10 /2009 )(Revised 3/15/09 )(Revised 7/10/2007) Zoning Clerk zip 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 roust be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature F Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Signature Contractor The foregoing instrument was acknowledged before me this day of .20 _, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: My Commission Expires: APPROVED BY Plans Examiner Structural Review (Revised 5/2 /2012)(Revised 3/12/2012) )(Revised 06/10 /2009 )(Revised 3/15/09 )(Revised 7/10/2007) Zoning Clerk Miami Shores Village 8OWh- g Department 10050` N.E.2nd. Avenue Miami Shords, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT NAME: ,jz0k,r + Tekke - DATE: to 117 1 i 3 ADDRESS: 6 rK c �e �(vd . 5A.e (03 - ZS7 V rG�( FL 3 313 LF Do hereby petition the MO of Miami Show to act as MY own contractor pursuant to 16 tags of the S#ate.of Fbrida, RS 489.1 t} M. And i have read and under Qod the. iioilo_Ing diacios! re statement, which satitles 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 dons 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 comunerdal building at a cost of $25,000.00 or lsss (.The: new form states - 75,000): The building °must be for yourown use and occupancy. It may not be turflt for sale orlease iff you'seti or. Idw a building you' have built youreeff withiffbwyear after the Construction la-WOW ftlo.1 iU? PWKM thahyoii lJTM for'eelO of Vie, which If violairoii bf thIfkb ition. 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 of 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 FICA and with- holdings tax and provide workers' compensation for that efnptdyee� a� as pt rtbed by law. Your bom ftfloin must comply with all applto6 laws," ordinances, buildings codes and zoning rsgulatibris. Please read and initial each paragraph. 1. 1 understand that state law requirm =rsductton to be done by a Qcansed contractor and hatra_appfied for an owner builder pem0t under an exemption from the law. The exemption specities that I, as the owner of the properly label, may act as my own contractor with certain restrictions even though I do not have a Ikerse. InIK 2. 1 understand that building permits are not MAW to be signed by s properly owner unless he or she is responsible for the omstructiorl mW Is not hiring a fioarsed r to assume resporsUlj. 3. i uralerstartd that, as an owner binder, I am to resp9m able party of record on a pod I understand that 1 may protect myself from potential fbsnclel risk by"a ftweed contractor and having the permit filed in his or her name I stead of my own name. I. aao undetsfarai that the contractor w requited by law 10 be lioersad In Fiorlda and to IM his or toerse n on permits and contracts. 4. 1 understand that 1 may build or knprove a one family or two4smlly resfderhse or a farm outbuilding. l may also build of improve a commerctal building If the costs do not Mad $75, 000. The building or residence must be for my we or o= -q)s' ncy. it may not be built or substantially knproved for safe or leve. ff a building or residence that I have built or suist d* Improved myself Is said or leased within 1 year after to construction Is complete, the law A presume that I built or knproved it for sale or lease, which violates the exemption. initial 5. 1 cundemland tad, as the owner-builder, I must provide direct, orsits supervision of the � 1 6. 1 understand that I may not hie an unlicensed person to act as my contractor or to supervise persons workig on my bugdh19 or residence. It Is my responsibility to ensure tat the persons Mom I employ have the H=m regtM by law and by cxnmty or muNtdpal orowoe. 1n I understand that it Is frequent practices of unlicensed person to have the property owner obtain an oemer twAder pod. that erron ly hrrp W that the property owner Is providing his or her own labor and materials. I, as an owry#r- Wiiderr�m be f old Me and subjected to serious financial risk for any hones sustain by an unticern person or his o'r stns r working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully. acting as o: . owrW4Mder and am aware of the limb of my insurance coverage for injuries to workers on my property. Initla. I understand that I may not delagate the responsibility for supervising work to be a ticersed'cortr�tor who rrot tioenses to perform the work being.done. Any „r , $ r�u °rkhhg on my building who is ,Hc armed must work under my direct supervision and must be employed by me, whidn WWthai I tnn semi with Iews rflqui the withhowing of federal Income tax and social security contribution under the Federal Insurance Contributions Act ( FICA) and must provide workers compensation for the employee. I understand that my failure to follow these may subject to serious; fmandal risk. I I agree that, as the party legally and finsn lslly response for this proceed Construction adivny, I will abide by all applicable laws and requirement INC- govern owner- bulidms" as well as employers. I also urdensfalid f 90M Construcfioh mustcomply with all applicable laws, ordinances, biitiding cam, -and zonhg regulations. IniSal 10. 1 understand that I may obtain more hhiomnation regarding my obligations as an employer from the Internet Revenue Service, the United States Stn Business Administration, and the Florida Department of Revenues. I also unrstan d trot I moy contest the Florida Construction Industry I.Wnshg Board at 850.487.1395 or • r inlSa 11. 1 ran aware of, and consent to; an corner- bulider building permit applied for In my name and und that 1 am the party legally and 6wrrdelly responsible for tie proposed construction adivity at the foirowi g address. 2160 MW UV6 TeN. j� �� S�'rz i FL D19? tniS . 1Z. I agree to notify Meet Shores Village immeft* of any additions, delellons, or changes to any of ttro hdorma�to Chow provided on the disclosure. Licensed contractors are regulated by laws designed to protect the public. N 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 MM any fitianclel loss that you sustaln as a result of Connector may be In dvfl court. h Is also hdpo W for you to understand that, ti an unlicensed contractor or employee t f'an individual or firm is injured while working on Our prol", you may be Ind liable for damages. If you obtain an own 4xfflder permit and wish to hire a licensed contractor, you will be responsible for vedfft Whetherthe contractor Is properly licensed and to status of the wntrec Ws workers compensation coverage. Before a building permit can be Issued, this disclosure siletiMerd must be completed and sign by the property owcror and returned to fie We! pemtltting agency respor & for Issuing the permit A copy of the property omirWi`driver license, the notarize sgriathne of the property owner, or other type of verification acceptable to *4 local p8m9ftagency Is required when the permit Is Issued. Was acknowledged before me this I day of"� 20 ® l' a° -) who was personally known to me or who has Y Produced there License or L4 � •��\``` P�`�� 8 SAD 3�p6s m I OWNER FLOh?-\O V�2 r k Pram and return to Renee Adwar, Esq. Renee Adwar, P.A. 848 Brickell Avenue Suite 830 Miami, FL 33131 305- 3744422 File Number: Bakerndiaz260NW [Space Alcove This Line For Recording Data] Warranty Deed CFN :2013RO589338 OR Bk 28744 Pss 1240 - 12411 (2p9s) RECORDED 07/27/2013 08:48 =20 DEED DOC TAX 1:OBO.00 HARVEY RUItINr CLERK OF COURT MIAMI -DADE COUNTY► FLORIDA le This Warranty Deed made this l day of 6 1 2013 between Philip Katman, an unremarried widower whose post office address is 1941 Present Drive, North Palm Beach, FL 33408, grantor, and Robert Baker and Eric Diaz whose post office address is 400 West 37th Street, Apt. 14P, New York, NY 10018 112 Terrace, Miami Shores, FL 3316% grantee: (Whenever used herein the terms "grantor" and "grantee• include all the Mies to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witmesseth, that said grantor, for and in consideration of the sum of TEN AND NO1100 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to-wit: Lot 12 Block 2 of NEW MIAMI SHORES ESTATES, according to the Plat thereon as recorded in Plat Book 51 at Page 84 of the Public Records of Dade County, Florida. Parcel Identification Number. 1121360010280 Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever, and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2012. In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. Signed, our presence: n i Ahilip.mn.� ,a DoubleTinte® Book28744 /Page124O CFN #20130589338 Page 1 of 2 PERMIT # CONTRA' oc: SUBMITTAL DATE: I ADDRESS: NAME: 2(Z— RESUBMITAL DATES: PROJECT TYPE: 'VA-rC I'VE ZONING FIRE STRUCTURAL IMPACT FEES 4�-nr ELECTRICAL PLUMBING - -- - -_ _— NOC MECHANICAL BLDG y t IKEA Home Planner Printout Robert Baker - West Wall 0000 - 5135 -4789 ADD SMOKE/CARBON MONOXIDE DETECTORS. ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED, worms Page 1 of 10 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. I f ��1 n�V�3(c�d C. .d 'n r-'. r 1wou � � ®® D OA QA i� http: //I itchenplanner eea ccom/us/UI/Pages/Pri: !R P� s All rneasurehent In Inches z ® z z 0 J �� 0 22 CAD t 9/30/2013 IKEA Home Planner Printout } Robert Baker - East/South Wall 0000 - 5135 -4789 Joy %4j f Page 2 of 10 a http: //kitchenplamer. ikea. com/ us /UI/Pages/Printouts/VPUISummary All measurement in Inches 9/30/2013 IKEA Home Planner Printout A;. Irg a � s �. Robert Baker - Plan View 0000 -5135 -4789 ADD SMOKE/CARB0N MONOXIDE DETECTORS. ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED. NO OTALONG COUNTER TO BE MORE THAN T 2 FEET FROM G.F..I PROTECTED RECEPTACLE PUT D/W RECEPTACLE UNDER SINK, ALL FIXED APPLIANCES ON DEDICATED QKTJ: Page 3 of 10 All measurement in Inches http: //kitchenplar ner.ikea.com/us/L Pages/ Printouts /VPUISummaryPrintout.htm 9/30/2013 IKEA Home Planner Printout Robert Baker - 3D View 0000 - 5135 -4789 Page 4 of 10 r i q 4 All measurement in inches Robert Baker 0000 - 5135 -4789 Total Price: $6,234.65 Price Quantity Total Price i S19823516 AK B41) AKURUM $194.96 1 $194.96 base cabinet with 4 drawers birch /Adel white 15" http : //kitchenplamer.ike&com/us/L Pages/ Printouts /VPUISummaryPrintout.htm 9/30/2013 Miami Shores Village Building Department IAA 2 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 z FBC 20 kd BUILDING Permit No. K C - i© - 13 - 2 -3 �- PERMIT APPLICATIO kEVIA&' = r Permit No. 4 Permit Type: BUILDING QFING G"af-jtodL Or C NYVACI S�— JOB ADDRESS: ' � o N w City: Miami Shores County: Miami Dade Folio/Parcel #: Is the Building Historically Designated: Yes NO �Q Flood Zone: 10 a OWNER: Name (Fee Simple Titleholder): F 4e t - ' (C e ✓ Phone #: (z/ /S) S a - `i Address: 260 4W (12- *" rt2 rf v c 2 City: State: t- Zip: '3716 F Tenantd,essee Name: — Phone #: -- Email: o 4 t.a A^ CONTRACTOR: Company Name: kqf� Phone #: M15 .0 liz p Address: City: State: Zip :La?/oR:;2 Qualifier Name, �li✓lU� 1 7 Phone #: CV a�� State Certification or Registration #: AIVX V^ly Cerlificate of Competency #: Contact Phone #: Email Address: )"% / 7_gn7r ..lC�l. r,,-y tom! DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: a 0'— _r$4uat�/Linear Footage of Work: _ Type of Work: ❑Addition DAlteration ONew ®Repair/Replace Description of Work : 44 X r9ru�YY.� S Qs�x l0 C is S.L -` 2 � � }g t 9 T a Vo ' � �, di 9tic '}�W � tl IP g •tra � , w "�.. thru'W)��. Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ IZ5_ ODemolition t W -2- II � 6 4r75 .w MCC $ 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 Mortgage Lender's Name (if applicable) & d dJ �, Mortgage Lender's Address City State zip Zip J Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant. As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is'issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature -� Signature Owner or Agent Contractor The foregoing instrume�nt,�was ackn wledged before me this -M The f�oing instrument was acknowledged before me this IS day of_ ,20w7 ,by day ofJa f' ,201 �i,by 444SL Z)iH*Z , who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did 411W, pA oath. as identification and who did take an oath. My Commission Expires: Print: Structural Review Clerk (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) t t Miami Shores Village Building Department 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* D. COPY OF WORKERS COMPENSATION INSURANCE* 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* D. COPY OF WORKERS COMPENSATION INSURANCE* *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ...... ............................... a..._.... a a 0 a 0 a 000 a w 0.000 a a a a a a a a a a a a a a a a a a a a a a a a a a a a al BUSINESS NAME: Ul )(Ct 7 LVr, BUSINESS ADDRESS: 2z��� B 10 CITY STATE ZIP CODE C =7 i BUSINESS PHONE: FAX NUMBER( CELL PHONES & S;2 ) 3Q� Qn QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: Created on 3M9109 BY MLDV I RV 3126109 MLDV I RV 6127111 AS � +r 002995 Local Business Tax Receipt Miami -Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY 6284131 BUSINESS NAMWLOCATION MDIAZ CORP 8000 NW 31 ST #15 DORAL FL 33122 OWNER MDIAZ CORP Worker(s) 3 RECEIPTNO. EXPIRES RENEMAL SEPTEMBER 30, 2014 6549761 Must be displayed at place of business Pursuant to County Code Chapter BA — Art. 9 & 10 SEC. TYPE OF BUSINESS PAYMENT RECEIVED 196 GENERAL BUILDING CONTRACTOR CGC1515794 BY TAX COLLECTOR $75.00 08/20/2013 TXHSI -13- 048266 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above mug be displayed on all commercial vehicles — Miami—Dads Code Sac Ba -276. For more information, visit www miamidade ovRaxco lector a. THIS DOCUlNENryHAS ACOLORED BACKGROUND MICROPRiNlItJGLihIEN1ARiC` PgTENTED PAPERS r,u'?' AC#6350138 STATE OF-FLORIDA DEPARTMENT I• _r r '• • i • CONSTRUCTION Irr BOARD SEQ#L1209090013 KEN LAWSON SIECRETARY , r 08 -03 -2012 :JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION e e 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: PERSON: FEIN: BUSINESS NAME INOIAZ CORP 12814 SW 71 LANE MIAMI 09/12/2012 DIAZ 205220428 AND ADDRESS: FL 33183 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR EXPIRATION DATE: 09/12/2014 MANUEL 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 440.06(12), 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 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shell be subject to revocation it, 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 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW 4i EFFECTIVE 08/12/2012 EXPIRATION DATE: 08/12/2014 PERSON: MANUEL DIAZ FEIN: 205220428 BUSINESS NAME AND ADDRESS: MDIAZ CORP 12814 SW 71 LANE MIAMI, FL 33183 SCOPE OF BUSINESS OR TRADE 1- LICENSED GENERAL CONTRACTOR IMPORTANT F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who 0 elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E Pursuant to Chapter 440.05(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. CUT HERE QUESTIONS? (850) 413-1609 * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 A� °® CERTIFICATE OF LIABILITY INSURANCE DATE(AAAMDlbYYYY) 1/16/2014 THIS CERTIFICATE IS ISSUED AS A FATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY IVELY 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms end conditions of the polity, certeln poildes way nxpdre an endorsement A eadement on this certificate does not confer rights to the certlflcate holder in lieu of such s . PRODUCER Gil, Garden, Avetrani Insurance Groff 10689 H. Kendall Drive Suite 208 Miami FL 33176 CONTACT mariela Ortega P 305)630 -4777 Fax 13051279 -3022 EMAIL INSUREIM AFFORDING COVERAGE NAIO # WWRERA:Cano ius US Insurance Inc GENERAL LIABILITY 8 COMMERCIAL GENERAL LIABILITY CLNMSMADE ® OCrUR INSURED MDiaz Corp. 8000 Nff 31 St Unit 15 Doral FL 33122 nmnmpts0ranada Insurance Cbmjumy - 0004326 -2 INSUREReAsses Insurance $ 1,000,000 INSURER D: $ 100,000 I E : $ 5,000 INSURER F: $ 1,000,000 COVERAGES CERTIFICATE NUMER:M.392004430 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. IMO LTA I TYPE OF INSURANCE POLICY EFF /19/2013 POLICY EXP /19/2014 La1IT8 A GENERAL LIABILITY 8 COMMERCIAL GENERAL LIABILITY CLNMSMADE ® OCrUR - 0004326 -2 EACH OCCURRENCE $ 1,000,000 $ 100,000 MED EXP mm $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 hGHd L AGGREGATE LIMIT APPLIES PEI: 1 Policy PRO- = M Loc PRODUCTS - COMPIOP AGG $ 2,000,000 $ B aurouaelLE uaelurr ANY AUTO ALL OWNED g PULED AUTOS AUTO HIRED AUTOS AUTOS 1701�L0001o3so -1 /21/2013 /21/2014 dens 100,00 BODILY INJURY (Pw p =w) $ gpDILyI1�WRY(�a $ DAMAGE $ PL $ 1010 X UMSR13 1 A LIAB E)CESSLIAB 8 OCCUR CLAIMS-MADE KOVA609413 9/19/13 O/19/14 EACH DICE $ 1,000,000 AGGREGATE $ 1,000,000 Dm $ WORI(EAS COMPENSATION AND EMPLOYERS' LIABILITY Y/p ANY PROPRIETORIP.� ❑ OFFICE ,.E.rER ERCLUD®7 (Mandalmyin Wo If yas describe under DESCP2IPTION OF OPERATIONS below N/A I WC STATU OTH- TORY LIMITS r-R E1 EACH ACCIDENT $ DISEASE -EA $ [EF-6LEmsEAsE-PoLcyLmmT I $ DESCRIPTION OF OPERATIONS /LOCATIO S1 VEHICLES (AUmch AGORD 101, AdMmal RmOm SdedulA H men spaw Is mqMeM Miami Shores Village BLDG Dept 10050 HE 2nd Ave Miami Shores, FL 33138 25 SHOULD ANY OF THE ADM DESCRIBED PAS BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISION& Noalrigues/VD @ 1188-2010 ACORD CORPORATION_ Ali rich s ramoved INPAM. mmn m m Tim Anemn roam oraR Innn pros raniouwm l arorkck rd AtNvpn Miami Shores Village Building Department 90050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: PLUMBING JOB ADDRESS: ?,b 0 N W l l?� 4 FBC 201 0 City: Miami Shores County: Miami Dade Zip: 3 Folio/Parcel #: Is the Building Historically Designated: Yes NO N Flood Zone: M O OWNER: Name (Fee Simple Titleholder): �D � e �} ?Ae✓ Phone #: 615) ,S-tF_93 j/ Address: I b e MW le ry a c e City: —8& r State: F L- Zip: - 31 b F Tenant/Lessee Name: Phone #: — Email: a ✓ Lj b&, G' nAa'I C o AA CONTRACTOR: Company Name: Address: Lt-) i e a u,, t T G' City: State: r r zip: _016 Qualifier Name: (-Y) �R. ,w U+-u rc: Phone #: ��[� )- �l y b State Certification or Registration #: C r C J V Z 4 Y Certificate f Competed Contact Phone #: U �` q'7 L 1 Email Address: Ja e � ,v1 C kJc�a SOJ DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddress DAlteration ONew Repair/Replace I � (� Descri t �, .l ri V1 v AA .%4 111MIKM ODemolition Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ 2,1.E - �.- Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ ' DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 4A ° Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City 9J0rN1� State zip zip. Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. S Signature Owner or Agent The foregoing instrument was acknowledged before me this day of `, 20 M by J1 &JU GAtk4A_, who is personally known to me or who has produced As identification and:Aq, did take an oath. Contractor The foregoing instrument was acknowledgg4before me this Ao day of 20 L , by f A y / P �°rv�— who is personally known tome or who has produced FL iL (�342-76 i 5 7 tJ2 Chas identification and who did take an oath. NOTARY PUBLIC: is , /�'o,, NOTAR PUBLIC: >� Sign: _� o i °.yam w° Sign: Print: Print: My Commission Expires: �. `, 5 \. • ........... p\ `�,�� My Co Aires: Q a ������� ►r► ,/. crate of Floft , ,. :.:nos Jul 18, 2014 a;;� Fts;�• Commission # EE 9773 APPROVED BY A ` / Plans Examiner Zoning Structural Review Clerk (ReAsed3 /12/2012 )(Revised 07/10/07 )(Revised 06 /10 /2009XRevised 3/15/09) Miami Shores Village r Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 3 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 e= FBC 2AV:;' JOB ADDRESS: L& 0 N W i I Z 4"'' Tarr" c� City: Miami Shores County: Miami Dade Zip: 3 16 F Foho/Parcel #: Is the Building Historically Designated: Yes NO _X� Flood Zone: M o OWNER: Name (Fee Simple Titleholder): R o 4e ,--' 13a k t v Phone #: C'-Il s-) Address: �� 4 N &dJ ➢12 =` '_E rr a c k City: At S k o b e 5 State: F (.- TenanvLessee Name: Phone #: Email: b b f� r�► d, e y CONTRACTOR: Company Name: Address: "-6� eel - / 6) >/Q f3&�-- --q-`-%r City: G State: 7Z71 ®GtCt Zip: z Qualifier Name: b r,P l 0/G Phone #: State Certification or Registration #: -e 7 O Certificate of competency #: Contact Phone# �- �'ld" `�`� y Email Address: d z Zw-z/ r­, '-- C 41 f DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $_X , Square/Linear Footage of Work: Type of Work: DAddress OAlteration PP DNew DRepair/Replace ODemolition Description of Work: �n�, c�_�� �� h ; , , w a�; -1. C-, Submittal Fee $ Permit Fee $ / /3w,:r6 CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ a TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) �--' Bonding Company's Address City State Mortgage Lender's Name (if applicable) _u my JL Mortgage Lender's Address City State zip 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. absencg of s°i ch° iosted notice, the inspection will not be approved and a reinspection fee will be charged. qr Signature Si Owner or Agent Contractor d g" The foregoing instrume t was acknowledged before me this �" day of , 20�, by who is personally known to me or who has produced. As identification and who did take an oath. NOTARY PUBLIC: g , Sign: Print: my ,o� .. _\ - :e o ......... q • '9 �� CJ The fore oing instrument was acknowledged before me this so / y of 20by ��" 6S , who is rsonally kn wn to me + who has produced # as identification and who did take an oath. C: Print: m—ry iiLcJda • . •5 y Comm. Expires May 30, 2015 MyCommiss� n Po Commission # EE 79436 �° �� ���� I Bonded Through National Notary Assn. � a�i9ede4eScstr4r4raY4: �YaY�k�YRrs YaFaYsi• �Y9edrrkArrk�irsY�FnYir�le�Y�YsF�F9e8e4r��Y4e3r9eaY3e&& dc4r4e�4es BrFrsYsY�Y�Tr3c8roYsk4c�Y9e9ent a�eaY3rdcae4edcdnYatsY&& a4�Y�Y�Ys4�N�Y4nY�Y4nYaY3nYdraYdz�Y sYdasY�Y�Y3eSnY�ir APPROVED BY E/ ,,',®" A-' Plans Examiner Zoning Structural Review Clerk (Revised 3 /12/2012)(Revised 07 /10 /07XRevised 06 /10/2009)(Revised 3/15/09) i I —Adowk, ' , CERTIFICATE OF LIABILITY INSURANCE I "In TIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOWL THIS WE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDW BY THE POLICIES THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER % AUTjqO=W MTATiVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ' It 111119 aerMICOW holder Is an ADDITIONAL INSURED, the policyges) Must M endorsed. if SUBROGATION IS WAIVED, mtp to and conditions of the policy, Certain policin may require an endorsement A Statement on this car�iCats does nail Corer holder In Ileu of Such endoreom S . Nghts to the Hance Insurance Solutions, LLC ID: (PEMCO) D Pt ressive Employer Management Company, Inc. P - 107 P�rkiand Dr - resota, FL 34243 Employer Management Company II, Inc. 3 /4ve )gs FL 34689 - i nrm . ERTifY THAT THE fwVw01w'N 41JIIICfl:Ti+ POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CeAlA1ERCGtL GeNERAL UABIUTY CWMSMADE Fj OCCUR 01 WL AGGREGATE LIMIT APPLIES PER: PULICY NI LOC Al LL4aLLrTY ANY AUTO AA T D 8 �� LED HIRED AUTOS �-0NMED 0916111" LUw I �C=SQAADF MMM UAB DEO LJ RETENTION s A Y✓ ARA NUTYEXECUTIVE YIN ( EXCLUDED! � NIA E de ibe wft TTIONS boy C t oo0v®raoesdUon 5301 1 3/612013 3/6/2014 Provided for all leased employees but not suboontrector$ of Mesa Brothers Inc Ova: 3/16/2013 MED EXP (Ay Ogg p�yppi PERSONAL & ADV INJURY $ w ATE IOP Aiiaso BODILY INJURY (Per pl) $ BODILY INJURY (Per $ $ $ EACH OCCURRENCE $ AGGREGATE $ 8 $ $ E.L. EACH ACCIDENT j E.L DISEASE - EA EMPLOyeE $ E.L DISEASE - POUCY UW $ This Is for Infor"pheii pu and nothlnst shalt d reate ar Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANQRI 1 RD BARE Building Deparment THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERBD IN tOO50 NOrMeest 2 avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami shores, FL 33138 Glen J alBtefan0 AC 2S (2041105) The ACORD name and logo are registered arks of 010 AC RD CORPClRAittifai. Ali reserved. CMT No. 180®9454 Rrletl Art4nx 4/22 /2013 12,07,28 PM Peg® 1 of 1 '1WG026 Local Business Tax Receipt Miami -Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY BUSINEW NA]Wlan a ATIoN MESA BROTHERS INC 5215 SW 103 AVE MIAMI FL 33165 RECBIPIr NO. EXPIRES Rape SEPTEMBER 30, 2014 405779 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE of BUSINESS PAYMENT RECEIVED MESA BROTHERS INC 196 ELECTRICAL CONTRACTOR BY TAX COLLECTOR Worker(s) 10 EC13001870 $75,00 08/16/2013 TXHS1 -13- 046132 This Local Business Tax Rooei� a* confirms of tlm Loos, Bnsinsss Tex The Receipt Is � a license. ggxgoiro�e� �s� romc�m s �i do bb�m aos�VlY witl� any gorsmiaenrtol or the RECEIPT N0. above oW be disphgred on all corm orciel vehicle,.- M10.1ladt We Sec to-= For amrs hdormarion. vish >v4b Gliltab STATE OF FLORIDA:_ UK S PR ' COI�i'�RA'T.OR3 I�3•:CgB . v ':.... to •�. .. rtres... t. '•' .....: � ..+ti):I. n' ...'.. � .'.. ' p .: ,t 03, ::' 0:000 00fl...' 0130016 4 _. , la thy - vi'oviraioae o* �rats. .,Oat ®: AUG 31, 2014, 6 •Y 5215 91W FL. 3:316 t' CK . 3CCITT, M6R DISPLAY AS REQUIRED BY LAW iifili Z= 1AW00a SffiCRWARY O&IS01003 .4CC>R I MESAB -1 OP ID: 080 �..-- CERTIFICATE OF LIAR11 ITV 1N -Q1 I D►TEIMMIDOMM I -- - -- - - -- • •r•• • •• 12/23/2013 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 BELOW. POLICIES THIS CERTIFICATE OF INSURANCE DOES 140T 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 pol(cy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemen s . PRODUCER Phone: 305-364-7800 FACT BROWN & BROWN OF FLORIDA INC PHONE 14800 NW 79th Court Sulte#200 Fax: 305. 714.4401 F Miami Lakes, FL 330164869 E-MAIL Ramon A Rodrigues ADDRESS: INSU S AFFORDING COVERAGE NAIC # INSURED Mesa Brothers Inc. INSURER A:FCCI Insurance Company 10178 5215 SW 103rd Avenue (Rear) INSURER B: Miami, FL 33165 INSURER C: INSURER D: INSURER E: INSURER 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 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 0 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. am L S L TYPE OF INSURANCE POLICY EFF POLICY EXP POUCYNUMBFR LaUTB A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY GL00147262 01101/2014 01101/2015 EACH OCCURRENCE $ 11000,0 X IERTM PREMISES re noe $ 100,00 CLA IMSdNADE X� OCCUR MED EXP (Any one n) S 5,00 PERSONAL & ADV INJURY $ 1,000-00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER;- PRODUCTS - COMPlOP AGO $ 2.000,0 X POLICY LOC t SI $ AUTOMOBILE LIABILITY ANY AUTO �,� NED AUTOE$DULEO a ant BODILY INJURY (Per perm) _ S O NED H BODILY INJURY (Per aoaident) $ I HIRED AUTOS -O $ Per aoddent $ UMBRELLA LIAR OCCUR $ EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ DED WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY R f1A ANY PRO PRIETORIPAI TNERIEXECUTIVE YIN 01 FICEWMEMBER EXCLUDED? El NIA E.L EACH ACCIDENT $ _ NH) If�desc tee under E.L. DISEASE - EA EMPLOYEE $ OF E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 707, Adddonal Roroaft Sctwdute, If more apace is required) CERTIFICATE HOLDER CANCELLATION MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 Northeast 2nd Avenue Miami Shores, FL 33138 AUTHORIMOREPRESP.NTATIVE ACORD 25 201010 0 1988 2010 ACORD CORPORATION. All rights reserved. ( The ACORD name and logo are registered marks of ACORD 1' 30' -1" r 0 cs— car— o -------------- I I I I I J I ti A 0 II II C) � cr— I �' 0 I r+1 I I O v z 0 �n 0 n �s e� i� Cli O0 o cNn s J = O `11 1' 30' -1" o v z z c� 0 27' -3" MIAMI 0 0 ZO 1NG �° I I Na m C Z F II 2 -- - - - - -- it F- g - m 60' -2" m �D VILLAGE DATE XRICAL WING � j� ®s2-3. M CHAN•CAL i ' DG• U-JECT TO t,;;MPLIANtl 'v41IH ALL FEDERAL, PTE AN 3 C UN fY RULES AND REGULATIONS• i 3 3►� -- O ----------- 0 o -------------- I I I I I J I II II C) I �' 0 I r+1 I I O v z 0 0 ' Cli O0 o cNn s J = O o v z z c� 0 27' -3" MIAMI 0 0 ZO 1NG �° I I Na m C Z F II 2 -- - - - - -- it F- g - m 60' -2" m �D VILLAGE DATE XRICAL WING � j� ®s2-3. M CHAN•CAL i ' DG• U-JECT TO t,;;MPLIANtl 'v41IH ALL FEDERAL, PTE AN 3 C UN fY RULES AND REGULATIONS• i 3 3►� -- O ----------- j J o v z z c� 0 27' -3" MIAMI 0 0 ZO 1NG �° I I Na m C Z F II 2 -- - - - - -- it F- g - m 60' -2" m �D VILLAGE DATE XRICAL WING � j� ®s2-3. M CHAN•CAL i ' DG• U-JECT TO t,;;MPLIANtl 'v41IH ALL FEDERAL, PTE AN 3 C UN fY RULES AND REGULATIONS• i 3 3►�