DS-14-1900Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-222318 Permit Number: DS -8-14-1900
Scheduled Inspection Date: October 28, 2014 Permit Type: Driveways/Sidewalks/Slabs
Inspector: Rodriguez, Jorge
Owner: HOLT, JAMES
Job Address: 361 NE 97 Street
Miami Shores, FL 33138-0000
Project: <NONE>
Contractor: STAR ISLAND CONCRETE DESIGN CORP
Building Department Comments
Inspection Type: Final
Work Classification: Addition/Alteration
Phone Number
Parcel Number 1132060135760
Phone: 305-253-5151
CREATE A PAVER DRIVEWAY AND THE APPROACH- -_ __......_.._
INSPECTOR COMMENTS False
Passed
Failed
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP-218834. No permit posted
October 27, 2014 For Inspections please call: (305)762-4949 Page 28 of 35
BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
❑BUILDING ❑ ELECTRIC ❑ ROOFING
v �1
AUG 2 8 2014
FBC 20 Lam'
Master Permit No. -05 I` -A — 19
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL XPLIBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 36 I w E 9-14""' SE
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): h'tt RP_J`lol 12A?-6�496A W L T Phone#:
Address: AJE 91"A 1547
City t1lami !�;;twPeS State: O ri a Zip: l t�
Tenant/Lessee Name:
Email: roarftt.aGt.tcia if\tee_J e-aJocorr
CONTRACTOR: Company Name: s T CA,:,C 1 SO atK' Cj20f nate- eS U) Phone#: be4 36-7-4-7),X
Address:
515 WW �A C -
City: 1- `\ axn k' State: r—L Zip: �S3 1 S
A -
Qualifier Name:
Ili 1
State Certification or Regd
istration#: �.0
of Competency #: Ec'�LO \ 9 03
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 14,500 Square/Unear Footage of Work: S®o
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: nre 0°r&t ay&A colt",ye,(A"243J 4+,,e ;2 pio 6-o cP,�A
Specify color of color thru tile:
Submittal Fee $Permit Fee $ � � CCF $ ' CO/CC $
Scanning Fee $ Radon Fee $ CD C) DBPR $ Notary $
Technology Fee $_ �f
Training/Education Fee $ �•®0 Double Fee $
Structural Reviews $ Bond $ .'�� -
00 at(j1*'vj X4
4 - «0,5 vpt/ 4 9/ ed CCAs TOTAL FEE NOW DUE $
(
(Revised02/24/2014) � 29 LVJ
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
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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 an
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issue 1n the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. Al
� 6 '
Signatures Signatur
OWNER or AGENT CONTRA OR
The foregoing instrum t was acknowledged before me this The foregoing in i nt was ac k wledged before me this
day of /� x_120 % L . by day of 20 by
r (9- who is personally known to who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBL NOTARY PU 3I,l ;; CARLOS RAUL CORPAS
MY COMMISSION # EE 827816
" PIRES August 16, 2016
Sign: 'Sign: ' .11
-PL'gtt: k-Tf 4 Print:
S ai Seal:
LA
RUTH A. MASH
Notary Public - State of a -*
My Comm. Expires liar 2C'billiSi9$i�fiSif r*xeemulmtTt NaU W _
/o
13Ya Plans Examiners ® / Zoning
Structural Review Clerk
(Revised02/24/2014)
CTQB
Construction Trades Qualifying Board
BUSINESS CERTIFICATE OF COMPETENCY
E201903
STAR ISLAND CONCRETE DESIGN CORP
D.B.A.:
Is certified under the provisions of Chapter 10 of Miami -Dade County
'^coRvINSURANCE
�..-
1 IN URAN E
o8/29M�4
PRODUCER Chaplan & Castro Winance
2552 NW 7 Stmt
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO MGM UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Miami, FL 33125
ALTER THE
CPVERAM AFFORPED BY THE PO MOW.
INSURERS AFFORDING COVERAGE MAIC #
Phow (345)541-4009 Fax (305)849-1513
INSURED STAR ISLAND CONCRETE DESING CORP
INSURER A: GRANADA INSURANCE CO.
815 NW 24 CT
MIAMI .FLORIDA 33125
INsuRER W.
INSURER C.
_
INSURER D:
INSURER E:
J
COVERAGES
INSURER F.
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERS 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 PAIN CLAIMS.OM
offimAMM
TYPE OF B,ISURANCE
POLICY NUMBER
DATE (WAONM
OAT9
LIMITS _
GENFRALUARKM
EACH OCCURRENCE 1 1,000,000
® COMMERCIAL GENERAL LIABILPT1f0185FL00052004
08/14/14
08/14/15
PREMISES 1x0,000
MED EXP &W one per) 5,0x01
A
❑
❑❑ CLAIMS MADE ® OCCUR
❑
PERSONAL & ADV INJURY 1,000,0001
❑
GENERAL AGGREGATE 2,000,0001
GM AGGREGATE LIMIT APPLIES
❑ POLICY ❑ PROJECT ❑ LOC
PRODUCTS - COMPfOP AGG 2,000,0000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
❑ ANY AUTO
(Ea
j
BODILY INJURY
❑
❑ ALL OWNED AUTOS
❑ sCHEDULED Auras
BODILY INJURY
atClde
❑ HIREDAUTOS
❑ NON OWNED AUTOS
❑
PROPERTY DAMAGE I
owa=bwm _{
El
GARALGE LIABILITY
AUTO ONLY - EA ACCIDENT j
OTHER THAN EA ACC _ I
❑
❑ ANY AUTO
El
ONLY: AGG
AGG
LSSAMERELLALUUML17Y
EACH OCCURRENCE
AGGREGATE
❑
❑ OCCUR ❑ CLAIMS MADE
❑ DEDUCTIBLE
❑ RETENTION S
WORKERS COMPENSATION AND
❑ ❑
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT '
ANY PROPRIETOR I PARTNER I EXECUTIVE
E.L. DISEASE - EA EMPLOYEE
OFFICER I MEMBER EXCLUDED?
I fres, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
a
OTHER
DESCRIPi10N OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT
I SPECIAL PROVISIONS
DRIVE, PARKING AREA OR SIDEWALK - PAVING OR REPAVING
�
I
!CONTRACTOR'S UCENSE # E201903
'
CERTIFICATE HOLDER CANCELLATION
MIANH SHORES VILLAGE HALL
10050 NE 2 AVE
MIAMI SHORES, FLORIDA 33138
SHOULD ANY OF THE ABOVE DESCRIBED POUCMS BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIF=TE HOLDER NAMED TO
THE UIFT, BUT FMJJRE TO DO 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATiVES-
(2001108) GF 0 ACORD CORPORATION 1988
4 Report Viewer
1 10091
https://apps&fldfs.com/crreportviiewer/reportvewer asPx?daW--kdvpg...
M�
� �V* * CERTIFICATE yOF EELLECrIION TO 13E MIEMPT FROM FLORIDA WORKERS' COMPENSATION LAW •
COM RUCTIM INWSTTI G/{� n0N
TWs,oertm tliat the uKfimdual hated below has elected to be exempt It= Florida Vdarl a Cmnwmftm taw.
EFFECTIVE DATE: 8i15i2013 EXPIRATION DATE: 8/1542015
PERSON: CORPAS M1GUEL A
FEft 483407579
BUSINESS NAME AND ADDRESS:
STAR ISLAND CONCRETE DESIGN CORP
815 NW24CT
MIAMI FL 33125
SCOPES OF BUSINESS OR TRADE:
CONCRETE OR CEMENT
WORK - FLOO
1W
of
ntMWN51(850)413-1609
I of 1 10/4/201312:16 PM
TT M7 M-7
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Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 44045
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 ownerJgp;
1 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. Consiruction 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. yo maybe
gggglft liable f ton Wuries of = per= &0� to work under this owinit. Please click with your
or ft worker gm=at:—
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.
QW&
Print Name: /-64yZj,+ fP-- MCC,,* /4-4
Signature:
State of Florida )
County of Miami -Dade
Sworn to and subscribed befo
day of
Sworn to and subscribed before me this
day of 20—L4(—.
*-" ---#FF136023
MY
COMMISSION
EXpIRFS June 24, 2018
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ry