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RC-14-1754Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-225125 Permit Number: RC -8-14-1754 Scheduled Inspection Date: December 15, 2014 Inspector: Rodriguez, Jorge Owner: , Job Address: 190 NW 103 Street Miami Shores, FL 33150 - Project: <NONE> Contractor: DOME ENTERPRISES INC dwiaing uepanment comments KITCHEN CABINETS REPLACEMENT. Permit Type: Residential Construction Inspection Type: Final Building Work Classification: Addition/Alteration Phone Number Parcel Number INSPECTOR COMMENTS False 1131010230010 December 12, 2014 For Inspections please call: (305)762-4949 Page 20 of 25 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. December 12, 2014 For Inspections please call: (305)762-4949 Page 20 of 25 BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 AUG Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 �Y FBC 20d) Master Permit No. Tom% ] 4' A 5 4 Sub Permit N BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: /9'0 '41al /,03 -5-/- 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): %te q ti to &ZP Phone#: Address: -X4 S -U if/ 4-E: 4S /i �/ i� y� /le, City State: _� Zip: Tenant/Lessee Name: e#: Email: _— 1'fcaleo j' fjmdez< L`Orss CONTRACTOR: Company Name: ,1J Z7&N0- e -/V act PSS` fPhone#: Address: C.ti City: State: r/ Zip: Qualifier Name: G✓s rig► Se �yI',# ,c/t Phone#: 3 7 If w"- y L.? Z, State Certification or Registration #: l'GC OZ Y7/cp Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit: $ �$�®o /� (% Square/Linear Footage of Work: Type of Work: ❑ Addition A Alteration ❑ New ❑ Re air/Re lace p p ❑Demolition Description of Work: ' f ��e �,P.7 Qq4, Os' lx // e pl-ne u e dj Specify color of color thru tile: Submittal Fee $ r Permit Fee $ LUV CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (Rev1sed02/24/2014) DBPR $ Notary 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 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 OWNER or AGENT The foregoing instrument was ac now a gee before me this day of 11, 20 _11K by ho is aersonoe to me or who has produced as identification and who did take an oath. NOTARY PUB '� �liba°•• Jessica Tamaw �+?CDWMN # FF 137966 DWIRES: JUL 01. 2018 Seal: Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of Jr. 7 / 20 / by /4'1 yr a 1'dl gi-Ae , who is personally known to me or who has produced as identification and who did take an oath. Jessica TamaP NOTARY PUBLIC: �; COMAdLSwN#FF137966 v•• --:EXPIRES: JUL 01, 2018 . ... eoNDec THRU •..-NOTAR% LLQ Sign: Print: v it Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Dated January 4 Zt 2013 POWER OF ATTORNEY BY RED RIVER USA LP TO TIMOTHY JAMES MARSH AND JAMES THOMAS BLACK Gibbons P.C. One Gateway Center Newark, New Jersey 07102-5310 #1897650V2 INDEX Clause Heading Page Na, 1 Appointment and Powers 2 Duration 3 validity 4 Governing Law and Jurisdiction #1887650 v2 This POWER OF ATTORNEY is granted on January 17ru , 2013 BY: (1) RED RIVER USA, LP, a Delaware limited partnership, with a registered office at c/o Corporation Service Company, 2711 Centerville Road, Suite 400, City of Wilmington, County of New Castle, State of Delaware, 19808 (herein, "Principal") TO (2) TIMOTHY JAMES MARSH, of 300 S Pointe Drive, Miami Beach, Florida 33139, and JAMES THOMAS BLACK, of 100 Jefferson Avenue, Miami Beach, Florida 33139 (collectively, "Attorney"). BACKGROUND: A. The Principal is a Delaware limited partnership (tae "Lr"). The general partner of the LP is Odyssey Venture Partners Limited Corp. B. The Principal has agreed to appoint the Attorney as its attorney-in-fact to do and execute certain documents and deeds on behalf of the Principal on the terms and conditions set out below. 1. Aupointment and Powers 1.1 The Principal appoints the Attorney as its attorney with full power to sign, seal, execute and deliver any deed or document necessary or desirable for the Principal to execute. 1.2 Each Attorney may act severally and individually in any matter. 2. Duration 2.1 This Power of Attorney shall continue until it is expressly revoked. The Principal may revoke this Power of Attorney by a writing delivered to the Attorneys in person, by registered mail or overnight mail service addressed to the Attorney at Cogent investments, 3250 NE 19t Avenue, Suite 316, Miami, FL 33137 (or such other address to which Cogent Investments may relocate) or by electronic mail addressed to jb@cogentinvestments. Com and tm@cogentinvestments.com. 2.2 If not previously revoked, this Power of Attorney shall cease to be effective on the dissolution of the LP. #1887650 Q , 1 , 3.yalidit The Principal declares that a person who deals with the Attorney in good faith may accept a written statement signed by the Attorney to the effect that this Power of Attorney has not been revoked as conclusive evidence of that fact. 4. Governing Law and Jurisdiction This Power of Attorney (and any dispute, controversy or proceedings or claim of whatever nature arising out of or in any way relating to this Power of Attorney or its formation or any act performed or claimed to be performed under it) shall be governed by and construed in accordance with the laws of the State of Florida, and the Principal submits by executing this Power of Attorney, and the Attorney submits by purporting to act under the terms of this Power of Attorney, to the exclusive jurisdiction of the courts in the State of Florida This instrument may not be changed orally. IN WITNESS WHEREOF, on behalf of the Principal,) have hereunto set my hand and seal this. N Al- day of January, 2013. Signed, Sealed and Delivered VERB m RR MYCOMM"Mus t X%M6 116e.( 0M. Principal: Red River USA LP By Odyssey Venture Partners Limited Corp. Its General Partner By: -?. a-92" Name: 54 r ,ck,, Title: 122A s Witness (�- 2ac�s✓2 S \ Address Witness 4 16 Address #1887650 v2 [ATTACH UK NOTARIAL ACKNOWLEDGMENT AND APOSTILW 41887650 v2 ;fAC 6168582, STATE OF, FLORIDA. DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING°BOARD SEQ# L12062001059 ,The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 -FS Expiration date: AUG 31, 2014 SCHNEIDER GUSTAVO A DOME ENTERPRISESINC 11341 SW 27 ST MIAMI FL 33165 R.ICK* .SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY W0239 Local Business TarReceipt Miami—Dade County, State of Florida —THIS IS NOTA BILL- DO NOT PAY 1841601 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES DOME ENTERPRISES INC RENEWAL SEPTEMBER 30, 2014 11341 SW 27 ST 1841601 Must be displayed at place of business MIAMI FL 33165 Pursuant to County Code Chapter 8A — Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED DOME ENTERPRISES INC 196 G`;;NERAL BUILDING CONTRACTOR BY TAX COLLECTOR Worker(s) 10 CGCO24710 $75.00 08/27/2013 TXHSI-13-050237 This Local Business Tax Receipt only confirms payment of the Local Business Tarr. The Receipt is not a license, permit or a certification of the holders qualfirutions, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above oust be displayed on all commercial vehicles — Miami—Dade Code Sec Ba—M For more information, visit www miamidade aovItmm iecmr Report Viewer * * CERnRCATE OF ELECTION TO BE EXEMPT FROM FLORIDA W ORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies thatthe individual listed below has elected to be a)emptfrom Florida Workers' Compensation law. EFFECTME DATE 7/2112013 EXPIRATION DATE 7/21 /2015 PERSON: SCHNEIDER GUSTAVO FEIN: 592754167 BUSINESS NAME AND ADDRESS: DOME ENTERPRISES INC 11341 SW 27 ST M AAI FL 33165 SCOPES OF BUSINESS ORTRADE LICENSED GENERAL DOOR AND WINDOW CONCRETE WALLBOARD,SHEETROC CONTRACTOR INSTALLATION CONSTRUCTION NOC K,DRYWALL, P or DFSF2-DWC-252 CERTIFICATE OF ELECTION TO BE DmAPT REVISED 07-12 QUESTIONS? ($50)413-1609 httpsJ/apps8.fldfs.c:oWcrreporNewer/repoitViewer.aspx?data= inc9D7Q3gH6TER6ePlKMZ%2fSz&X<yfB)kekBESOpVy\4NPOPN4ZKeirDRGXVWbdi:. 1/2 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 prrt-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. Owner Print Name: Signature:� /.✓y � �_—/j� State of Florida ) County of Miami -Dade ) Sworn to anq subs ribed before day of _ .2( (SEAL) Type of Identification Contractor Print Name: Signature: /A iL/ef_.> State of Florida ) County of Miami -Dade) Swornto suj� ribed before me this day of �I ! -20 °`" '• ``°4 ROBERTO UNOSAY (pDW By MY COWISSION # FF 012651 # FF 012651 EXPIRES: APr2 28, 2017 kw -0"7 (SEAL) oR `O Bo TlwButlpetNomryBfrvo a ' " CERTIFICATE OF LIABILITY INSURANCE DA�0 rn TYPE OF INSURANCE 1D4 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: lithe certificate holder Is an ADDITIONAL INSURED, the pollcypes) must be endorsed. If SUBROGATION IS 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 endorsrerert(sJ PRODUCER CONTACT Hemisphere Insurance Group 11441 SW 40 St Ste 344 (305)501-2801 • (345) 553.90143 L4ML hemisphereinsgrp@aol.com Miami, FL 33165 Phone 305) 501-2841 Fax (305) 553-9010 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ACCIDENT INSURANCE COMPANY INSURED B: Dome Enterprises irr. C: V45URER 0; 11341 SW 27 ST INSURER E: MIAMI, FL 33165 INSURER F: PRODUCTS -COWIOPAGG $ 2,000,000.00 vvva.wav�.a ur-mi ir1VA1 C iVUM6GK: RFVM1r7N IU"MRFR- 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. RR TYPE OF INSURANCE AD POLICY NUMBER POLICY EFF POLICY EXP LITS A GENERAL LIABILITY CMUMRCIAL GENERAL LIABILITY ❑ ❑ CLAIMSBMDE © OCCUR El ❑ CPP0006172 02 10/06/2013 10/06/2014 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES soccun ao $ 100,040.00 MED EXP (Any one person $ 5,000.00 PERSONAL &ADV INJURY $ 1,4W,0W.00 GENERAL AGGREGATE $ 2,000,000.00 GEWLAGGREGATE L TAPPLIESPER* ❑ POLICY ❑ SEPT- ❑ Lac PRODUCTS -COWIOPAGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANYAUTO ❑ AUTOS OWNED ❑ AUTOS D ❑ HIREDAUTOS ❑ qUTNO'OSWNE D U ❑ a eccideCOMBINED ldSINGLE LBNIT BODILY INJURY (Per parson) $ BODILY INJURY(Perscdderd) $ PR�ERd1Y tiE $ erg $ ❑ UlIBRELLA UAB ❑ OCCUR ❑ EXCESS LIABCLAMISMADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETDRIPARTNERIEXECUTNE OFFI:ERAIEMBEREXCLUDED? �s h1 NH) DESCRWTI�1 OF ORATIONS beowr NIA El WC STA RJ El OlF!- E.L.EACH ACCIDENT $ _ E1 bWEASE-EAEfoLgyE $ E.L, LEASE - POLICY LOW $ DESCRPMN OF OPERATIONS 1 LOCA71ONS I VEMCLES MMch ACORD 1e1, Adelonal Remarks 8dledule, if more space Is mgwred) GENERAL CONTRACTOR LICENSE CGC 024710 a.cK r 1rra.Ar c nvurrlrt CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT. 10050 NE 2rX) Ave Miami Shores, FL 33138 ACORD 25 (2010105) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORI2ED REPRESENTATIVE 01SSS-2010 ACORD CORPORATION. All rights remved. The ACORD name and logo are registered narks of ACORD