RC-14-1845Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-218407 Permit Number: RC -8-14-1845
Scheduled Inspection Date: December 23, 2014 Permit Type: Residential Construction
Inspector: Rodriguez, Jorge
Inspection Type: Final
Owner: KIMBERLY KRAUSE, JACK EFROMSON Work Classification: Repair
Job Address: 290 NE 100 Street
Miami Shores, FL
Project: <NONE>
Phone Number
Parcel Number
1132060134440
Contractor: MHENDAZ CORP Phone: (786)556-2258
Building Department Comments
BATHROOM REMODELING
INSPECTOR COMMENTS False
December 22, 2014 For Inspections please call: (305)762-4949 Page 4 of 30
Inspector Comments
Passed
Failed
Correction
Needed ❑
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
December 22, 2014 For Inspections please call: (305)762-4949 Page 4 of 30
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: (30S) 762-4949
7 X7F7 �1711 ED
;AU5 2014
FBC 20�O
Master Permit No o,- i Y, `- 1 145
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL E] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Q CONTRACTOR DRAWINGS
JOB ADDRESS: _ q / D �` L D 0
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 822 oy 013 g4(40 Is the Building Historically Designated: Yes NO i
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder) :(1 —w 14. 7E Fid 0 S -A5 Sal Phone#:
Address: COLA 0 LA -C
City:
State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Na;��e::-, 14 �G� dqZ &Q.-0 �• Phone#: -7
Address: c2L0 (D 02—
DSS'
City: 1'� "1� ��M.� State: r � Zip: Q3 �
Qualifier Name: Qn 1n AAL) cteZ Phone#: -766 --SZ� nD&S;
State Certification or Reaistra?ion #: [_ GAJ(_ /St
DESIGNER: Architect/Engineer:
of Competency #:
ne#:
Address: City: State: Zip:
Value of Work for this Permit: $ W.d'�Z - Square/Linear Footage of Work: !S• () ga
Type of Work: ❑ Addition A `diition ElAlteration ❑ New Repair/Replace F1 Demolition
Description of Work: r ->C VTtL ULOID H V k -&'l ® 04-""
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ �® s� CCF $(G7 CO/CC $
Scanning Fee $ Radon Fee $ Q1 DBPR $ • Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ may,
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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
Jf
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.
0
Slgnature� 0%- --
Signature
4NER or AGEYT f CONTRACTOR
The foregoing instrument was acknowledged before me this
1 day of 17J��t9s T , 20 , by
fv �RrJ fit* who is personally known to
me or who has produced
identification and who did take an oath.
f�I�Ti �_T3'11�I7T1"�A
as
The foregoing instrument was acknowledged before me this
=1 day of & U 20 t 4 , by
tc who is personally known to
me or who has produced Kiri ClA` v4-14 [4C" as
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print
Seal
APPROVED BY ' o Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
CGC 1513835 ISSUED:. 09/24/2014
CERTIFIED GENERAL CONTRACTOR
MENDEZ, RAYMOND.E
MHENDAZ CORP
IS CERTIFIED under the provisions of Ch.489 FS.
Expiration date : AUG 31, 2016 L1409240000839
AtORV CERTIFICATE OF LIABILITY INSURANCE FDATE(MM ONYM
08/22/2014
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 policy may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER AMERICAN INSURANCE BROKERS NAM, JOHANNA GONZALEZ
3650 N.W. 82ND. AVE. PHONE . (305) 715-9956Fax .(305) 715-7316
PH 504 E-MAIL JGONZALEZ AMERICANINSURANCEBROKERS.COM
DORAL FL 33166 INSURERM AFFORDING COVERAGE NAI
INSURE A: Cypress Insurance Group
INSURED
INSURER
MHENDAZ CORP INSURER
C:
2061 RENAISSANCE BLVD #202 INSURER D:
Miramar FL 33025 -
INSURER :
INSURER r:
r.OVERArEC (`F0T9FI(_ATF kIIIRARFD• nMnernkr unruoco.
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.
INSR
TYPE OF INSURANCE
ADM
SUIBR
POLICY NUMBER
POLICY EFF
04/17/2014
POLICY EXP
LIMBS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE FX OCCUR
X
20POO49805
04/17/2015
EACH OCCURRENCE 1,000,000
DAMAGE TO RENTED 100,000
MED EXP oneperson) 5,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
X POLICY 0 jECT � LOC
GENERAL AGGREGATE $ 2,000,000
PRODUCTS -COMPIOPAGG $ 2,000,000
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
BODILY INJURY (Per Person) $
ANYAUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
HIREDAUTOS ANON -OWNED
PROPERTY DAMAGE $
UMBRELLA LIAB
HLAMS-.E
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAR
D
WORKERS COMPENSATION
PER FIT
AND EMPLOYERS' LIABILITY Y N
ANY PROPRIEiORlPARTNER/FXECLmVE
OFF,CERIMEMBER EXCLUDED?
N t A
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE
(Mandatory In NH)
ff �,desalba under
S hoi.
E.L. DISEASE - POLICY LIMB
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addllonal Remarks Schedule, may be attached H more space Is required)
HANDYPERSON
LICENSE #CGC1513835
r u uuur I 1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NORTHEAST 2ND AVENUE
MIAMI SHORES FL 33138- AUTHORIZED REPRESENTATIVE
(71988-2n14 ACORC CORPORATION_ All rinhts rr+_carwarl
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
-tY
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * 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:
12/10/2013
PERSON:
MENDEZ
FEIN:
331114235
BUSINESS NAME AND ADDRESS:
bAENDAZ CORP
2061 RENAISSANCE BLD
SUITE 102
I+IIRAI+AR
FL 33025
SCOPES OF BUSINESS OR TRADE:
1- Conduct Construction
EXPIRATION DATE: 12/10/2015
RAYMOND
IMPORTANT: Pursusrd to Chapter 440. 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a cartifkete of election under this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), 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 440.05(1 3), F.S., Noes of election to be exempt and certificates of election to be exempt shall be subject to revocation H, at any time after the filing of the notice or the
lesuanu of the-rtHleate, the person named on the notice or
certificate no longer mete the requirements of this section for Issuance of a certificate. The department shell revoke a cartificate at any time for failure of the person
named on the certificate to moat the requirements of this section.
DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
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
r�r
Print Name: !a M' & fl
Signature:
State of Florida)
County of Miami -Dade )
Sworn to and sub cribed before me this I
day of
� �E1YC�iy� J
B
y t fll <l 20 17'
IR nP 9mttk J �!,.0 +roy Fiw. uwc+arae:03!i-7018
(SEAL)
Type of Identification produced
Contractor
Print Name:
Signature:
State of Florida )
County of Miami -Dade )
Sworn to d subscribed before:
day of 2�I0
By PSH M dv\ V � "��` �
of
A,2
1i4--ci7 -:: 2e _ g, l q4 LBel,�--
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015
DBA:
Business Name: MHEND`Z CORP
Receipt #:180-257525 CONTRACTOR (CERTIFIED
Business Type:GENERAL CONTRACTOR)
Owner Name: RAYMOND MENDEz Business Opened:o9/06/2013
Business Location: 2001 RENAISSANCE BLVD STE #10 to/County/Cerf/Re9:CGC1513835
MIRAMAR Exemption Code:
Business Phone: 786-556-2258
Rooms seats Employees Machines Professionals
1
For VencBrtg Business only
Number o1 Machines- For
Tv..n•
Tax Amount
Transfer Fee
NSF Fee
Penalty
Prior Years
ColteCtion Cost
Total Paid
27.00
0.00
0.00 1-0.001
0.001
0.00 1
0.00
27.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Browrard County and Is
non -regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has Changed or you have moved the
business location. This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
RAYMOND MENDEZ Receipt #03A-13-00009845
2001 RENAISSANCE BLVD STE Paid 08/18/2014 27.00
#102
MIRAMAR, FL 33025
2014 -2015
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015
DBA:MHENDAZ CORP
Business Name:
RecelptM 180-257525
Business Type: GENERAL CONTRACTOR (CERTIFIED
GENERAL CONTRACTOR)
Owner Name: RAYMOND MENDEZ Business Opened: 09/06/2013
Business Location: 2001 RENAISSANCE BLVD STE #10:State/County/Cerr/Reg:CGC1513835
MIRAMAR Exemption Code.
Business Phone: 786-556-2258
Rooms seats Employees Machines Professionals
1
signature For Vending Business only
plumifer of M9whtnne• v..—aa.... •eti......
Tax Amount I
Transfer Fee
NSF Fee
Penalty Prior Years
Cotiection Cost
Total Paid
27.001
0.001
0.001
0.001 0.001
0.001
27.00
Receipt #03A-13-00009845
Paid 08/18/2014 27.00