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DS-15-564Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-230306 Permit Number: DS -3-15-564 Scheduled Inspection Date: April 03, 2015 Permit Type: Driveways/Sidewalks/Slabs Inspector: Rodriguez, Jorge Inspection Type: Final Owner: MANGAS, GRACE Work Classification: Repair Job Address: 94 NW 94 Street Miami Shores, FL Phone Number Parcel Number 1131010340230 Project: <NONE> Contractor: T. SMALL CONSTRUCTION INC Phone: (954)584-3764 Building Department Comments REPAIR SIDEWALK SECTION INSPECTOR COMMENTS False April 03, 2015 For Inspections please call: (305)762-4949 Page 10 of 32 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid April 03, 2015 For Inspections please call: (305)762-4949 Page 10 of 32 Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 rrolect Aaaress Parcel Number Applicant 94 NW 94 Street 1131010340230 GRACE MANGAS Miami Shores, FL Block: Lot: Owner Information Address Phone Cell GRACE MANGAS 94 NW 94 Street MIAMI SHORES FL 33150-2238 202 SW 7 Court POMPANO BEACH FL 33060 - Contractors) Phone Cell Phone T. SMALL CONSTRUCTION INC (954)584-3764 In Review Date Approved:: In Review Date Denied: Type of Work: REPAIR SIDEWALK SECTION Bond Return Scanning: 3 Fees Due Amount CCF $1,20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $116.20 Additional Info: Classification: Residential Valuation: $ 1,200.00 Total Sq Feet: 30 Pay Date Pay Type Amt Paid Amt Due Invoice # DS -3-15-54802 03/16/2015 Credit Card $ 50.00 $ 66.20 03/27/2015 Credit Card $ 66.20 $ 0.00 Avanaoie inspections: Inspection Type: Final In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities'of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certifyAWt all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoniWFuthj6FYfore, I ay.thprize the above-named contractor to do the work stated. March 27, 2015 Authorized Signature: Owher / Applicant / Contractors / Agent Building Department Copy March 27, 2015 1 �1 � pj\ F.-� Miami Shores VillageFBY: A? Building Department 20 5 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 t. -D BUILDING Master Permit No. DSI S —S(aL' PERMIT APPLICATION Sub Permit No. UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL E] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: � v City: Miami Shores County: Miami Dade Zip:: l , Folio/Parcel#: // 3jol —0 34- ®0230 Is the Building Historically Designated: Yes NO Occupancy Type: .S`1' Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): b-814 6 Phone#:3,�TfxQ4C) Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: ® Sjs� �4LL �,° Side �/®,�✓ Phone#: %� ��¢ A Address: P®• 60)-- /609-3 City: &,j,+7-A77o,-V -State: �'Z- Zip: Qualifier Name: �° ^��9 �rin �9' �" Phone#: State Certification or Registration #: C !� a 16-o7 74 % Certificate of Competency #: DESIGNER: Architect/Engineer: 101 Phone#: Address: City: State: Zip: Value of Work for this Permit: $ i ®®` Square/Linear Footage of Work: 30 Type of Work: ❑ Addition ❑ Alteration ❑ New repair/Replace ❑ Demolition Description of Work: dobEr Il> oe.,g 170^d 14o,, hs- "emh, oe R Specify color of color thru tile: ry� Submittal Fee $'6a Permit Fee $ � ®LCCF Scanning Fee $ Radon Fee $ DBF Technology Fee $ Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) ;p CO/CC $ Double Fee $ Bond $ L �/ 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 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. Signature /�_ Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this Wit day of rn (inc t -t 20 15 by �� day of trv` r.\.tZG–t 20 IS by 6*&C6 M 1i'b &&- who is personally known to � `°"t �TM°��� who is personally known to me or who has produced p& OL as me or who has produced f= -C— L ® as identification and who did take an oath. identification and who did take an \\\\\v ufl 1ti � •► ► u �''��i NOTARY PUBLIC: NOTARY PUBLIC: �,,` SSi\vera gSign: Sign: Print: [pPr^ 6coOSTe:rd Print: Seal: Seal: ADAM GOODSTEIN ��,,►�►►►�►��1�1N���\`\\ ?? ° E Notary Public State of Flottda 's,�„ oQ;' My Comm Expires Sep 2, 2017 +nna� APPROVED BY r Plans Examiner �{� [ Zoning Structural Review (Revised02/24/2014) Clerk 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 and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 131-l` day of i17 OPIC-IY, 20 - By who is personally known to me or has produced 1. as identification. ���� ADAM GOODSTEIN �� �•o �r Puei,4 4 �� Notary: %�� ,° = Notary Public • State of Flotlda My Comm. Expires Sep 2, 2017 SEAL: '%4'� a` Commission # FF 050385 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. PY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: BUSINESS ADDRESS: /�® lfflv1e /6 ® 9 3 CITY STATE )Z— ZIP 31 BUSINESS PHONE: (%��) �� �� FAX NUMBER ( %�� .��� s�7lo� CELL PHONE 32-6 9 20 QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: G /6-0 7 747 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954831-4000 VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015 DBA: Receipt#:GEBNE ALS CONTRACTOR Business Name' T SMALL CONSTRUCTION INC Business Type'CONTRACTOR) Owner Name: TONEY SMALL Business Opened:11/01/2004 Business Location: 3890 W COMMERCIAL BLVD STE 21StatelCOunty/Cert/Reg:CGC1507747 TAMARAC Exemption Code: Business Phone: 954-326-9953 Rooms seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending TvDa: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost I Total Paid 27.00 0.00 0.00 0.00 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 Broward 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: TONEY SMALL PO BOX 16093 PLANTATION, FL 33318 2014 -2015 Receipt #IOB-13-00003108 Paid 07/07/2014 27.00 t • a JEFF ATWATER CHIEF FINANCIAL OFFICER ,ryCOL WE f?vv STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION x * 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: 6/11/2013 PERSON: SMALL FEIN: 201499463 BUSINESS NAME AND ADDRESS: T SMALL CONSTRUCTION INC P.O. BOX 16093 EXPIRATION DATE: 6/11/2015 TONEY PLANTATION FL 33318 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONCRETE WORK CONTRACTOR -PROJECT FENCE INSTALLATION CONTRACTOR INCIDENTAL TO TH MANAGER, CO AND REPAIR - 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 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 an�SaA clacLs = sulrE 404 -�' } ®%n A S J . K E L LY , C . �L GABLES, Fl -A. X3134 (305)444-7892 LAND SURVEYOR (305) 779- 3288 SURVEY NO.'ZAq SHEET OF— FAX lava S{CETCy �F SURVE•Y SCALE: I"= 7(1) Ak & �5vp 10 y�. Lia,V P - LC -V l4J 0 5t) V • - A7' p Lor €, -io f a= 9G -DEPT C✓ h \S Sl�lf(l1f-CTn g�u't T UM L,nNC WITH ALL FEDERA4 ,. 1 } JI_FS AND FIMUTTIC)NS k • � .i q 11 -ZS• / � L�t �1:. 10 , {.. ;��: 1-("'0,(' � � -fit'• 11 �71�'� ,� I �' ,Sf (Z? -� ` � t Lo to 01 Oho 'iz S ( itn � � w A �o �Sh 0-19ZFE *..9b 11 03/12/2015 12:02 9547770231 AMERICAN:INS PAGE 01/01 CERTIFICATE OF LIABILITY INSURANCE °" 03/1221209 ""1201""" 5 THIS CERTIFICATE IS ISSUED ASA 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 TIME CERTIFICATE HOLDER. IMPORTANT: if the Mnfflexlte holder Is an ADDITIONAL. INSURED, the polIvAles) must be endorsed. If SUBROGATION IS WAIVED, sWbJeCt to the terms and condttlona of the policy, Ce"Aln policies may require an endorsement A statement on this cediflcate does not confer rights to the certificate holder In Ileu of such endomement(sj ADD UBR PRODUCER MMlDD/YYYn. Rams CONfAUr �N. F; ROBERT BEL. American Insurance Agency GENERAL LU191LITY d OonmVfEROIAL GENERAL LIA131LITY ❑ ❑ CLAIMS -MADE ® OCCUR ❑ ❑ SONE (954) 777-9980 _ _ ND (954) TT7-0231 1391 Sunset Strip 11/21/2014 -MAIL rob@amertcanfmsuranceonlina,com Sunrise, FL 33313 PERSONAL & ADV INJURY $ 300,000.00 GENERAL AGGREGATE 3 6D0,000.00 INSURER AFFORDING COVERAGE NAIC it Phone (954) 777-9980 Fax (054) 777-0231 INSURER A : FEDERATED NATIONAL INSURANCE INURED Nall B $ T Small Construction, Inc. AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNSCHMULED AUTOSED ❑ AU?O ❑ ❑ HIRED AUTOS ❑ p 6WN>"D _❑ INRc. PO Box 16093 planation FL 33318 - THIS IS TO CERTIFY THAT THE POLICI8S OF SURANcE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY Be ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POt,1c1Es DESCRIBED HEREIN IS SU6.IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ MR TYPE OF INSURANCE ADD UBR POLICY NUIVrBER MMlDD/YYYn. Rams .ICY EXP e'Jra1 LIMITS A GENERAL LU191LITY d OonmVfEROIAL GENERAL LIA131LITY ❑ ❑ CLAIMS -MADE ® OCCUR ❑ ❑ GL05o4009989 11/21/2014 110=15 EACH OCCURRENCE s 300,000.00 DA ©E TO _pgr�I.�ss IEe oeeurrorteel 3 100A00,00 MED EXP oro pers>en) $ 5,000,00 PERSONAL & ADV INJURY $ 300,000.00 GENERAL AGGREGATE 3 6D0,000.00 GEML AGGREGATE UMI' APP—LIES PER, 11 POLICY ElEl LOC PRODUc s, coMP/OP AOG 3 600,OOD.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNSCHMULED AUTOSED ❑ AU?O ❑ ❑ HIRED AUTOS ❑ p 6WN>"D _❑ M91NED SINGLE UM BODILY INJURY (Per person) 3 BODILY INJURY (Per w4d� S P er acd +DA ora S S © UMBRELLA L10 Q OCCUR ❑ EXOMS UAD ❑ MAIMs.MAD€ N I A EACH OCCURRENCE s AGGREGATE $ DED ❑ NS 3 RPER OTIi. STAlUiF WORKERS COMPENSATION AND EMPLOYERS` LIABILITY Y / N OFFlCERJMEMBEI� EXCLUDED? ",,,'ED ANY PROPRIETORIPARTNERtM Edeeaib (Msntlatary In NII) It yea, e under E L EACH ACCIDENT 3 E L triSEASE - EA EMPLOYE .$ EL DISEASE - POLICY UMFF S DESCRIPTION OF OPERATIONS below DESOR'"ON OF OPERATIONS / LOCATIONS/ YEMCLE.b (Athell ACORD 101. Addltlonal Remarks Scrodutfl, If more space is required) LICENSE NUMBER: CGC1507747 e -M ICre5fIrt un1 nren SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE OANCELLM 13EPORE CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELWRED IN MIAMI SHORES VILLAGE BLDG DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE AUTHORLMD REPRESENTATIVE MIAMI SHORES. FL 33138 ACORD 25 (2014101) OF01 014 ACORD CORPORATION. All rights mserlred. The ACORD name and logo are registered TMWS of ACORD