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DS-13-2284BUILDING 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 FBC 20 Master Permit No. DS ` ` 2 -2 - Sub Permit No. 0BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL ❑ PLUMBING [—]MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: Com: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes N0_X _ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder),:{ �.� Phone#:® Address: `3 43- `� '3 ' City: 04 14. (o r� %jd „e S State: � �' Zip: Tenani Email: CONTRACTOR: Company Name: ���.-ti (-2U C c�N'Gk+� /��r %0 Phone#: Address: D 0% 0 S V✓ - City: D1 /�- y State E L Zip: /1 P Qualifier Name: ��M a,c16Phone#: State Certification or Registration #: T/`Zr (VE Certificate of Competency M DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 41tI � i?dr2:9 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration, g� � ,^New EQ Repair/Replace- El Demolition Description of Work: V fie, En,4 `�Y,l®c � d, V� L z i , ,' ITI Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews S (Revised02/24/2014) Double Fee $ Bond $ 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 Zip w° 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 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 seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature 10000 OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The f regoing instrument was acknowledged before me this dayof 20 by day of , ` 20 , by wh ' ersonally kno to JAIM d /'Or""who is pe II know me or who has produced as (: or who has produced identification and who did take an oath. identification and who did take an oath. as NOTARY PUBLIC: NOTARY PUBLIC: \\\e\\ en������s/� '�i'Z. '''. ,ass y°p°Uioo John 13ryan Nu>gen • M Sign: Sign: oma: commiSS100EE831664 Print: Print Seal:c�mVi l _ Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Term NQS — �3 ?- -2-� 4 f; Whe1's Name .(Fee: Simple We Holder): Owner's Address: ,� a City: t 6 re 5 Job Address (Of where work is being done): - City: ---->( Miami one):_City:Miami Shores State : E /-- State:_Florida Zip Code:, .5� Lf Contractor's Company Name: sol - 1 �c dh �o � Phone #: 6 •3C2-6 140 Address: 110 S' w (CW Nye City: � �,r-%. State: Zip Code: 33 q Qualifier's Name: Js4ir" 4e!%d Lic. Number: iE e%20 (JO—q.-61 Architect/ Engineer of Record Name: Phone M Address: City: State: Zip Code: Describe Work: I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the lama Shores harmless for all legal i Signature Signature ��'orjAgent The foregoing trument was aknowledged before me The foregoin this day of 20 ('�,by Y'" �2'J this Wh to me or who has produced e"ificafioi \ eir1 Nota t Public: coi ° '3 Sign: J> ;s 5881:` all e ee R I who r orArch00 stru ent was aknowledged before me of 2014y F.�k r��, me or who has produced as indenti8cdon. Notaryfu " ° John Bryan Nugen Sign:' cobiss!6:,; EE831664 IKES: SEP 03,2016 Seal: 'o,,�oU �°@•• WWW.AAHONNOTARYam 5--7- Lei -^-l e Q' lee ®-..� W13 Notary Pt+blia State of Florida Joanna M Feliciano y Commission FF n92753 C� -- w Expires0+rt2r?niq. Vy Local Business Tax Receipt Miami—Dade County, State of Florida THISIS NOTA'BILL—DO NOTPAY B ISINESS NAME/LOCATKM RWEWT NO. E'�CPIt WMiTECH CONI M& RaaEwai SEP BER PAV M ENG NEER NG 611M C 611M 890!. W 128 AVE ands``t rirsp[eyea ' -' Ptrrs/JaetCoCo MIRML FL 33184 C6,'IA-` A A OWNER SEC_ TYPE OF BUSINESS SOMI TECH CO NCRffE & PAVING 1 PAYMENT SPECK�r BY TAX at 'ENGINEERING Workers) 1 E06014 � CT 4228-14 ( This Local Besiness Tax Receipptonly con5tms payment oithe Local Bns om Tax.Tha permit.or a:certification ofthe fielder's quali6catioss,to do business. Holder must comp or uoagoveumental regulatory laws and requirementsw6ieh apply to the hesiaess. The RECEIPT N0. above mart be displayed an a8 commercial vehicles—Miami-0a Farmers information, vWtvv�n w.miamidade,gavRaxeollec tef 13 Receipt is site license, 4 with any governmental de Code Set 8a-276, Municipal Contractor's Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY CC NO: E0601099 BUSINESS NAME/LOCATION SOMI TECH CONCRETE & PAVING ENGINEERING INC 890 SW 128 AVE MIAMI, FL 33184 MC RECEIPT NO. EXPIRES NEW BUSINESS SEPTEMBER 309 2014 7453492 Must be displayed at place of business Pursuant to County Code Sec 10-24 OWNER TYPE OF BUSINESS SOMI TECH CONCRETE & PAVING SPECIALTY ENGINEERING CONTRACTOR Restricted to City of Miami Shores MIMID For more information, visit www.miamidade.gov/taxcollectoMEr PAYMENT RECEIVED BY TAX COLLECTOR 18.75 08/19/2014 0228-14-008252 CERTIFICATE OF LIABILITY INSURANCE DATE0MMIDO4 NYYY) 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 INSURERS?, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If 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 D'Gonzale2 Insurance Agency, Inc 2711 S.W 137 Ave Suite 77 CONTACT d onzalez NAME: aYse 9 M.PHON c : (305) 225-6283 1 (FAAIXCNo)' (305) 225-6022 EIL DDR daysegiez@faol.com INSURERS AFFORDING COVERAGE NAIC # Miami, FL 33175 INSURER A: Endurance american specialty, ins. Comp Phone (305) 225-6283 Fax (305) 225-6022 INSURED INSURER B: INSURER C: somi-tech concrete & paving engineering inc INSURER D: 890 SW 128 Ave INSURER E: Miami, FL 33184 (786) 360-0140 AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AALQOSWNED ❑ SSICHHE LED ❑ HIRED AUTOS ❑ AUTO NED ❑ ❑ 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. LMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTR TYPE OF INSURANCE ADSL UBR POLICY NUMBER POLICY EFF MMIDPOLICY EXP LIMITS A GENERAL LIABILITY O COMMERCIAL GENERAL LIABILITY O ❑ CLAIMS -MADE O OCCUR y 140306 05/27/2014 05/27/2015 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED 100,000.00 PREMISES a occurrence $ MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: El POLICY ❑PRO ❑LOC PRODUCTS - COMP/OP AGG $ 1,000,000.00 CONTRACTUAL LIABILIT $ 1,000,000.00 AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AALQOSWNED ❑ SSICHHE LED ❑ HIRED AUTOS ❑ AUTO NED ❑ ❑ COaccid n SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P OPER cc, tDAMAGE $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION❑ AND EMPLOYERS' LIABILITY Y / N ANY PROPRIErOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) El If yes describe under DESCRIPTION OF OPERATIONS below N I A WC STATU; El OR - LIM E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) driveway,parking area or sidewalk -paving or repaving The Florida international University Board of Trustees, Florida international university, The state of Flodda,The Florida Board of Governors, and their respective trustees, directors, of oers,employees and agents are additional Insureds CERTIFICATE HOLDER CANCELLATION ©1011010 AGGRI�CORPORAT(ON. All rights reserved. ACORD 26 (2010/06) QF The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Bldg Dept THE EXPIRATION DATE THEREOF, NOTIC BE DELIVERED IN ACCORDANCE WITH THE POLICY P S. 10050 NE 2 Ave Miami Shores, FI 33138 AUTHORIZED REPRESENTATIVE ©1011010 AGGRI�CORPORAT(ON. All rights reserved. ACORD 26 (2010/06) QF The ACORD name and logo are registered marks of ACORD STATE OF FLORIDA DIVISION OF WORKERS' COMPENSATION BUREAU OF COMPLIANCE EMPLOYER EXEMPTIONS REPORT Employer ID: X00014381 FEIWSSN: 205015637 Name: SOMITECH CONCRETE & PAVING ENGINEERING Street1: 890 SW 128 AVE Street2: City: MIAMI State: FL Zip: 33184- First Name 751 Last Name SF Title Effective Date I Expires/Revocation Date Form Type �N • • • - MOLE AUG 19 ay. of Wftw com avig , 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 maybe 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 Print Name: o ,v Signature: State of Florida) County of Miami -Dade) Sworn t and subscribed before me s day o , 20 i By (SEA'), JEAN M UMM TvpeofIden t y odIMISSIONtFF094067 Print Name: Signature: Contractor State of Florida ) County of Miami -Dade) Sworn to and subscribed before me this day of —, ,20h3 7111, .\���lllunnrNr� Arlo z=e ;��M AB9dtrP1111111 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 EFFECTIVE: 10/03/2013 EXPIRATION DATE: 10/03/2015 PERSON: FRANCISCO SOMOHANO FEIN: 205015637 BUSINESS NAME AND ADDRESS: SOMITECH CONCRETE & PAVING ENGINEERING INC 890 SW 128 AVE MIAMI, FL 33184 SCOPE OF BUSINESS OR TRADE: 1- CONCRETE OR CEMENT WORK - FLOO IMPORTANT OPursuant to Chapter 440.05(14), 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. Pursuant to Chapter 440.05021, F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E 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 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 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-200756 Scheduled Inspection Date: October 08, 2014 Inspector: Rodriguez, Jorge Owner: NUGEN, JOHN Job Address: 375 NE 99 Street Miami Shores, FL 33138-2436 Project: <NONE> Permit Number: DS -10-13-2284 Permit Type: Driveways/Sidewalks/Slabs Inspection Type: Final Work Classification: New Contractor: SOMITECH CONCRETE & PAVING ENGINEERING INC comments NEW DRIVEWAY Passed Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Phone Number Parcel Number INSPECTOR COMMENTS False Inspector Comments PERMIT WILL BE POSTED INSIDE THE MAIL BOX 1132060135530 Phone: (786)380-0140 October 07, 2014 For Inspections please call: (305)762-4949 Page 2 of 25 D.+v44A'Y '_' (� ft_""" Miami Shores Village Building Department 10050 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 Permit Type: BUILDING JOB ADDRESS: `3 / S Permit No. FBC 20 Master Permit No.VS_ — ZZ -01 - IZIZ1I"L City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11 J 7106d13J-5-7 Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple I Ssti,,,L,/ Tenant/Lessee Name: Phone#: Email: b rGr ( 'I lam✓ ,"� 1 �1 �U CONTRACTOR: Company Name: 60L0 i',Fa':,66�' Igk ,� (��.c�S1Uc Phone#: ZOS- c / Address: 1 Zgn an cid" City: *,A � _®ry.� i State: 7-L Zip: M Z Y i % Qualifier Name: to i C,J 2: t, -A . �' - b'nP9 H ® Phone#: State Certification or Registration #: c', e, en- 1 L1 5 C.'7 7 r-1 Certificate of Competency #: Contact Phone#: 30S ., ZZZ-. 22_;_ -ea Email Address: ) 6-11 00 T7 . 1i0_ DESIGNER: Architect/Engineer: °' Phone#: ti Value of Work for this Permit: $13 .04�2 Square/Linear Footage of Work: R00 0 Type of Work: DAddition OAlteration _ ONew URepair/Replace LIDemolition Description of Work:- ` _ 1-4 _w Color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ CCF $ CO/CC $ DBPR $ Bond $ Notary $ Training/Education 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) �L/ / , 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 seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not bproved and a reinspection fee will be charged. caner or Agent The foZ6,20 ment was acknowledged before me this 30 day of r> by li1`f N)06& , who is personally known to me or who has produced I�l� As identification and who did take an oath. NOTARY PUBLIC: ����� � 1133 ••' • d' �''� Sign: ZZ,RIM U6ISSIWWO'J Print: = a119(Id My Commission Expires: cc \� APPROVED BY The forego' instrument was,\acknowled ed11 before me this -3 day ofU� , 20IL3, by IISJC.I .Y who is personally known to me or who has produced Plans Examiner Structural Review (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) as identification and who did take an oath. NOTARY PUBLIC' \0\j1111111JOIJI ere Sign: Sign: Print: My Commission Expire3,�� WZoning Clerk 4 2013 a� SUti„ iI C; Vdrll 1 ALL f=EDER ry 1 EXISTING PAVERS 21-111 -0 ' 1J112Cfnj® C) ® M NEW PAVER 4f 814 S.F. N � Y,,,.�. O CV 5'-0" 51-011 51—�11 3 � , % �p 1 �a O NE 99 ST DRIVE WAY DIMENSION 1/811=1 WALKWAY IS PART OF POOL DECK at J-ec-e1; A minimum of two 12ft shade trees must be present in the parkway/swale for each 75 feet of frontage in order to pave any portion of the parkway/swale. The adjoining property owner proposing to pave a portion of the parkway/swale shall plant sufficient shade trees approved by the public works director to meet the minimum requirement.