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PT-14-1361Inspection -Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-214822 Permit Number: PT -6-14-1361 Scheduled Inspection Date: August 11, 2014 Permit Type: Paint Inspector: Rodriguez, Jorge Inspection Type: Final Owner: RAUSCHER, STEVEN Work Classification: Addition/Alteration Job Address: 78 NE 98 Street Miami Shores, FL Phone Number (623)523-7138 Parcel Number 1132060130900 Project: <NONE> Contractor: WPH CONSTRUCTION COMPANY Phone: (305)244-2392 Building Department Comments PAINT INSPECTOR COMMENTS False August 08, 2014 For Inspections please call: (305)762-4949 Page 6 of 27 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. August 08, 2014 For Inspections please call: (305)762-4949 Page 6 of 27 Miami Shores Village Building Department JUN 5 2014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138- J3 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PAINT Permit No. Master Permit No %/V— L2V t OWNER: Name (Fee Simple Titleholder): 2Je„a hone#: �" S ' 463 Address: s� City: to 1 a vv,, , 25'VtG K 25 State: Zip:1.25 B Tenant/Lessee Name: AZ I iA Phone#: Email: bo, IA, C!L lrvt 1 . Q t fat JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: 3-3 N 3 2 Foho/Parcel#: Is the Building Historically Designated: Yes Zone: o CONTRACTOR: Company Name: Phone#:2� Address: A��s �� City:. State: Zip: 3-Z z, Qualifier Name: t v� �f`_._3t1Phone#: 0- 4 q�- A State Certification or Registration #: to c LS-LJ--3Lf Certificate of Competency #: Contact Phone#% 3r%S a Lfr Email Address: Value of Work for this Permit: $ 6 0 Ui I Square/Linear Footage of Work: Description of Work: OA 1 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..... "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 an inspection fee will be charged. Permit Fee $ CCF $ Notary $ Training/Education Fee $ Technninov Fee S Double Fee $ TOTAL FEE NOW DUE $ D 9 - PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be i�ainted DIRECTIONS: Please circle corresponding number to appropriate color sample. Walls: 1 2 3 4 Fascia: 1 2 3 4 Drip edge: 2 3 4 Soffit: 1 2 3 4 Roof KlPt- 1 2 3 4 Flower Bins: 1 2 3 4 Shutters: 1 3 4 Awnings: 1 ,�2^y E 2r 3 4 Chimney: 1„ 2 33� 4 Doors & Jambs: l , 2 f a t 4 Garage Doorsollt 2 3 4 Railings: `ql 2 3 4 km Fences: 1 2 3 4 All Brick: WIN 2 3 4 Stucco Bands: 1 2 3 4 Other Stucco Feature: ( 1 2 3 4 Accessory Bldg: 1 hL [ 2 3 4 Attach color sum 'le with nameAnd.numh- 1. 2. 3. 4. 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. Signature.-,�E / Owner or Agent The foregoing instrument was acknowledged before me this /9 dayofJU , 20 by�L r e/1�_ ham., who is personally known to me or who has produce �S z03,91,6 As identification and who did take an oath. NOTARY PUBLIC: Signature: "-� Contractor The foregoing instrument was acknowledged before me this day of I r/I 20,�/, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign ' rw ., CAlt O WART MY MMURRON # MUM Print: o 28, 2095 My Commission Expires; t4M 390.0163 APPROVED BY: , 1114 Code Official Preservation Board r "V H 60-8'95-6A-703-0 r� .SC,f1 PWRR+E �E NMI IWU NE 12 AVE N HLUK FL 321624 WVOptlMs'aI� �wogr wiwple erMsNAh M any a w "V ftm 0- b, ibw STATE OF FLORIDA AC# 6 '2 7 8 1 3 1 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CBC1255356 08/17/12 128043499 CERTIFIED BUILDING CONTRACTOR HENRY, WILSON P WPH CONSTRUCTION COMPANY IS CERTIFIED under the provisions of Ch.489 FS mcpirption date: AUG 31, 2014 L12 0 8 17 0 129 9 -PLEASk CUT OUT THE CARO &FLOW AND ItiMh FOR FUTURE RkFERENCE S-5nT%MaL=1CTffPt6 2VAI�J Y CERTIFICATE C0�i W"Im T� Ex nPr FROM FLORIDA WFORKERT4 EFFECTIVE 10/16/'2014 EXPIRAritlN DATE: 10/16/2014 PERSON: WILSON P HENRY FEIN_ 2047821304 BUSINESS NAIVE AND ADDRESS- WPH CONSTRUCTION COMPANY 15724 NE 12 AVE MiAML FL 33182 SCOPE OF, BUSINESS OR TRADE 1- ROOFING 2- LICENSED BUILDING CONTRACTOR OPursuant to Chapt4 440.05(14), F;S, an officer of w corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under, tris D Purest to Cutter 440.05021 F.S., Certificates of election to. be H exempt- apply only within the scope of the business or trade listed on Ethe notice of election to be exempt t'Pursuant to Chapter 440.05031 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 meet the requirements of this section for issicatce of a certificate. The department slall 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 * Carry bottom portion on the job, keep upper portion for your records. t. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 '(�I? ��!y CERTIFICATE OF LIABILITY INSURANCE DAO 102/'ia ' PRODUCER Annette Willis Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 18401 N.W. 27 Ave ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33056 Phone (305) 625-2403 Fax (305) 625-6472 INSURED WPH CONTRUCTION COMPANY " P O Box 600149 MIAMI, FL 33160 - COVERAGES INSURERS AFFORDING COVERAGE wR11RFR A• Seneca SDecIality Insu INSURER E: Com NAIC # 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 ADD'LiYpE INSRD OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE WOD/YYYY POLICY EXPIRATION DATE LIMITS APERSONAL ❑ GENERAL LIABILITY © COMMERCIAL GENERAL LIABILITY ❑❑ CLAWISMADE 0 OCCUR F%#1 500 deductible per daim ❑ GEN'L AGGREGATE LIMIT APPLIES PER: © POLICY ❑ PROJECT ❑ LOC BAG -1010158-1 01/11/2014 01/11/2015 EACH OCCURRENCE 1,000,000 PREMISES Ea rrrence 100,000 MED EXP (AM one. person) 5,000 &ADV INJURY 1,000,000 GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 ❑ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULEDAUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS ❑ COMBINED SINGLE LIMIT (Ea accident) INJURY (per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY --EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG EXCESS I UMBRELLA A LIABILI Y ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR / PARTNER I EXECUTIVE OFFICER I MEMBER EXCLUDED? (Mandatory In NH) Kyes describe under SPEG�IAL PROVISIONS below ❑ WC STATU- ❑ OTH- T RER EL EACH ACCIDENT EL DISEASE - EA EMPLOYEE EL DISEASE -POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS GENERAL CONTRACTOR <t19Lf11;L7�AIa:Lei vja: LWLI'10i:41W_1I1010 J%%.Vw w tcuvmv-1/ w CEJ TWtFwAW V At:UKU ( KKMATION. All nglls reserved. The ACORD name and logo are reglsWW marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL MIAMI SHORES VILLAGE 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 1050 NE 2 AVE THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI SHORES, FL 33138 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 305-756-8972 J� J%%.Vw w tcuvmv-1/ w CEJ TWtFwAW V At:UKU ( KKMATION. All nglls reserved. The ACORD name and logo are reglsWW marks of ACORD Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner —Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, youmay be personally liable for the worker compensation injuries of any person allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Contractor Print Name: Print Name: Signature: gn � Signature: State of Florida) State of Florida) County of Miami -Dade) County of Miami -Dade ) Sworn to qnd subscribed before me this Sworn to and subscribed before me this day of , 201V- day of f cr ale 2 V , 201_ _. (SEAL) 1141 N1 NO W' a of Mr COMMISSION i# EEI