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DEMO-14-358Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 207813 Permit Number: DEMO -2 -14 -358 Scheduled Inspection Date: March 10, 2014 Inspector: Rodriguez, Jorge Owner: TER HORST, BARBARA Job Address: 1130 NE 91 Terrace Miami Shores, FL Project: <NONE> Contractor: OBRA PRIMA CONSTRUCTION GROUP LLC tsuuaina uepan:ment comments Permit Type: Demolition Inspection Type: Final Work Classification: Building Phone Number (305)432 -1775 Parcel Number 1132050010410 Phone: (305)825 -2300 REMOVAL OF OLD DRYWALL FROM BEDROOMS AND ' ' - - ----- DINING AREA INSPECTOR COMMENTS False March 10, 2014 For Inspections please call: (305)762 -4949 Page 18 of 24 Inspector Comments Passed Failed Correction Needed ❑ Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. March 10, 2014 For Inspections please call: (305)762 -4949 Page 18 of 24 PERMIT # - C� CONTRACTOR: 06 9 I SUBMITTAL DATE: v 'J ADDRESS: I I �e, NAME: 80-1 RESUBMITAL DATES: PROJECT TYPE: of --+Y-Off) ZONING 07�1�.. FIRE STRUCTURAL IMPACT FEES ELECTRICAL HRS /DERM PLUMBING NOC MECHANICAL BLDG ,G Ahn `J &, V BUILDIN PERMIT. Permit Type: I. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PRONE NUMBER: (305) 762.4949 ATION `L-> v b SA JOB ADDRESS: 1130 NE 91 Terrace FBC 20 Permit No, Master Permit No.o p—U o r ci rr-.,n ROOFING City: Miami Shores County: Miami Dade 4p: 33138 Folio/Parcel #: 11- 3205 - 001 -0410 Is the Building Historically Designated: Yes NO X Flood Zone: Yes - AE OWNER: Name (Fee Simple Titleholder): Barbara Ter Horst phone#: (772) 579 -9651 Address: 1130 NE 91 Terrace City: Miami Shores State: Fl- Zip: 33138 Tenant/Lessee Name: Owner Occupied Phone#: Email: terhorstb @gmail.com CONTRACTOR: Company Name: OBRA PRIMA Construction Group LLC Phone#: (305) 825 -2300 Address: 3408 W. 84 Street, Suite 316 City: Hialeah State: FL Zip: 33018 Qualifier Name: Joel Ripoll Phone#: (305) 825 -2300 State Certification or Registration #: CGC 1521523 Certificate of Competency #: Contact Phone #: (305) 308 -5601 Email Address: info @obrapdmacg.com DESIGNER: Architect/Engineer: Value of Work for this Permit: $1,800 Square/Linear Footage of Work: 900 sq. ft. Type of Work: ❑Addition ❑Alteration ❑New ORepair/Replace Demolition Description of Work: Removal of Old Drywall from bedrooms and dining area. Color thru tile: Submittal Fee Scanning Fee $ Notary $ Permit Fee $ Radon Fee $ Training/Education Fee $ Double Fee $ Structural Review $ CCF CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 6 q - �o Bonding Company's Name (if applicable) Not Applicable Bonding Company's Address City State Mortgage Lender's Name (if applicable) Not Applicable 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 EMPROVEMENTS 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 d t N a U" 6 ' _d Signature ��f:f Owner or Agent Contractor The foregoing instrument was acknowl dged be ore me s day ofd ��, 0 y, �who 's personally wn to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: '_: MY COMMISSION # DD994339 My Commission Expires: .'' tn�,.�` EXPIRES June 14, 2014 The fore oing instrument was a knowjedged be re me day of '� , 20 was JA, lw� , who i personally known to me r who has produced as identification and who did take an oath. NOTARY IFET -1 1 01 men►, ".Y' APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 February 25. 2014 Re: 1130 NE 91. Terrace, Miami Shores, FL 33138 To Whom It May Concern, I, Barbara ter Horst owner of the above referred to house, hereby authorize Obra Prima Construction Group (CGC # 1521523) of 3408 W. 84 Street, Suite 316, Hialeah, FL 33118, to perform demolition as specified in the drawing. No plumbing, electrical or gas connection demolition is required. Best regards, Barbara ter Horst 1130 NE 91st Terrace Miami Shores, FL 33138 (305) 4321775 NELSON MEDINA JR =' �c MY COMMISSION # DD994339 EXPIRES June 14, 2014 (407) 398-0153 Fb*iallot9 .com ,a►coRn� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD1YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 02/24/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(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 endorsement(s). PRODUCER CONTACT Frank Rodriguez Florida Premium Insurance PHONE 954 400 -5665 FAX M. no ( ) A/C. No): 954-320 -0389 gppp�: frank @floridapremiuminsurance.com 2690 Weston Road Ste 200 INSURER(S) AFFORDING COVERAGE NAIC d EACH OCCURRENCE INSURER A: Endurance American Specialty Insurance Company Weston FL 33331 INSURED INSURER B INSURER C: Obra Prima Construction Group INSURER D: MED EXP (Any one person) 3408 West 84 Street, Suite 316 INSURER E: $ 1,000,000 Suite 316 INSURER F: Hialeah FL 33018 COVERAGES CERTIFICATE NIIMRPR- RFVISInIJ M11IRAIaR13• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL InIL UBR WVI) POLICY NUMBER POLICY EFF M D POLICY EXP M D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FRI OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 CBC10001636000 06/08/2013 06/08/2014 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidern BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAR EACH OCCURRENCE $ HOCCUR AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- 0TH - AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? ❑ N/A lfli1T ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, M more space is required) General Contractor Polic Miami Shores Village Bldg. Dept. 10050 NE 2 Avenue Miami Shores, FI 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .B - f -:'� .v_e AL;UHU 25 (2070/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATER 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: 6/14/2013 PERSON: MEDINA FEIN: 261944396 BUSINESS NAME AND ADDRESS: OBRA PRIMA CONSTRUCTION GROUP LLC 3408 W. 84 STREET, SUITE 316 HIALEAH EXPIRATION DATE: 6/14/2015 NELSON FL 33018 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(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 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. DFS- F2 -DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07 -12 QUESTIONS? (850)413 -1609 JEFF ATWATER 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: 2/11/2014 PERSON: RIPOLL FEIN: 261944396 BUSINESS NAME AND ADDRESS: OBRA PRIMA CONSTRUCTION GROUP LLC EXPIRATION DATE: 2/11/2016 JOEL 3408 W. 84 STREET, STE 316 HIALEAH FL 33018 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(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 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. DFS- F2 -DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07 -12 QUESTIONS? (850 )413 -1609 Local Business flax Receipt Miami- Crude County, State of Florida -THIS IS NOT A BILL -00 NOT PAY 7163973 BUSINESS NAME/LOCATION RECEIPT NO. OBRA PRMA CONSTRUCTION NEW BUSINESS GROUP LLC 7442178 3408 W 84 ST 316 ' H IALEAM FL .33018 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEMED OBRA PRIMA CONSTRUCTION 196 GENERAL BUILDING BY TAX COLLECTOR GROUP LLC CONTRACTOR 45.00 t21142013 r:tn Lwn[NA NFI -,nN .IR Worker(S) 2 CGC1521523 0227 -14- 002383 This LocalBmaioess Tax Roceiptouly confirm; paymeut of the Local Business Tax. The Receipt is Rate license, permit. or a certification of the holder's gaalificetioos to do business. Holder must comply with any goveromeutai ar nougovernmeutal regulatory Ipws and requirements which apply to the business. The RECE(PT N0. above most be displayed on all commercial vehicles- Miami -Dade Code See Sash;. IoM for more information, visitwwev,otiaptid�}lggov(taxeo loctor RIPOLL, JOEL OBRA PRIMA CONSTRUCTION GROUP LLC 3408 WEST 84 STREET SUITE 316 HIALEAH FL 33018 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! (850) 487 -1395 The Department of State is leading the commemoration of Florida's 500th anniversary in 2013. _ For more information, please go to www.VivaFlorida.org. tl'dd !!taQ�t!il�!I DETACH HERE STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 10 c� IN Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795;2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: MA kz-2Fll4 C.oa-'-'S'-�CT i GQwp BUSINESS ADDRESSAD ) U). CITY O-OLEA4 STATE '�n--- ZIP CODE 3&3 k8 BUSINESS PHONE: (5 ) ��� �� FAX NUMBER CELL PHONE) ��00 -5 COD QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: cc.'c' 1's a , s E -MAIL ADDRESS (IF APPLICABLE): l r� c Created on 3119109 BY MLDV 1 RV 3126109 MLDV