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RC-13-2335Miami 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: 10090 N Miami Ave Permit No. OCT 2 uas s FBC 20.)-6' Master Permit No. RCA �3 - Ok 3:3-S ROOFING :3 - ROOFING City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-3101-021-0090 Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder): Luisa F Luna e,M,. - 10090 N Miami Ave City: Miami Shores State: FL NO Flood Zone: Tenant/Lessee Name: Phone#: Email: Iunamoon7556@gmail.com CONTRACTOR: Company Name: GENEREVE CONSTRUCTION & REMODELING LLC Address: 1300 NE 200 Terrace City: Miami State: FL Qualifier Name: Nelson Polanco State Certification or Registration #: CGC1521162 Contact Phone#: 954 397 9134 Ei Address: Certificate of Competency #: info@genereve.com DESIGNER: Architect/Engineer: Phone#: 33150 305 7573133 Zip: 33150 954 397 9134 Zip: 33179 954 397 9134 Value of Work for this Permit: $ 250 Square/Linear Footage of Work: Type of Work: ❑Addition ❑Alteration ❑New epair/Replace ❑Demolition Description of Work: Replacing wooden panels damaged by water under trim around house Color thru tile: Submittal Fee $0Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ 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) 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 absences of such posted notice, the inspection will not be approved and a reinspection fee will be charged. �i/ Signature Signature " O er or Agent Contractor 1 The foregoing instrument was acknowledged before me this /8,-7q, day of DC:4--_, 20 03 , by who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sigi My 6' The foregoing instrument was acknowledged before me this day of L1 _200, by �.(Z IESuN e who is personally known to me or who has produced f4 as identification and who did take an oath. NOTARY PUBLIC: \\\`O\k�lllit�rrrr/���%�, Sign: � -n a. � Print: My Commission Expires:............ APPROVED BY Plans Examiner Zoning Structural Review (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. X COPY OF QUALIFIER'S STATE LIC CARD B. X COPY OF LOCAL BUSINESS TAX RECEIPT C. X COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. X COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT -, C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: GENEREVE CONSTRUCTION & REMODLEING BUSINESS ADDRESS: 1300 NE 200 TERRACE CITY MIAMI STATE FL ZIP CODE 33179 BUSINESS PHONE:9(- 54 ) 3979134 FAX NUMBER (_) CELL PHONE91 54 ) 3979134 QUALIFIER'S NAME: NELSON POLANCO QUALIFIER'S LIC NUMBER: CGC 1521162 E-MAIL ADDRESS (IF APPLICABLE): Info@genereve.com Created on 3/19/09 BY MLDV / RV 3126109 MLDV . ll. R CERTIFICATE OF LIABILITY INSURANCE � DATE(MMIDD/YYYY) 10/21/2013 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(ies) 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 The Contractors Choice Agency PO Box 13645 Chandler AZ 85248 CONTACT Jon Rock - NAME: PHONE (800) 918-3584 T(A/C. No: (877) 684-9951 EMAIL s: Jon@nginsuranceonline.com ADDRE INSURERS AFFORDING COVERAGE NAIC N INSURER A:Pref erred Contractors Insurance 12497 INSURED Genereve Construction and Remodeling LLC 1300 NE 200th Terrace Miami FL 33179 INSURER B: INSURER C: INSURER D: INSURER E : 1 INSURER F : COVERAGES CERTIFICATE NUMBER:CL1332720600 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AD -DL BR POLICY NUMBER MM/DDYEFF /YYYY POLICY M/ DYE LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1 OCCUR PCIC5026-PCA505871 9/19/2013 9/19/2014 EACH OCCURRENCE $ 1,000,000 DA GET RENTED PREMISES III occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JI PRO- LOC PRODUCTS - COM PIOPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS Ea acc.IcidentSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE('� OFFICER/MEMBER EXCLUDED? u (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A I VVC STATU- OTH- E.L. EACH ACCIDENT $ - E.L. DISEASE - EA _MPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) (305)756-8972 Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138 ACORD 25 (2010105) INS025 rgmnnso m 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 REPRESENTATIVE Rock/JDA ©1988-2010 ACORD CORPORATION. All rights reserved. Thn Ar`npn n- and Inn^ mro rnnie}sarrari morlre ^f annizil JEFF ATWATER CHIEF FINANCIAL OFFICER ,— WEN STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TU 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: 1/18/2013 EXPIRATION DATE: 1/18/2015 PERSON: POLANCO NELSON FEIN: 461467506 BUSINESS NAME AND ADDRESS: GENEREVE CONSTRUCT:ON & REMODELING LLC 1300 NE 200TH TERRACE MIAMI FL 33179 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate 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(13), F.S., Notices of election to be exempt and certificates of election to el C6 n t shall be subject :o revtcatic:, i.`; st any time af'er Wt filing of the notice or the issua:.ce of th.- cer;;f:,.to, the perso,l named on the notice sr 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 .3f this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION 1'0 BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1521162 I The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 POLANCO, NELSON GENEREVE CONSTRUCTION & REMODELING LLC 1300 NE 200 TERRACE MIAMI FL 33179 . RICK SCOTT ISSUED: 01/07/2013 SEQ # L1301070000468 GOVERNOR DISPLAY AS REQUIRED BY LAW 004920 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7093313 KEN LAWSON SECRETARY BUSINESS NAME&OCATION RECEIPT NO. EXPIRES GENEREVE CONSTRUCTION & REMODELING LLC RENEWAL SEPTEMBER 30, 2014 1300 NE 200 TERR 7371214 Must be displayed at place of business MIAMI FL 33179 Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS GENEREVE CONSTRUCTION & 196 GENERAL BUILDING CONTRACTOR PAYMENT RECEIVED CGC1521162 BY TAX COLLECTOR Worker(s) t $75.00 07/09/2013 TXHSI-13-016918 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles Miami -Dade Code Sec 8a-276. For more information, visit www.mipmidade,gov/taxcollector So���h l���Lj1�1 �ye 4�QW SI Oce S FL ;3ISc I OCT 15 2013 co CITY 7:Y- COPYCOPY k i2e�lace