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DS-13-1408 (3)Miami Shores Village g Building Department 40050 NY -2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (303) 762.4949 FSC 20 1 i:) BUILDING Permit No. PERMIT APPLICATION Master Permit No.DS — Y 0 Permit Type: BUILDING ROOFING JOB ADDRESS: WM 301 1 C-- r 5"- -�j ir.e- cf t - city: Miami Shores County: Miami Dade Zip: I Folio/Parcel#: Is the Building Historically Defteate& Yes NO Flood Zane: OWNER: Name (Fee Simple Titleholder): J"`, nil►',CuJ I-e-,MVV—f—/ 1° an,, M6J:i6 Phone#: :-0- S leoo loci Address: 30 7 N C 3 5t- S -tweet city: Mom, .S hoc g �2 State: r:1— dip: -331:32) Tenantaxssee Name: Phone* Email: _ ncit'eeae tn 0or LGkm L �ov matt, COvv-\ CONTRACTOR: Company Name: Address: ')CI l'_ Cl W _ t 6 3)vv-i0485o City: vwnI .� zip: > > i State• Qualifier Name:t ! 'i� N /R Phone#. I -e)6 �% `�Y State Certification or Registration #: Certificate of 41cy#1 3 S 3 contact Phan#: 5 3 1 `1'��' Email Address: 1�/�M A A7"4 Lvt4ff -rc• CZ*A DESIGNER: Architect/Engineer• Phon#: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: IIAddition OAlteration QNew (]Rgir/Replace UDemolition Description of Work: ikr4kw C— Color thru tiles_ Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $. Training/Edncatiou 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) Mortgage Lender's Address Zip City State I 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 nit 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, BOH.ERS. 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 consmwtion 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 etc ung $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction Z' brochur will be delivered to the person whose properly is subject to attachment; Also, a certffl%d copy of the recorded non of c rtc t must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is the ab a of such posted notice, the inspection will not be approve¢uad a reinspection fee will be charged A A y V A N Owner or Agent The foregoing instrument was acknowle,ftW re me this day of ' No,/ (3 by �/(4-W who is personally known to me or who has produce As identification and w did take oath. RODRIGO AL MY COMMISSION t Sign: 1 Print: (4017 398 01 My Commission Expires: The foregoing instrument Nv acknowledged before me this day of NOV 20 .10 by i M` N -AA b/O fJeA, who is personally known to me or who has produced APPROVED BY `> Plans Examiner Structural Review Otev;eed 3/12M12XRev1sed 07/10/O7XRevbW 06/1011.0 XRevised 3/15/09) as identification and who did NOTARY PUBLIC: RODRIGO ALVARE Sign:��'"" •..�. : j COMMISSION #EE8!!4 4 Print: + "" ''a --EXPIRES h 14, 20 1 jyly Co • Floridallot"serolee.com �e�4a��e►ss��ea�ws�te�e��e�n�au�a��a�ffie�s►��,aeea zoning F'; 7 Miami shores Village Building Department CONTRACTORS' REGISTRATION 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 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 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: N1\N'0k-7f,, N f , BUSINESS ADDRESS: �w G &T CITY STATE �L ZIP CODE �71' `� BUSINESS PHONE: �15 �0 ��j l7 NUMBER �� ) FAX �) CELL PHONE ( ) d 163 5 4 QUALIFIER'S NAME: �A w U tjX12� QUALIFIER'S LIC NUMBER: 13 S Cb 6 40 Created on 3119109 BY MLDV 1 RV 3126109 MUNI RV 6127111 AS a Constrtion Tree B 9 g Board a.jSlN;FSS CERTIFICATE 01 -*,,GM MIAMICRETE INC t -T,*--V,lj NUN E ENRIQUE S ceplifiec under the Drovmions of Chapter 10 of Viami Dade Coult-) IA I` FOR CONTRACTING UNTIL 09/30/2u" Local Business Tax Receipt Miami—Dade County, State of FloridaLBT, -THIS IS NOT A BILL - 00 NOT PAY 5147566 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES MIAMICRM INC REQ SEPTEMBER 30, 2014 7910 SW 16 ST 537$ Must be displayed at place of business MIAMI FL 33155 Pursuant to County Code Chapter $A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS -Mlmcwm INC 196 WtaALTY BUILDING CONTRACTOR-, PAYMENT RECEIVED 03BS00653 BY TAX COLLECTOR:: Worker(s) t - $75.00; 07/11/2013 TViS1=1 -024555 This Local Business Tax Receipt only con*= paymem of the Local Bre:iness Tax. The Receipt Is note iicensa, pormit, or a eortificatiop of the holders gaal`11141�do business. Hol ed r mum comply with awf govemmeNai or nonovehuneatal regulatory [am and retpdreme* which apply to tha bgsiness. -Titi RECEIPTND.above mM til displayed on aR cwhmeroiel vahfufes- Afrrami-oade code Sec iia -276. _-T�moreintom�aiion,visiEwww.mlamidede.gav/tacoofleetor - _. ' - � _ OWNER TYC-F vK BUSINESS PAYMENT RECEIVED AJ11VJIe•CREETE INC C. ' = I C--NTrRACTOR BY TAX COLLECTOR 225.00 11/04/2013 0229-14.000381 MIAWFAM for more inSoematien,visyrwws^+,niiernidade�onitaxeoUsetor ACC�R V CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 08-12-201- THIS CERTIFICATEIS 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 ADDITIONALINSURED, the pobcyties) must be endorsed. If SUBROGATIONIS 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 NORTHEAST AGENCIES INC/PHS ICONTACT N�f FAX 866)467-8730 I c,w: (888)443-61: 210204 P:(866)467-8730 F:(888)443-6112 AM&PExt: 301 WOODS PARK DRIVE ADDRESS: CLINTON NY 13323 INSURER(S) AFFORDING COVERAGE MAIC I< INSURER A: Hartford Casualty Iris Co COMMERCIAL GENERAL LIABILITY INSURED INSURER B INSURER C MIAMICRETE INC PREMISES(Ea occurrence) I $ 300,000 7910 SW 16TH ST INSURER D _ U MIAMI FL 33155 INSURER E 08/25/2013 I MED EXP IAny one person) 1$10,000 O8/25/2014IPERSONAL &ADVINJURY 1$1,000,000 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. INSH LTR TYPE OF INSURANCE D POLICY NUMBER LICY EFF (MM/DD/YYYY) (MNI/DD/YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) I $ 300,000 A CLAIMS -MADE II OCCUR X General Liab _ U _ U 01 SBM AN2271 08/25/2013 I MED EXP IAny one person) 1$10,000 O8/25/2014IPERSONAL &ADVINJURY 1$1,000,000 GENERAL AGGREGATE s 2,000,00 0 PRODUCTS - COMP/OP AGG 5 2 , 0 0 0 , 0 0 0 GEN'L AGGREGATE LIMIT APPI IES PER: POLICY LXJ PRO- U LOCJECT $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS U AUTOS HIRED AUTOS NON -OWNED U AUTOS u u PROPERTY DAMAGE $ (Par accident) S UMBRELLA LIAO U OCCUR EACH OCCURRENCE $ AGGREGATE y $ EXCESS LIAR CLAIMS -MADE u u DEDI I RETENTION $ $ WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y / N ANY PROPMETOR/PARTNERIEXECUTIVEi OFFI CER/MEMBER EXCLUDED? (Mandatary in NH) N / a STATU• 0TH - TORY 1 T ER E.L. EACH ACCIDENT $ —'-- E.L. DISEASE - EA EMPLOYF4 $ if yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ FOESOR H TK)N 00 OP 7O S / LOCATIONS i VEHICLES (Attach ACORD 101, Additional Remarks Sd%edule. If more space ie requtrad) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2ND AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEC BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A ESENTATIVE ®1988-2010 A ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD rights reservec MIAMINC-01 MATERAT CERTIFICATE OF LIABILITY INSURANCE F° 11/1 202013 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and aonditlone of the policy, certain policy nay require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such 9 PRODUCER insurance Office of America -LNG 1855 West State Road 434 Longwood: FL 32750 NAS: PHONE�� i8�3000 ae �� 7M-7933 PDD-EgS: AFFORDING COVERAGE NArB r INSURER A: Star Ifourarm Company 18023 INSURED Mlamicrete Inc 7910 SW 16th St Miami, FL 33165 INSURER B : WSW" C: INSURER D : INSURERE: 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. LTR TYPE OF INSURANCE POLICY NUMBER Lam OENERAL LIASUlW COMMERCIAL GENERAL LIABILITY CLANS -MADE 7 OCCUR EACH OCCURRENCE $ DAIWAGE TO RENTED PREMISE nae $ MED EXP (Any am parser) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: POLICY F—IJPERC(T-LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIAgLLrry ANY AUTO AUTOS OOYMED SCHEDULED AUTOS HIRED AUTOS ASO 4 ED COMBINED SINGER LIMIT BODILY INJURY (Per parson) $ BODILY INJURY (Per eoddent) $ POS R A GE $ $ UMBRELLA LIAB EXCESS LIAR HCLARAS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ D£DI RETENTION $ $ A WORKERS COMPENSATION AND AND EMPLOYERS' LIABLITY Yf N NY APROPRIETORIPARTNERfEXECUTIVE OFFICERIMEMBEREXCLUDEDT (Llyoidstwr In NH) DESL�Rid PATIO OF OPERATIONS below N/A W OWSM OMM13 X14 TH- IITT E.L. EACH ACCIDENT $ 1,000,000 EL DISEASE - EA EMPLOYE $ t,� EL DISEASE - POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATLONS f LOCATIONSI VEHICLES (AtRaah ACORD tot, Aditanal Remoft Sotredut% I acme apace M required) Miami Shores Viflage Bullding Department 10050 NE 2 ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOtRIEW REPRRESMA1flrE &'� •' ®1880-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010" The ACORD name and logo are registered marks of ACORD Nov 15 2013 3:29PM ORONI INC 305-688-9550 p.1 NOV 1 ORONI, INC. A00fla meda company'` 0@12518 (305) 685-0412 (OM (305) 68&9350 (Fax) 14040 NW a Court Miami, Florida 33168 November 15, 2013 To: The Village of Miami Shores Public Works Dept. Ref 3 07 N.E. 99 St. Permit #DS - 13-1408 To Whom It May Concern: I would like to request permit #DS -13-1408 to be cancelled. The reason For this roquest is that we are not the contractors that the homeowner chose to do the job with. Your prompt attenti<m to this matter 1s greatiy appreciated. Sincerely, Orlando Iglesias Sr. ORONI, Inc. - President Oct a 12013 o. .o........ 4-4— LYS - 6 ` P< — m