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PT-14-1751Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-217673 Permit Number: PT -8-14-1751 Scheduled Inspection Date: August 26, 2014 Inspector: Rodriguez, Jorge Owner: DOWSON, A DAVID Job Address: 454 NE 93 Street Miami Shores, FL Project: <NONE> Permit Type: Paint Inspection Type: Final Work Classification: Addition/Alteration Phone Number Parcel Number 1132060140190 Contractor: MAIRES PAINTING CONTRACTORS INC Phone: (786)399-9042 lsunamg uepartment comments PAINTING EXTERIOR INSPECTOR COMMENTS False Passed Inspector Comments Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. August 25, 2014 For Inspections please call: (305)762-4949 Page 21 of 39 Miami Shores Village RRC Building Department AUG 10050 N.E.2nd Avenue Miami Shores Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 L _ PAINT Master Permit No, 1(4- I � � PERMIT APPLICATION Sub Permit No. JOB ADDRESS: AnE �� S/— City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO OWNER: Name (Fee Simple Tenant/Lessee Name: Email: ,l ped hone#: � v .e CONTRACTOR: Company Name: A# i2 6's &I A )1 ii 0 C�0' 4- Phone#: 7R6'3 91-90 4'0 Address: 315 / S %A.� 2 -7 4,& OJ "I - City: d Q State: Zip: .3 1 Qualifier`Name: � l i� Fd I ��M I ry Phone#: State Certification or Registration #: Certificate of Competency #: ®f 5 0c) I F Value of Work for this Permit: $ r Square/Linear Footage of Work: Description of Work: I I\J 1 v C 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, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, l' HEATERS, TANKS, 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. r Permit Fee $ CCF Fee $ Notary $ _ Technology Fee $ Training/Education Fee $ Double Fee $ TOTAL FEE NOW DUE $ 4;-S -2-6 PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be painted DIRECTIONS: Please circle corresponding number to appropriate color sample. Walls: 2 2 3 Fascia: n 2 3 4 4 Drip edge: � 2 3 4 3 4 Soffit: n, 2 3 4 Flower Bins: 1 2 3 4 Shutters: 1 2 3 4 Awnings: 1 2 3 4 Chimney: 1 2 3 4 Doors & Jambs: 1 2 3 4 Garage Doors: 1 2 3 4 Railings: 1 2 3 4 Fences: 1 2 3 4 All Brick: 1 2 3 4 Stucco Bands: 1 2 3 4 Other Stucco Feature: 1 2 3 4 Accessory Bldg: 1 2 3 4 Attach color sample with name and number 1. 2. /Y 3. 4. w OWNER'S AFFIDAVIT: I certify that all egoing information is accurate and that all work will be done in compliance with all applicable laws regulating onstructio o ing. U � Signature Signature / " g g 0 WNPk or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of me or who has produced 20 , by who is personally known to identification and who did take an oath. NOTARY PUBLIC: ad RUTH A. PALIVIIERI MY COMMISSION # "042046 EXPIRES: Septm*w 02, 2017 Sign: I Print:° `^ APPROVED BY: as _0 day of "Q V , 20 ( � , by 11 1 fwLr-1..N t f AAM 1 i-,! Why personally known to me or who has produced VL� as identification and who did take an oath. NOTARY PUBLIC: 0�����sioiiuuui°j� Sign: Print: Seal: ....... Code Official Historic Preservation Board PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE — — — — — — — — — — — — — - - I- — — — — — — IMPORTANT — — STATE OF FLORIDA I Pursuant to Chapter 440.05(14), F.S., an officer of a corporation DEPARTMENT OF FINANCIAL SERVICES who elects exemption from this chapter by filing a certificate of DMSION OF WORKERS' COMPENSATION F election under this section may not recover benefits or CONSTRUCTION INDUSTRY EXEMPTION `'�o„re 10 compensation under this chapter. CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA I L Pursuant to Chapter 440.05(12), F.S., Certificates of election to WORI(EW COMPENSATION LAW D be exempt... apply only within the scope of the business or trade EFFECTIVE DATE: 11/6=13 EXPIRATION DATE: 1 tr5rmt5 I listed on the notice of election to be exempt. PERSON: RAMIREZ MAIRENI I H Pursuant to Chapter 440.05(13), F.S., Notices of election to be FEIN: e5ttlr�T33 E exempt and certificates of election to be exempt shall be BUSINESS NAME AND ADDRESS: R subject to revocation if, at any time after the filing of the notice MAIRE'S PAINTING CONTRACTORS IN I E or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this 3161 SW 27 LANE section for Issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the MIAMI FL 33133 I certificate to meet the requirements of this section. I SCOPES OF BUSINESS OR TRA I 1PAINTING NOC & SHOP OPERATIONS DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 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, you may 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. State of Florida) County of Miami -Dade) t Sworn to and subsc 'bed before Tes day of , �0. an Contractor Print Name: A C.— 1_� Signature: A'1 (2 r -LE -N I Q -Ary-%% RR_Z State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this day of AuUur ,201� 0 (SEAL) " ff 4M rgSTATE OF FLEA (SEAL) Type of Identification produce . _ . Co mm# FF042635 Type of Identification wa SEC. TSP Q (3 T$1NESSUu 4YMEI p,��' INC NTING CONORS p 96 BUILD�Iv TAX 0iRCfOR x#5.00 lz- 4 IBS s Local �ti' iris Tax mit, or a6V , kation iongoverrmehtal regi The RECEIPT NO at ,only con'Ihe Local Business ilder's quircati�ii`busmess t1 gws and r' uiremerch applyj�. 3t he dispY -ad on all commercialJAM W, pore infor�asrbn, visit www mramtl�� F13 23-130080 ¢eipt i0 of a license, with airy governmental tU ,. Code Sid,'8° 36.... 08/1112014 15:33 #0127 P.001/001 tlulxrcawYY) ® A4CCM0 CERTIFICATE OF LIABILITY INSUI�!►NCE DATE 08/11/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP ON THE CERTIFICATE HOLDER. THIS l CERTIFICATE DOSS NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THIS COVE' AGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE 130ES NOT CONSTITUTE A CONTRACT BETWEEN THE SSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. - IMPORTANT! If the certificate homer is an ADDITIONAL INeuREA, the poncy(tes) must be endorsed. ff SUBROGATII 1$ Is WAIVED, subject to the terms and condldorm of the policy, certain policies may require an endoreement. A statement on this certificate c c is not Confer rights to the certificate holler In ueu of such endorsement(s), PRODUCER All Casualty.Insurance of Naples 5425 Golden Gate Pkwy. Suite #8-E Naples, FL 34116 Phone (239)348.7779 Fax (239)348-7713 INSURED MAIRE'S PAINTING CONTRACTORS, INC 3151 SW 27 Lane MIAMI, FL 33133- (786) 399-9042 INSURER E r (239)348.7779_ lir- Ne:- (239)348-7713 INSURER(S)AJ�E' RDMGCOVK"E _ ASCENDANT INSL i ANCE CO COVERAGES CERTIFICATE NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED P INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEF EXCLUSIONS AND CON13MONS OF SUCH POLICIFS..LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS A _ TYPE OF INSURANCE GENERAI- I -IML ITY ® COMMf=RCW- GENERAL LIABILITY ❑ ❑ CLANS -MADE © OCCUR ❑ •- ID GEML AGGREGATE LIMIT APPLIES PER; © POLICY ❑ P�C ❑ LOC AUTOMOBILE OAdlt-nY ❑ ANYAUTO GL -43382.0 ❑ SDS IEP t•-1 SOSULED El HIREDAUTOS' l❑•J AUTO eNUI El ❑ UMBRFI W LIAR ❑ OCCUR — ESS UAS ❑ CLAIMs.NInDE Q giEr) U RETENTION WOrtKEFtB COMPENSATION ti •� .. ANO EMPLOYERS' LIABILITY YI N OFFICeRR(PMEMBFR D(�CI�UOE Gtn 1NIAl 11 /09!2013 111/09/201 QESCNFnON OF OPERATIONS ( LOCATIONS I VENOM (Auech ACORD 101, A44111enal Remado Sepedrds, If nmre' apace to roquiroe PAINTING INTERIOR AND EXTERIOR CERTIFICATE HOLDER MIAMI SHORES VILLAGES BUILDING DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 FAX 305-758-8972 ACORD 25 (2010105) QF CANCELLATION MED ABOVE FOR THE POLICY PERIOD - MENT WITH RESPECT TO WHICH THIS .IN IS SU13JF-CT TO ALL THE TERMS, I IN9TS EACH OCCURRENCE _ 50O 000.00 DAMAGE TO RENTED -- 1158nemL— 100,000.00 _ MED EXP (Anv one Damen) $ 5,000.00 PERSONAL & ADV INJURY S_ 500,000.00 GENERAL AGGREGATE s 500,000.00 PRODU4TS . COMP/OP AGO S 500,000.00 C MEIN D INGL£ LIMIT OOOILY INJURY (Por person) S BODILY INJURY (Per ucWdentl, $ P OPE Jw; $ EACH OCCURRENCE L $ AGGREGATF $ S ❑ WC STAri1- OTH- 8ff2fS_El ER E,L EACH ACCMMT $ E.L. DISEASE - EA EI APi.0YE ; S P.L 018EME -POLICY LIMIT S , it 1 SHOULD ANY OF THE ABOV I DESCRIBED POLICIES BE CANCELLED BEFORE THE FXPIRATION DATE THE I EOF. NOTICE WILL RE OF_LIVEREP IN ACCORDANCE WITH THE P( I JCY PROVISIONS. /' "' AUTHOWWD 0 l 88 -201(i ACO ORATION. All rights reserved, The ACORD f; Ime aft logo are registered //larks of ACORD