RC-14-2621Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-227152
Scheduled Inspection Date: January 27, 2015
Inspector: Rodriguez, Jorge
Owner: GRUNDHAUSER, JOHN
Job Address: 640 NE 101 Street
Miami Shores, FL 33138-2468
Project: <NONE>
Contractor:
FELMAT CORPORATION
Building Department comments
CUT NEW OPENING FOR A WINDOW
Permit Number: RC -12-14-2621
Permit Type: Residential Construction
Inspection Type: Final
Work Classification: Alteration
Phone Number
Parcel Number
INSPECTOR COMMENTS False
1132060172090
Phone: (954)729-5877
January 26, 2016 For Inspections please call: (305)762-4949 Page 27 of 29
Inspector Comments
Passed
Failed
Correction
Needed ❑
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
January 26, 2016 For Inspections please call: (305)762-4949 Page 27 of 29
F
jail
BUILDING
Miami 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
PERMIT APPLICATION
Permit Type: BUILDING
DEC 01.2014
FBC 20 10
Permit No.
�L )Y-2�1,1--
Master Permit No.
ROOFING
JOB ADDRESS: _ G !NQ VS) f— k o > t; -T.
City: Miami Shores County. Miami Dade Tp:
Folio/ParceW.
Is the Building Historically Deft ated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): GRa-g\DN% 1k /l,�eczliway& Phone#: SM - 40 - S -14Z
Address:_ G '-G %i t 16) %-T-
city: ";guui.R.T& State: Zip: , 331.
Tenant(Lessee Name: Phone#.
Email: _L m V comp, S1 0") 0'ak . CO N&A
CONTRACTOR: Company Name:_FP.` m Q,i �R �® Phone#: W4_12ts S7,1
Address: 3 gP-� INA.- \ Ste` AVP
City: ® T i9��, State: L. Zip:
Qualifier Name: �� `Ja��\�, Phone#: 5s 9 S 'jj
State Certification or Registration#: C. G C. % S 1 5 5 Z Z Certificate of Competency #.
Contact Phone*Email Address: 1 Yrt } Cq
6.4
DESIGNER: ArchiteaMngineer. h aa- k,:cV %&C' Phone#:
Value of Work for this Permit: $ 3 • a ® 4 e'er Square/Linear Footage of Work: X • 2.1 S�a f ® •
Type of Work: LIAddition ifAlteration ONew ORepaidReplaceUDemolition
Descrildon of Work: _- - 0. Uk W e W ®%-0k\K . wQ C G IL q uU A
c\flG W
Color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ ',4n Stnwt ual Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ � �+ 9 0
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
Zip
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, BEATERS, 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
CONMENCEMENT 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs .seven (7) days after the building permit is In the absence pJ�s,Aosted ^e, the
inspection will not be approved and a reinspection fee will be charged o
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of., _, 201
�, by _L®li a),
who is personally known to me or who has produced
As identification and who did take an oath.
The foregoing instrument was acknowledged before me this I
day of 20 �, by Mil "IrKi ® D,:* sb %Jb3
who is personally known to me or who has produced
NOTARY UBLIC: ADRIpNA M DOS SMITO$
MY COMMISSION # EE 070801
EXPIRES: March 7,20%
Si 9 cv�o�`O� ihru Budget Matey S6s
My Commission Expires: AAO-rtk -7 ( 2-0 (S— -
APPROVED BY
�14?A-4plans Examiner
My Commission Expires: Z -)'-04;1r
WIN
Zoning
N Staucttrral Review Clerk
(Revised 3/12/2012)(Revised 07/10107)(Revised 06✓1012009)(Revised 3/15/09)
OMIRAN 8AJ@UDl,
To
M.tt 80 mwa.mmo YU
SUM 41 Ab
Miami tiVillage
Building Department
10060 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
t2"6"!y
Permit No: eC 14 -1 G 2l
Structural Critique Sheet
Page 1 of 1
1, "� 1'9V
STOPPED REVIEW
Plan review is not complete, when all Items above are corrected, we will do a complete plan review.
If any sheets are voided, remove them from the plans and replace with new revised sheets and Include one
set of voided sheets in the re -submittal drawings.
Mehdl Asraf
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
W, PROFESSlC KLReouLATiON.
CGC1519922 - ` a ILlE 07/30/2014
CERTIFIED G QON CTbR
DOS SANTO,;,- SIS
FELMAT CORRCF ATM- .
IS CERTIFIED under the provisions of Ch.489 FS.
Expiration date ! AU0 31, 2016 L1407300001791
V1.
CERTIFICATE OF LIABILITY INSURANCE
>�►TE
'TDDL
YPE OF INSURANCE
11l19l111911IYYYY)
4
THIS CERTIFICATE IS.ISSUED AS A MATTER OE INFCIRMATION ONLY AND CONFERS NO RIGHTS UPpN THE CERTIFICATE HOLOWL 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 THECERTIFICATE BOLDER.
IMPORTANTS if the certificate holder is an ADDITIONAL. INSURED, the policy(les) must be endorsed. N SUBROGATION IS WANED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conifer rights to the
certificate Holder in lieu of such endoraemengs),
PRODUCER
Express Service Insurance Agency
900 E. Atlantic Blvd. #10
CONTAC
NAME:
PHo (954) 943-70 (1) 943-1810
E4VIAILADDRM& paulo�ress4lt.rret
INSUR B .AFFOROM OOVERAdE "Do
Pompano Beach, FL 33060
Phone (954) 943-79D6 - Fax (954) 9431810
INSURER A: LkWS Of:London 78444
INSURED
INSURER B
INSURER C:
Felmat Corporation
INSURER D.:
3921 NE 15th ,Ave
INSURER E
Pompano Bch, FL 33064 () _
❑
GENERAL AGGREGATE $ 2,000;000.00
INSURER
U0VtKA0b§ CERTIFICATE NUMBER: 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, TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WHICH THIS
CERTIFICATE MIRY BE ISSUED 09 MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIOIE3 tIESCR18Eo HEREIN IS suwecT TQ ALL THE TERMS,
CONDITIONS OF SUCH. POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAJD CLA4VIS.
g�EXCLUSKINS.AND
I TR
'TDDL
YPE OF INSURANCE
AM
O
POLE NUMBER
amommi
ICT' Eli
LIMITS
A
GENERAL LIABILITY
Q COMMERCIAL GENERAL LIABILITY
❑ ❑ CLAIMS -MADE ® OCCUR
❑
CIBFL0003669
07112/2014
07112!2015
EACH OCCURRENCE $ 1,W0,000-00
TORNTIED
DAMAGESf a a:currerrce $
PREMISES 100,000;00
REED EXP (A tole person) $ 5.x-00
PERSONAL 8c ADV INJURY $ 1 ,OW,000:00
❑
GENERAL AGGREGATE $ 2,000;000.00
E LAGOREGATELIMITAPPLIESPER:
POLICY ❑, ❑ LOC
PRODUCTS -COMIRiOPAGG9: $ Z000,000.00
$
AUTOMOBILE LIABILITYaf:
❑ ANY AUTO
ALL OC INEDD SCHEDULED
AUTG3�a ❑ A. 0$
❑ HIRED AUTOS ❑ NO SINNED
t nNEDtSINGLE LIMIT
BODILY INJURY (Per person) S
BODILY INJURYVer aeeiderM $
E!? M G
UMBRELLA LIAS ❑OCCUR
❑
❑ EXCESS LIAR ❑ CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE
❑ DED ❑ RETENTION $
$
WORKERS COM PENSATIOtd❑
EMn.OVERS' LIABILITY YIN
ANY PROPRIETORIPARTNERO(ECUnVE
OFFICERIM5MBER EXCLUDED?
(MaridatoryinNH) El
If yyes describe rurder
IDAUIPTICNJ OF OPERATIONS I b.
N I A
WC STA711• SRI"
I t ACT
E.L. EACH ACCIDENT $
I-L.DISEASE -EAEMPLOYE $
EL DISEASE • POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES %Uch ACORD 101, Addli[cmai Remarks Schedule, if more'space Is r"alred)
Contractors license: CGG:1519922
CERTIFICATE HOLDER CANCELLATION
city of Miami Share$
10050 NE 2nd Avenue
Miami Shores, FL 3313B
Fal: (305) 75648972
ACORD 25 j20%06) QF
SHOULD ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATETHEREOF NOTICE WILL BE DELIVERED IN
ACCORDANCE VWH THE POLICY PROVLSIQNS.
AUTHORIZED REPRESENTATIVE
01M-2010 ACORD CORPORATION. All fights resented.
Thee ACORD name and b90 are registered »!arks of ACORD
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORA WORMW COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
Ths indMo al NsWd below has sleded to be exempt frtxn Florida Workers' Ctlrtper� law
EFFECTIVE DATE: 9/2512013
PERSON: DOSSANTOS
FEIN: 200467630
BUSINESS NSE AND ADDRESS:
FELMAT CORPORATION
3921 NE 15TH AVE
EXPIRATION DATE: 9125;1015
MAURYSIO
POMPANO BEACH FL 33084
SCOPES OF. BUSINESS OR TRADE:
LICENSED GENERAL
CONTRACTOR
PWWW to CNWW 444.0.5(14). FA, an ~ of a emporaft vft eked emloW f m by ftj a ambficne of decdon under Oft Secben MOY
ftW mwwbwwftor=mWw3Wft WWWVftdw0w. F1a tot pW 444.0N12), FS, of eW tobe •.. Oft0"WOWthescope
of do badness or waft ftw on me nowe of eieow to be mompt Pun" to Owoer 440:45(13), F.S.. Noftes of eWW to be exert aced of
61000M to be exp SW be md*d to rpt d. at any thm sW Me ftV of me notft or Ow ftumm of flys aftliame. the pew OWNd an Me House or
00cate no WW nseM Me m ,of Vft sett fw ftuarwo of a certfcate, The depw6not SW revoke a cerbuft at any tip for faftre of Me
pnon named on the to tit me MwAvmwft of to mch s.
DFS-F2-DWC»252 {FRTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12
OUESTIONS? (OW)413-ION
Scanned by CamScanner
Miami shores Y
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
hersonallv liable for the worker comhensation iniuries of anv person allowed to work under this hermit Please check with your
insurance carver 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: La i S2i S iMcr.r1-
Signature r
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this -.0
day of 4—bCe h, , 20-01.
By
(SEAL) �/www�nn
Tune of Iam a �
MY Caen*loi EE131=6
Expkw 121MA18
Contractor
Mill -He.
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this
day of��,R0_L4
Nowy iia Sty" d Inbft
mom
Mlk. GtcLwdVo,se ;k /-s4\o&
moo -,a\ l Ut c s
L
'I-,' qv -t -i
DEC 0 2 2014
Ro a F-. 3. !\
I
.2.te,
2.110
PERMIT #.-
-
Miami—Shom Villaqq
EAPPRO'v,ED
Zo
ZONEING DEPT At
IILDG DEPT
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STATE ANO CCUMY RULES AND REGULATIONS