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DS-14-1044BUILDING Miami Shores Village CEIVE g' MAY 2 2014 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 =C'1 LjPermit No. �`" �� `� PERMIT APPLICATION FBC 20 Permit Type: BUILDING OWNER: Name (Fee Simple Master Permit No. Lr_e_� A=-ZeoMON-ii) i City: l a.WLL-� 65 ,Ou_d__ State: Zip: Tenant/Lessee Name: N A Phone#:_ Email: RAs`A41 A -6k pv jn_k JOB ADDRESS: City: Miami Shores County: _ Miami Dade Zip: Fofio/Parcel#: -IL 172 16 5 0— 69 ® l f Is the Building Historically Designated: Yes NO Y Float Zone: s-.? CONTRACTOR: Company Name: _!�!v2ca,Phone#: Address City: / P/� / fState:' Qualifier Name: C &Z.7 �� C'a Phone#: -5 a!�- Ci 9f z q-'6_ r State Certification or Registration #: %1 D T AQ 74/Y Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer. Phone#: Value of Work for this Permit: $ Q -D d 0 Square/Linear Footage of Work: 6 tld p Type of Work: UAddress / OAlteration UNew d4air/Replack ODemolition Description of Work: � C� CO- [9V,P.of— e� � e7<l � %/ ,D.vC � %� AD c9 Zr COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by: �+�,��,r,�s�*�a+seu�araa r,��aa, msc�aa,mr�,a,�a,a,x,�,aaaF�,x$a �,�,aa�,rs�,�waaar,�,x�*,t�,ro�,�,�,u+�*sr*,�a,�a�,�,��,�,�,�,��• Submittal Fee $ Pernik Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ I l - 40 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 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 be approved and a reinspe io ee will be charged Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this _L The foregoing instrument was acknowledged before me this day of20 f by , 4Lday of O=e 20,(by who is pe;Wally known to me or who has produced 40A,;APA . who is personall own tom r who has produced el C e2r- 4 Q As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: / Print: YG i Print: yA-a� rwb $ G67t- fz My Commission Expires: y�7 ARAWA OOWAU2 b ly Commission Expires: W COMMISSION #EE131020 S Q/" 1.7 2-01S EXPIRES: SEP 18, 2015 �^ Bonded through 1 st StMe Insurance oU"' ARANELIS eovAFZ WQ§MM=lOf #EE13IM0 D(PIRES: SEP 18, 2015 APPROVED BY Plans Examiner f Z (1 l & Q► 9h 1st State Imurance Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)(rev6/4/10) 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 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 Contractor E4ZPrint Name: / 1� �%/�� Print Name: Signature: Signature: State of Florida) State of Florida ) County of Miami -Dade Sworn t before - � County of Miami -Dade ) and subscribed me this -30 % Sworn to and subscribed before me this 2q day of , 20 !� ��a y o y � day of In �9-t/ 20�. BY Iv, OY7 Z. FLS , By t!G1 iG ARANEUS 60pp n U o (SEAL) C% (SEAL) EXPIRES: UP is, Type of Identification produced T e of Identification produced She =o,. -V7 MY WW OVA1020 CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDnmrY) TYPE OF INSURANCE 05/20/14 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 policy(les) 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 endorsement(s). PRODUCER Yes Insurance Agencies, Inc. 9507 Bird Road CONTACT ------ NAME: _ PAHfCO.NNEo �: (305)225-5757 a No : (305)223-8158 SIL arminday@bellsouth.net Miami, FL 33165 Phone (305) 225-5757 Fax (305) 223-8158 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : GRANADA INS,CO. INSURED INSURER B: True Stamped Concrete Llc. INSURER C : 8320 SW 38 St INSURER D: INSURER E: Miami, FL 33155- (305) 494-4465 MSURERF: rnvG�er_r=c n�eT.�.....•� ......e��. • �V.�.YVn. 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. ILTR TYPE OF INSURANCE ADD WVD UB POLICY NUMBERMPOLILICCY EFF MIDOMM MPOOLII D EXP YYYl LIMITS A GENERAL LIABILITY © COMMERCIAL GENERAL LIABILITY F-1❑CLAIMS MADE 0 OCCUR ❑ N 0185FL00020506 08101/2013 08/01/2014 EACH OCCURRENCE $ 500,000.00 DAMAGE A MASES RE once $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 500,000.00 ---- -- ❑ GENERAL AGGREGATE $ 1,000,000.00 GEWL AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO- ❑ LOC PRODUCTS -COMP/OPAGG $ 1,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ❑ AUTOS ❑ SAUTOSCHEDULED ElHIRED AUTOS ❑ AUTOSWNED ❑ ❑ COMBINED SINGLE LINR Ea acddent BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PP OPaE�RIdn7DAMAGE $ d $ ❑ UMBRELLA LIAR ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE NIA EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION$ WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY N �ICEWMEMBER�EXXC UDED?�C ❑ (Mandatory in NH) if yes, describe wider DESCRIPTION OF OPERATIONS below $ ❑ WC ST TU ❑ OTH- �L E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E. L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CONCRETE PAVING CERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPT. 10050 NE 2 AVE MIAMI SHORES FL, 33118 r_e61f P1 I ATlndl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2010 ACORD C-0-M"FU O- N. All riehta rc-narvarl "iv The ACORD name and logo are registered marks of ACORD Co► ructian Trades QuaWng Board . BUSINESS CEf2TIFICATE OF COMPETENCY •E0800748 ' A . -.� " z. TRUE STAMPED CONCRETE LLC Per 0.BA.: EBA WLLIAM Is caerti W under the PmvisbM of Chapter 10 of Afmmi-Dade County s VALID FOR CONTRACTING UNTIL 09/30/2015 QUALIFYING TRADE(S) 0008 CONCRETE ENGINEER L'AwftDmWP.E. ! Gl(/SOON" ClUm 8=d�aim • by ® 07-18-2012 JEFF ATWATER CHIEF FINANCIAL OFFICERSTATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS` COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' CONSTRUCTION INDUSTRY EXEMPTION COMPENSATION LAW This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation taw. EFFECTIVE DATE- 07/18/2012 ` PERSON: TRUEBA FEIN: 203060130 BUSINESS NAME AND ADDRESS: TRUE STAMPED CONCRETE LLC 8320 SW 38 STREET MIAMI FL 331SS SCOPES OF BUSINESS OR TRADE. 1- CONCRETE OR CEMENT WORK IMPORTANT: Pnrsaant to Chapter 440 EXPIRATION DATE: 07/11812014 WILLIAM 2- CONCRETE WORK INCIDENTAL TO TH �.� wry not recover benefits or compeasacts Unit under this �chaptere Purspitant to Chapter who 440-05112). 005(tmit" nF.from this chapter of ay filn9a be slept of the business or hada subject t the notice of election to be exempt. Pursuant to Chapter 440.05113). F.S.�Nptiees of,ielectianetoif betexempte of election and certificatesof certificate to he exempt shall be subject to revocation ff, at nay time after the filing al the notice or the issuance of the cef election the person named on the ica exempt... aRPIY aaly v�itbia the named on ao longer meets m trequirementsTheqr of this section for issuance of a cerli(icate. The department shat) revoke' a certificate at an named on the certificate to meet the requirements of this section. notice or OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Y time far failure Of the person (1UESTIONS? (850) 413-1E a STATE OF FLORIDA PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE D-111 MENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTNDUSTRY CERTIFICATE OFONELECTELECTION TOE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 07/18/2012 0EXPIRATION DATE: 07/18/2014 PERSON. WILLIAM TRUEBA FEIN: 203060130 BUSINESS NAME AND ADDRESS: TRUE STAMPED CONCRETE LLC 8320 SW 38 STREET MIAMI, Ft 33155 SCOPE OF BUSINESS OR TRADE. 1- CONCRETE OR CEMENT WOR[ 2- CONCRETE WORK INCIDENTAL TO TH IMPORTANT O Pursuant to Chapter 440.05114), 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 tinder this D chapter. H Pursuant to Chapter 440.05(12), F.S., Certificates of election to be Rexempt-, apply only within the scope of the business or trade listed on the 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 theissuance 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. L CUT HERE t (1UESTIONS? {850) 413-1909 Carry bottom portion on the job, keep upper portion for your records. 'WC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Municipal Contractor's Tax Receipt Miami—Dade County, State of Florida THIS IS NOT A BILL — 00 NOT PAY CC NO: E0800748 MEILOCATIoN TRUE STAMPED CONCRETE LLC RECEIPT NO. EXPIRES 8320 SW 38 ST NEIN BUSINESS SEPTEMBER 30, 2014 MIAMI, FL 33155 7437319 Must be displayed at place of business Pursuant to County Code Chapter BA — Art. 9 & 10 OWNER TYPE OF BUSINESS TRUE STAMPED CONCRETE LLC SPECIALTY ENGINEERING PAYMENT RECEIVED CONTRACTOR BY TAX COLLECTOR 175.00 09/17/2013 0227-13-001453 MW4FOADE `: For more idarQ id=, Visit wwwmia nP ami Lot �•y 2, pp ,�-a S` as .0 according din ,t thereof �d+. 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