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DS-13-1803Miami Shores village "Building Department 90050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 6D Permit No. Master Permit NoD 51 � I Permit Type: BUILDING ROOFING JOB ADDRESS: / -33 0 1&7 a P City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): ' -� A a i � � Phone#: 3 �� - � • � `�� �!� Address: Aa 6 City: State: Tenant/Lessee Name: cto I • ,0 Email: 6 -'777 --716 J CONTRACTOR: Company Name: 7? COS (3 V1 t,7 "S C-COLP , Phone#: 3 d J • <31®. , j �,��f Address: k?10q N%4-) (S -t4 S! *'�'Z.I Z - City: _ `t /� c --t KG,S State: Zip: T 3 ®I & Qualifier Name: ` S 7 -EW- 2) £--8 S Phone#: _34-05,30.4 P7 State Certification or Registration #: C& - ID 13 Certificate of Competency #: Contact Phone#: 306. 7 /! 6 ,S1 319 DC.& j Byj iAg-s . coy-% DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $_TQa Square/Linear Footage of Work: Qb Type of Work: UAddition L3Alteration ANew ORepair/Replace ODemolition Description of Work: Color thru tile: t44jy-1 Comr$ - $-.ice G ju Ta'A . CAIn}- j Submittal Fee $ J ° Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ 471 1 01 znk TOTAL FEE NOW DUE $ • Bonding Company's Name (if applicable) Bonding Company's Address City State 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 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 se n (7) days after the building permit is issued. In the absence of such posted notice, the inspection w' no a approve a ret pection fee will be charged. Signature '��"'� Signature Owner or Agent [/ Contractor The foregoi g instrument was acknowledged before me this 2 T The foregoing instrument was acknowledged before me this, day of , 20 -L3,by Ma ri a "T An %n • , day of v f- , 2012, by L—L sTIEA� Z? fg who is personally known to me or who has produced wh!i�was to me or who has produced As identification who cq Y entification and who did take an oath. NOTARY PUBLIC: NOTARY F'USUC "STATE OF FLORIDA -' G=m# EE Sign: g�� Iree 10/21/2014 Print: 6 r1G My Commission Expires: 10 C'Z t 1 Z-0 4 DAVEWA L AFNSTRM —CCOtAMOWEE1 My Commission Expires: �Ib�t� �x��x•a�x��xx��x�a���x��x�+xx��x•����n��a��x�x��xx������n�m�*x�m�x�xx�x�x�����xx��x��xm�x�xx�����x���x��x����x�xx��x��xx�x��xx��xx��x���a��x�x��ux��xa�u��xx�a��xx��a����x�x APPROVED BY�> Plans Examiner Zoning r° Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Reviwd 3/15/09) 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. A. v COPY OF QUALIFIER'S STATE LIC CARD B. �OPY OF LOCAL BUSINESS TAX RECEIPT C. CQPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) 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: P s 8 LI ! t -p 5 C_� fe-p BUSINESS ADDRESS: 00'-1 AJ"-) 15'115 % CITY STATE ;eL ZIP CODES BUSINESS PHONE: ( O�)y FAX NUMBER () CELL PHONE () QUALIFIER'S NAME: L r- 57y -n- 0 sa _��_ QUALIFIER'S LIC NUMBER: C- &- G l y ! " E-MAIL ADDRESS (IF APPLICABLE): Z- c'STe'tz • Dta-S e ®6,0S 13 U 11, . co" Created on 3119109 BY MLDV 1 RV 3126109 MLDV • s � 1 1 10-18-2011 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 10/18/2011 PERSON: DESS FEIN: 272239854 BUSINESS NAME AND ADDRESS: DESS BUILDERS CORP 8601 NW 16 STREET HOLLYWOOD FL 33024 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED GENERAL CONTRACTOR EXPIRATION DATE: 10/17/2013 LESTER IMPORTANT. Pursuant to Chapter 440 . 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election ander 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 scopeof 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 atter 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 0 EFFECTIVE: 10/18/2011 EXPIRATION DATE: 10/17/2013 PERSON: LESTER DESS FEIN: 272239854 BUSINESS NAME AND ADDRESS: DESS BUILDERS CORP 8601 NW 16 STREET HOLLYWOOD, FL 33024 SCOPE OF BUSINESS OR TRADE: 1- CERTIFIED GENERAL CONTRACTOR IMPORTANT 0 Pursuant to Chapter 440.05(141, F.S., an officer of a corporation who 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. H 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 Rthe notice of election to be exempt 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. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 AC# 6:22391-1 DE STATE. OF FLORIDA GOVRRNOR 3f :3 �YJAW �LREGUL"-TION B SEQ#L12072401035 FJM LAWSON SECRETARY LICENSE; NBR.,,,,* 071.24/a. 012, 1CGC15 1877 The .GENHRAL CONTRACTOR ny Named below IS CERTIFIED Under the provisions of Chapter !'0#'ft Expiration date: AUG 31, 2014* DEB S, LESTER DEBS BUILDERS CORP. 1p 8004 NW 154TH ST #212 MIAMI LAKES PL 33016 RICK SCOTT GOVRRNOR 3f :3 �YJAW �LREGUL"-TION B SEQ#L12072401035 FJM LAWSON SECRETARY ACIORtf CERTIFICATE OF LIABILITY INSURANCE DATE o1D� 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: N the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, 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 Patr(aa Fernandez NAME: PHONNo.E Ext : (30 5) 956-7818 FAX No): (305) 9W5946 Assure -US, Inc. patricia@assureus.us 1880 NE 163rd Street INSU 8 AFFORDING COVERAGE MAIC 0 North Miami Beach, FL 33162 INSURER A: Markel (Essex Insurance Company) Phone (305) 956-7818 Fax (305) 956-5946 INSURED INSURER B: INSURER C: Dabs Builders INSURER D : 8004 nW 154th Street Suite 212 INSURER E: Miami Lakes, Fl. 33016 305 310-5939 INSURER F: 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 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 ADD UBR POLICY NUMBER POLICY EFF POLIO EXP LIMITS A GENERAL LIABILITY © COMMERCIAL GENERAL LIABILITY F-] ❑ CLAIMS -MADE 0 OCCUR F-1 2265480 04119!2013 04/19/2014 EACH OCCURRENCE $ 1,000,000.00 PREM SES TOGE RENTED r arca $ 100,000.00 MED EXP (Any one person $ 5,000.00 PERSONALN PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY © PRO- ❑ LOC PRODUCTS - COMPIOP AGG $ 1,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS NON -OWNED ❑ HIRED AUTOS ❑ AUTOS ❑ ❑ �Dt INGLE LIMB $ O eBIINccl BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PROPER77yy DAMAGE $ Peracadent $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LLAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y! N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) El If yes describe under DESCRIPTION OF OPERATIONS below N 1 A ❑ WC Y TAT T El OR - E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DES"ON OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace is raquired) CERTIFICATE HOLDER CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) QF The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Dept THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE Miami Shores, Fl. 33138 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) QF The ACORD name and logo are registered marks of ACORD C. v 781.63' ell - 105TH STREET*:*;,`-,-*-'-:'-:--. 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F.P.&L 9 ^LL!WP(UPA MilLQ. D CQNC. PA' 1.81 CONJ 200.009 SEAWALL BISCAYNE CANAL (75' RIGHT—OF—WAY) WITS] u%_ z LO m ft 0 Lo r to T_ ,Qgl -9.98' AUG 0 8 2011 SET NAIL AND DISC #5734 o/s 1.00*(N) f- SCALE: I" = 30' I SKETCH NO.: 11 -0870 DRAWN BY: Q.D.I. SIDE 2 OF 2