DS-14-1205Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-217290
Scheduled Inspection Date: August 07, 2014
Inspector: Rodriguez, Jorge
Owner: MIAMI, ARCHDIOCESE OF
Job Address: 9401 BISCAYNE Boulevard
Miami Shores, FL
Project: <NONE>
Permit Number: DS -6-14-1205
Permit Type: Driveways/Sidewalks/Slabs
Inspection Type: Final
Work Classification: New
Phone Number (305)762-1033
Parcel Number 1132060490010
Contractor: UNITED C LLC Phone: (954)401-0208
timialing uepanment comments
GENERATOR SLAB
Passed
Failed
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
INSPECTOR COMMENTS False
Inspector Comments
CREATED AS REINSPECTION FOR INSP-213883. No permit on site
PP5w I�V'4 0106,
August 06, 2014 For Inspections please call: (305)762-4949 Page 20 of 25
Miami Shores Village
Building Department
90050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (3057 762.4949
' C E7
JUN 10 2 14
BY:
FBC20
BUILDING Permit No. V--4 W -S
PERMIT APPLICATION Master Permit No 0- — qI L4 1
Permit TYP<
BUILDING ROOFING
JOB ADDRESS: 9401 Biscayne Blvd.
City: Miami Shores County: Miami Dade Zip: 33180
Folio/Parcel#: 11-3206-049-0010
Is the Building Historically Designated: Yes
NO X Flood Zone:
OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami phone#: 305-762-1032
Address: 9401 Biscayne Blvd.
City:
Miami Shores
Stare: FL. zip: 33180
Tenant/Lessee Name: N/A Phone#:
Email:
CONTRACTOR: Company Name: UNITED C, LLC phone#. 954-401-0208
Address: 10621 N W 53 ST.
City: Sunrise
FL. zip: 33351
Qualifier Name: Maurieio Gonzalez phone#: 954-401-0208
State Certification or Registration #: CGC 1504 858 Certificate of Competency #
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer. Phone#:
Value of Work for this Permit: $ 3200.00 Square/Linear Footage of Work:
Type of Work: OAddition OAlteration
Description of Work: Generator Slab.
Color thru tile:
ONew ORepair/Replace ODemolition
Submittal Fee Permit Fee $ CCF $ CO/CC $
Rmnninu Fpr $ Rndnn Fnn .4k DBPR $ Bond $
Notary $ Trainiag/Education Fee $
Double Fee $ Structural Review $
_ Technology Fee $
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
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 reinspection fee will be charged.
Signature Signaturoinginstrument
Ow�erorAgent Contractor
The foregoing instrument was o� ledged before me this The fore was acknowledged before me this2
day of �, 20 A, by ,
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
WAS
_ /L111I MR We
�uv �
APPROVED BY
day of MaV 20L -J_, by mAy— tcl* c,.mNZu&L;
who is personally known to me or who has produced
as identification and who did take an oath.
If/c—t Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
NOTARY PUBLIC:
My Com'171 r 6ARLOS VALDEZ
MY COMMISSION # EE042401
Zoning
Clerk
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That the most Reverend Thomas Wenski, as Archbishop of the Archdiocese of Miami, his
successors in office, a corporation sole, has made, constituted and appointed, and by these
presents does hereby make, constitute and appoint Sister Elizabeth A. Worley, C.O.O., his true
and4awful attorney for him and in his name, place; and stead.
Giving and granting unto Sister Elizabeth A. Worley, C.O.O., his said attorney full power and
authority to do and perform all and every act and thing whatsoever requisite and necessary to be
done in and about the premises as fully, to all intents and purposes, as he might or could do if
personally present, with full power of substitution and revocation, hereby ratifying and
confirming all that Sister Elizabeth A. Worley, C.O.O., his said attorney or his substitute shall
lawfully do or cause to be done by virtue hereof.
In Witness Whereof, I have hereunto set my hand and seal this 15 day of August, A.D., 2013.
Signed, sealed and delivered in the presence of.
Wi ss•
W ess Signature
XCthe- - nv
Printed Name
— / "I -
40t,
Witness Signature
Rcy Caroli'mo Qvotdor
Print& Name
STATE OF FLORIDA
SS:
COUNTY OF DADE
®� Oji
B
The Most Reverend Thomas Wenski
As Archbishop of the Archdiocese of
Miami his successors in office, a
corporation sole
I hereby certify that on this day, before me, an officer duly authorized to administer oaths. and
take acknowledgements, personally appeared The Most Reverend Thomas Wenski, as
Archbishop of the Archdiocese of Miami, his successors in office, a corporation sole, known to
me to be the person described in and who executed the forgoing instrument, who acknowledged
before me that he executed the forgoing instrument, who acknowledged before me that he
executed the same, and an oath was not taken. Said person is personally known to me
Said person provided the following type of identification:
Witness my hand and official seal in the County and State last aforesaid this 15 day of August,
A.D., 2013.
My Commission Expires: 2AYM EWNA SS °
'� c�
My Commbsbn Exna Jan. 27, 2015
CERTIFICATE OF LIABILITY INSURANCE
r DATE�® M°nWM
PRODUCER
Warren Insurance Corporation
950 Peninsula Corporate Circle
Suite 1012
Boca Raton FL 33487
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE MAIC #
INSURED United C, LLC
10621 NW 53 St.
Sunrise, FL 33351
INSURER A. Evanston Insurance
INSURER B: Progressive
INSURER C: Mormandy Harbor Insurance Company
INSURER D:
INSURER E
rnVFRAGFA
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVEFORTHE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
D:OFi
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
POLICY NUMBER
EFFECnVE
POLICY EXPIRATION
LIMITS
AUTHORIZED REPRESENTA <SS9 .
GENERAL LIABILITY
EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
100,000
rA
K COMMERCIAL GENERAL LIA uTy
CLAIMS MADE a OCCUR
3CO4812
5/2013
08/25/2013
08f25/2014
MED EXP one $ 5,000
PERSONAL &ADV INJURY $1,000,000
GENERALAGGREGATE $2,000,000
GEWL AGGREGATE LIMIT APPLIES PER
PRODUCTS - COMP/OP AGG $1,000,000
X POLICY PRO LOC
B
AUTOMOBILE
LIABILITY
ANYAUTO
01808036-1
08/25/2013
05/20/2014
COMBINED SINGLE LIMIT
(Eaacadent) $ 1,000,000
BODILY INJURY
(P- ) $
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident) $
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER.THAN EA ACC $
ANY AUTO
AUTO ONLY, AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $ 1,000,000
AGGREGATE
A
x I OCCUR ❑ cLA=MADE
XOVA611113
08/25/2013
08/25/2014
$
$
DEDUCTIBLE
$
RETENTION
C
WORKERS COMPENSATION
AND EMPLOYERS' LI UMM
ANY PROPRIErORIPARTNER/EXE YIN
NHIC05035
12/09/2013
12/09/2014
X WC STATU- OF -
EL EACH ACCIDENT $1000,000
E.L DISEASE - EA PLOYEE $1,000,000
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
E.L. DISEASE - POLICY LIMIT $ 1,000 000
ff Yes desv under
SPEC P OVISIONS below
OTHER
DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
305-756-8972
License # CG1504858
General Contractor Services
r_FRTIFIr_ATF 41nl nFR CANCFLLATION
ACORD 25 (2009/01) o 7988-2IH19 AGORD GuwuttA I IVn. All rlgnls reserveo.
The ACORD name and logo are registered marks of ACORD
SHOULDANYOFTHE ABOVE DESCRIBED POLICIES BECANCELLED BEFORETHE EXPIRATION
City of Miami Shores
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
10050 NE 2nd Ave
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY MO UPON THE INSURER, ITS AGENTS OR
Miami Shores, FL 33138
REPRESENrAmE3
AUTHORIZED REPRESENTA <SS9 .
ACORD 25 (2009/01) o 7988-2IH19 AGORD GuwuttA I IVn. All rlgnls reserveo.
The ACORD name and logo are registered marks of ACORD
JEFF ATWATER
CHIEF FINANCIAL OFFICER
P
�f
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
08-13-2012
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 07/31/2012
PERSON: GONZALEZ
FEIN: 205039078
BUSINESS NAME AND ADDRESS:
UNITED C LLC
625 RACQUET CLUB RD. 1!137-2
WESTON FL 33326
SCOPES OF BUSINESS OR TRADE:
1- CARPENTRY - DWELLINGS - THREE
3- LICENSED GENERAL CONTRACTOR
EXPIRATION DATE: 07/31/2014
MAURICIO J
2- CARPENTRY - DETACHED ONE OR TW
IMPORTANT: Pursuant to Chapter 440 . 06414), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election ander this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt.., apply only within the
scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05413), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation it, 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 shell revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section. (IUESTIONS? (850) 413-1809
,WC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
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 9
EFFECTIVE: 07/31/2012 EXPIRATION DATE: 07/31/2014
PERSON: MAURICIO d GONZALEZ
FEIN: 205039078
BUSINESS NAME AND ADDRESS:
UNITED C LLC
625 RACQUET CLUB RD. 9137-2
WESTON, FL 33326
SCOPE OF BUSINESS OR TRADE
1- CARPENTRY - DWELLINGS - THREE 2- CARPENTRY - DETACHED ONE OR TW
3- LICENSED GENERAL CONTRACTOR
IMPORTANT
OPursuant to Chapter 440.0504), 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 440.05(12), F.S., Certificates of election to be
H exempt.. apply only within the scope of the business or trade listed on
Rthe 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 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.
CUT HERE
QUESTIONS? (850) 413-1609
* Carry bottom portion on the job, keep upper portion for your records.
INC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11