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DS-14-2127Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-234029 Scheduled Inspection Date: May 22, 2015 Inspector: Rodriguez, Jorge Owner: LAYUG, VICTOR & MARILOU Job Address: 136 NE 110 Street Miami Shores, FL 33161-7046 Project: <NONE> Contractor: ONE STOP PAVING INC Building Department Comments Permit Number: DS -9-14-2127 Permit Type: Driveways/Sidewalks/Slabs Inspection Type: Final Work Classification: New Phone Number Parcel Number 1121360040430 Phone: 786-299-1354 NEW BRICK PAVERS DRIVEWAY AND WALK WAY. Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction ❑ Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP-220581. Sod disturbed areas next to driveway May 21, 2015 For Inspections please call: (305)762-4949 Page 12 of 36 r Miami Shores Village R F, CEI y Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 SPE IONLINE PHONE NUMBER: (305) 762-4949 waft Rg!miV1 FBC 20 I 0 BU I LD I N Master Permit No. l� - �•` 'i PERMIT - - --- Sub Permit No. *11 ILDING ❑ ELECTRIC ❑ ROOFING ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS QK REVISION ❑ EXTENSION [:]RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: to ST City. Miami Shores Countv: Miami Dade Zin_ the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): / d Phone#: %p G' 3 / A- :K2 S/ Address: 9/0 LL -- d S City: M�� a.lil�l l�� State: Zip: f Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: E' i 37 -CIV RAV4W _ h Phone#: 2 Address: % l/ 3 i73 �Y .1QJ'N� 3% % Z -- City: State: Zip: Qualifier Name: Phone#: State Certification or Registration M Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Square/linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: r21X &V (LIQ Specify color of color thru tile: Submittal Fee $2 #�i?erii:Fee:$ 3� ' W CCF $ CO/CC $ Scanning Fee $ J• Oz� Radon Fee $ DBPR $ Notary $ Technology Fee Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 3, . 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 are' spec 'on fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of 20 % by Vt G 1 V,( who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign The foregoing instrument was a�nowledged before me this 10 day of f2 20 t'S by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: as 1 Print: Print: �J � ph20 S R..Lp Seal:5. P ` 80 0 Seal: '_F.. Y COMMISSION 9 FF 195634 s�� •.o, �17N BRINO EXPIRES: February 3, 2019: MY 9 FF 195634 Bir TTn NOMY Public Umfwi tters EXPIRES: February 3,2019 6-1011 goaded Tin try PW &c Uftwrts APPROVED BY <� Plans Examiner �� G Zoning Structural Review (RevisedO2/24/2014) Clerk A minimum of two 12ft shade trees must be present in the parkway/swale for each 75 feet of frontage in order to pave any portion of the parkway/®wale, The adjoining property owner proposing to pave a portion of the parkway/swale shall plant sufficiont shade trees approved by the public works dire - r to meet the minimum roquiror FEB 10 2015 i t-4 t0 jimi Shores Viiiar)e DATE 7001MG DEPT <► Sl IRJFCT TO ,C)MPI In.NCF WITH AI -L FEDERAL srr,rF P n CCII IPJTY nl II FS r,�1I-ATInNS 17— / Uori 0'101• .o N' •S,? X� PAWR 16—Z-� 3.30 a4,eQ /�// �f�/f �, 05L i �� , i�.' :XT n : *.ON TOULOCI T T` • ' oN--X:tTununuoj dims o �i N I LVW2to3NI Qooz,4 o, y P�EytR 1��.�..: x :3Noz . aoo'I3 UTuiza ap r orifi drtlsIauMo JU •'�d 'TebaT•.••ATuo: suea>tt,•Zensin )Aq :dTgssaUMo 93ue3 , -pa-4Ieoot M� aOLI 'AU 3T:�.'sa -4TMn pue }�uaiugoeozoua punQzbzapun :94ON tX epPolA 'k4uno0 aped '�k�e,�,`�t�•''�y �._>,�_�,�-�.'',, ��,� ay °• � u`�"" �4 `�.�' .��3 p oaab a tlqnd a4l 10 rte:. y..,f ,�...::=w .�•. :.P..ti „�.. .. fig abed • `Zb X009.4eld U l papaooa,A Se '3,08aa44 . •subrsse 4eLd a44.03 6uLpa000e o-10/pue sIossaoons _ 94T 'uoT4raodioD 96eb4.zow 'S1H9I3H. 3931103 z� ONd Pup •K noTTarN LnAvq Iuoiqeaod.zo3 `Z 10019 `n'.401 -aoue-insul aT�ts a�e�S—suety :os p9T3T sad :Sr pagp3S'ap k!.Aado,Ad ' PERMIT APPLICATION -NtUILDING ❑ ELECTRIC 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: (305) 762-4949 FBC 201 (0 ° Master Permit No. I `T- � 2:? ❑ ROOFING .REVISION Sub Permit No. ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR ❑ EXTENSION [:]RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: ( J1 & lei. it t l © .$? N& I A, M l S Wo Vag, City: Miami Shores County: Miami Dade Zip: I.V/G / Folio/Parcel#: i I Zug 004 0x'50 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):y l CTOK 1,AU95 Phone#: %his" ago -42S/ Address: 1514 / n Ifo 51 . City: A4]A !M i 3 A Y State: R ZiD: 3j 1 1� t Tenant/Lessee Name: Phone#: Email: ,V Le!tw k fs M CONTRACTOR: Company Name: PVC- ��[-bJ� p14✓III1 of 3WC Phone#: zFe- Address: I !bO lI P: 17.4 57° City: lq ° Miami 91-444 State: F L Zip: 33 Qualifier Name: CAO—us A cvsTA Phone#: 2%9"41 — X99 -1' - State Certification or Registration #: �%� B ..i' I3 719 Certificate of Competency #: 5'D0 DESIGNER: Architect/Engineer: Address: Value of Work for this Permit: $ C`Sque Type of,Work: ❑ Addition ❑ Alteration ❑ New Description of Work: AI E W a! i CK A i✓EM -9Y'Il/& hone#: City: State: Zip: WA it Footage of Work: l '0 0 ❑ Repair/Replace ❑ Demolition Specifycolor of calor thry Submittal Fee $ Permit Fee $::�3J' CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $�- C'O (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 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.. t "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 $2600, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. in the absence of such posted notice, the inspection will not be approved and are' ction fee will be charged. Signature Signatur , OWNER or AG The foregoing instrument was acknowledged before me this I day of 20 /s , by V/ cl L2 W-�`ry (/ , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: . Sign: Print: Seal as CONTRACTOR The foregoing instrument was acknowledged ,before me this 1CJ_ day of �® 20 IS , by . who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ,r I = Sign: C _ s Print: Seal: `r lfilp1111 #e W C0WSSi0I i EE 055435 EXPIRES: January 27, 201$ WWW n" Nay PUWb W*M1= APPROVED BY /"Z' J Plans Examiner I ( Zoning Structural Review Clerk (ReAsed02/24/2014) 'This propel^ty ' descri bed as • Certified To: Trans -State -Title Insurance Corporation, ,Layug, Marilou A. and PNC . Lot .12, Block' 2, • • � COLLEGE :HEIGHTS, Mortgage Corporation, its successors and%or§. according to the..Pl..at assigns. there of,.as'recorded in Plat Book 4�'•Pa e 8 + -ei: ...r S ', v".fv r4 yR Y irK +y r,. r 3 ,•'p�' - ^ t 1 afi-the Pu��17 c Recgrds. 'pf' l. Dade Coun ••Florida t •%; • ..'•�••.•• ,' ,. xi •,les i#',�•0^V i J Y' r , VD4e: UnUrgr0_u_nd encroachment and: ut'il%tie's", ,i ��•0041AX r Icoaated.. 'Ps: S? Fship• .by' e wne . 41,;means only; legal Vl dwne ship'not dA drinined. V1 A.4�? zolyF•. X' .:•,••�., r4 Cork . �. ^ FLOW. INFrdRMATION : Community 'No .,120652_ / ��/ /� i / / q Pin' No!" >93.. :.::Suffix: J' .i';,i /. '� ' �SD ��'�� //i �� r ��r: o. Date' .of F-A*-R.M*': 3-�2rt9�4:. Base n / Elevation. Not '~ V Available'.��d?: ` t O �O mob IW 11& i POo - .. — - ,ass' .5' ... d � � _ . �• . � •.. y F cL, w s0 ,, :r'._ _..� ter-, _ i. r.t �y moi/ •.�e. /l9i� /J 04 roe e f?e f07 44 /'.i' C•�../f�'C�e:.�//. rlQ'l� r _ ,. ,c 1.4 is y " •{ ••i'^•'I /'`/'.�iri�flf•�!i/-Vl-��� 4 f.i.1-Y pl'.!Y.. '� �- 4 ' `' ., •� ,`��s��� A • �iu_M,iJ1f��4+e �.w.. 4 •W:rTL,%. 4+4 i ♦ •aM..la..I - - ., . - u.. e I A 5`oa o drN SNOLLVInD31d aNV. `I1t' 1•�Nrl J:� ONd 3lViS WU3(]33 _nV WIM 3OI4V f)dh03 0.1 103f OnS Z J ld3a Jaffe VI (� J_d30 SNINOZ 31da el C13�O�;ddd % I w �(,00 L_.0 %..� of & t A BUILDING �'� PERMIT APPLICA FBC 2004 liami Shores Village NV 3uilding Department ' � ` 150 N.E.2nd Avenue, Miami Shores, Florida 33138 SEP 3 0 Tel: (305) 7952204 Fag: (305) 756.8972 JBY: Permit No.. ON Permit Type (cirele): �ildfing ) Roofing Owner's Name (Fee Simple Titleholder) Owner's Address '13(0 tJ & City k� . S k 0 ,rr S State TenantlLessee Name Job Address (where the work is being City Miami Shores Vil M FOLIO / PARCEL # Ll 2l 3 Is Building Historically Designated Contractor's Company Name Contractor's Address LJr( Citv +- CWwti i Qualifier Name 1,� t -a State Certificate or Registration Architect/Engineer's Name (if Value of Work For this Permit $ Type of Work: []Addition Describe Work: Irk G_ Submittal Fee $ • 1 Pe Notary $ 7 - QQ TmhdnWE Scanning $ ':T, Radon Bond $ Code E Structural Review. $ Master Permit No. zip # 3or 45(o ®Cozq 33161 t3 (0 Mre ILO .� County Miami -Dade Zip 3 3 l G I O43o NO t ti% 6 -,�RCLhone # Z9& ZgA _ state 'VU zip 3316 2 Phone # -78G l3 4 L S Certificate of Competency No. F 231 Qy .0 C Phone # Square / ear Footage Of Work: 1,20 0 WTew ❑ RepairM*ace ❑ Demolition t Fee $ 1 G (i - Ck) CCF $ __-3, C -O O CO/CC stion Fee $ 1, 2n Technology Fee $ • �1 _ �- DPBR $ 0� Zoning $ cement $ Double Fee $ Total Fee Now Due $ See Reverse side 'Bonding Company's Name (if applicable) Bonding Company's Address City Sts Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State ziP Application is hereby made to obtain a pe anit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a I ermit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understi nd that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BO , HEATERS, TANKS and AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify tlmt a I the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction am zoning. ,"WARNING TO OWNER: YOUR FAJ LURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEM ENTS TO YOUR PROPERTY, IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LEND R 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 i wfice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attac;qr nt Iso, a cert(fied copy of the recorded notice of commencement must be posted at the job site for the first inspection which occ(7) drrys after the building permit is issued In the absence of such posted notice, the inspection will not be approved re' coon fee will be charged. The foregoing instrume—ut w s acknowledged before me this day of AJ 20N.by v� z_ y , who is personally known to me or who hai i, produces As identification # who did take an oath. NOTARY sip: My Commission APPLICATION APPROVED BY: 0twisai 07/10/07) [�Tq_m 2015 Signature Contractor The foregoing ern was aclrnowle ed efore this 5 day of � s' 2014 by � 0 S who is personally known to me or who has produced as idenfification and who did take an oath. NOTARY SPr int - My Commission (L(-Aq RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1513719 The GENERAL CONTRACTOR Named below IS CERTIFIED Under theorovisions of Chapter 489 FS. Expiration date: AUG 31, 2016 Sep -25. 2014 3:50PM FIRST CLASS INS No. 5869 P. 1 CERTIFICATE OF LIABILITY INSURANCECFE°"T �;'a "' 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: It the cerORcate holder Is an ADDITIONAL INSURED, the poligps) muat be eadersed. if SUI7ROOATION 13 WAIVED, subject to the terms and eanditlons of the poQoy, certaln pogplea may require an endorsement. A statement an this eer110eate does not confer rights to the cartlBCete holder in Ileo of such enderaeonant(a). 1 PRODUCER CT First Class Insurance Market P DNp (305)441-2997 F`eu (305)441-6443 4101 NW 9th Street I toimc�eal.com _ Miami, FL 33128 IN311MR181APYORDING COVORAGIRNAI rr Phone (305)441-2997 _ Fax (305)441-6443 INSORERA: ATLANTIC CASUALTY INSURANCE COMPANY INSURED U 11RB; I' ONE STOP PAVING, INC.. INS ITER C., i 1463 NE 173 STREET o: ilii NORTH MIAMI BEACH, FL 33162 INSURER_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 1SISUED TO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 SUSMOT TO ALL THE: TERMS, EXCI.USIONSAND CONDITIONS OF SUCH POLICIES. UWITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 9R 1312. TypgDP(NSURANCE A� UBJIM YNUMBER P I E P0L EMP LIMITS A GENERAL LIABILFIY RRLL0.1TY © C0MAi1ERC1AL0LNE1A8 ❑❑ ❑ C"S-MADE ® OCCUR ❑ OUR AGGREGATE LINTAPPLUPEri ❑ POLO ❑ P ❑ LDCS 0717714 07/1112014 01117/2015 ISM OCCUR NOE 5 1,000 000.00 D GfiTORENTED 100.000.00 �f, Emoacu n $ mwEKP(smyoftpmwj 3 8.000.00 PERSONAL a ADV INJURY $ 1.000,000.00 GENEWAGM9ATS s 2 000 000.00 PRODUCTa-ww1OPAGe S 2,000000.00 i AvroxloelLsuABruTY ❑ ANY AUTO ALL N0ElAOS❑"ULEO N�ED ❑ HEDAUTOS ❑ AUTOS 0 0 SINGLE LIMIT BODILY INJURY (Per person) BODILY URY(Par eaadeet S8S POg G $ ❑ IJMBR$LIALIAD ❑DCCT EXCESS LIAR ❑ CLAIM64MM FACHO RRENCE S AGGREGATEapo 11 RETEtWQX8 9 WORKBRG COMPENSATION AND EMPLOYERS' LIABILITY Y r N ANY PROpRIETORIPARjN XEGUTIVb OFFICEWM[M9�REXCLUDEE?NIA (Myyind�(cIyIn NN) ❑ 9118 71yOPeOPERATIONS beloW ❑ C 4TAT . H- E.L. EACH ACCIDENT S 6.L DISEASE. ElA EMPLOYE " S 61. DISEASE -POLICY LIMITI S DESCRIPTION OF OPERATIONS I LOCATIONS I VBHICLUS (AltasD ACOr+o las, neauonel se+narKe seneaae, o more spase w requrroal • CGC 1513719 — E231500 CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES BUILDING DEPARTMENT 10050 NE 2 AVENUE MIAMI SHORES, FL 33138 FAX: 305-755-8972 - ACORD 25 (x010106) OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES INE CANCELLED BEFORE THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCII WITH THE POLICY PROVISIONS. 0 jSU-2010 ACORD CORPORATION. All rights reserved. he CORD name and logo are registered marks of ACORD } JEFF AT'WATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 12-26-2012 * * 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: 03/03/2013 PERSON: ACOSTA FEIN: 020688821 BUSINESS NAME AND ADDRESS: ONE STOP PAVING INC 1463 NE 173 ST NORTH MIAMI BEACH FL 33162 SCOPES OF BUSINESS OR TRADE: 1— STREET OR ROAD CONSTRUCTION: P 3— LICENSED GENERAL CONTRACTOR EXPIRATION DATE: 03/03/2015 CARLOS M 2— CONCRETE OR CEMENT WORK — FLOG P Imrun IAN r: Pursuant to Chapter 440 • 06(14), F.S., an officer of a corporation who elects exemption from this chapter by fillog a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.06112), 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 441.05{13), 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 shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DwC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1609 r STATE OF (FLORIDA) COUNTY OF (DADE) Miami Shores Village Building Department SURVEY AFFIDAVIT 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 The undersigned Affiant, KOD16v R. La V k , does hereby attest that (Property owner The attached survey, performed by 1.A&)ue5 4nmcI► CAReia_ :ZaC (Name of surveyor's company) For address:No Aj9-110 9+0-e.efi r(iA,ShoRes, L331b( Performed on io 19 s (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits. Fu er, Affiant say a Haug ////////fAA..`` , *X /. 4 t, Property Owner Signature Property Owner Print Name . SWORN TO AND SUBSCRIBED before me this day of i 01 . Affiant is _e��alpersonally known to me, produced"b L"C ftjSe_ as identification. Revised on 5/22/2009/ Revised on 6/12/09 Notary r� MIA MAM MORRM IEXPIFES: September 8, 201T ''�mo BOW nmk getNoWyServicss or . WHEREAS, � V described property: Legal description/follo# Lot Tax Folio It l l M i Shores Village 10050 Northeast Second Avenue Miami Shores, Florida 33138-2382 Telephone: (305) 795-2207 Fax: (305) 756-8972 www.miamishoresvillage.com OF CONSTRUCTION WITHIN RIGHT OF WAY P.S hereinafter referred to as the Owner of the following 3-3161 ck G1 00 '4 0 43 0 I Block 'y Subdivision Requests permission to install: I' Asphalt, concrete, brick ❑ Landscaping ❑ Other Within the public road right of way of IN CONSIDERATION of the approval 1. To maintain and repair, when If it becomes necessary for M public right of way including n paid by the Owner or shall co 2. The owner does hereby agree and all liability, which may rte 3. The Owner does hereby agre by the Village to do so. Failur removed and a Hen being pla removal and disposal of the 0 4. The undersigned further agre shall remain in full force and this obligations has been can Village Manager of Miami Sh SIGNED, SEALED, EXECUTED SIGNED, SEALED, AND l0 (address) this permit by the Village, the owner agrees as follows: wessary, the above-mentioned itern(s) installed within the dedicated right of way. rmi Shores Village or Dade County to make repairs or maintain said Items within 3toration of street by reason of the Owner's failure to do so, such expense shall be route alien against the above described property until paid. to indemnify and hold Miami Shores Village or Dade County harmless from any by virtue of permitting the installation of these Items within the pubic right of way. to remove or relocate their facilites at their own expense, within 60 days notice to comply with this notes will result in the Village causing the Item(s) to be 3d on the property and/or assessed against the Owner for all costs incurred in the that these conditions shall be deemed a covenant running with the land and xg and be binding on the undersigned, their heirs and assigns, until such time as ed by an affidavit filed in the Public Records of Dade County, Florida by the s Village (or his fully authorized representative). on this in the presence of: of �+ -z 0 (Cl SOBRMto ON 8 EE 05x935 EXPIRES: January 27, 2015 Bonded 7W Notary Puft W dwrhm au►rlow uimpm mm-NASHINum r: (itis llroparty cicsc.riww ,: -Lot 12 Block 2, COLLEGL• IK AITS, ea ccord i !tel I•u the Plat at 1.110 -1.1 -of ' cis recor•dlf!tl ill Plat Rook 42, Pale is of the: l"Libl i c Records of Dade County, Florida. cur rici a r, l. inn t il-D d► cltlso _ T -U3 P.06/01 F-236 • •e„u._Ay.•e Y 1•i • .-' M: z�'�2 tlMtli' i 7t»'�',ty-'� siF.i'•.•.C7G • •_" ' `i` r: n i -i =�:`� cit t: c •.t' i r..1. �: ,t t•r 5 u t't� r� �:� �= �: yutj, Ka it uu A. anti Note: Underground t:=:oac:lwient and ut:ilit:Los, if any, not lova toll. Fawco owncrshih by visual means only, legal owner:*hip not: t•oterminod. FLOOD ZONE: x FLOOD INFORI>MA` I ON: Community No.0652 ranol No.: 93 Suffix: J Date Ui r.1.11. Ai.: 3-2-94 Basen / 1si eta tx -t- Not � �/ i a Available �anu' aunil"9 �. • M Z. 11 ' �� l Y. - lff Y - t11 N • M Z. 11 ' �� l r7 . ;�f ;Lia •ii � ce I fi3,EF' i� `• i't ' TATE Ah9 1 if ell l ,d4 ftEQF1� H13 — - ' Layag, 11ar.ilou A., PROPERTY OF: 1 136 tI. C . 1100 5tl'00t, ;=Naini. Not valid un►e6s ambo secs Willi Su, ix Seal. ii—':,�+Y'°tt (tt:Ct,t•isi. A BOUttDARY SURVEY I horFby entity Ihbt iltt• w(yoy reltre- tented hrrean merit the Met-JiMim teehnital trandar.la tet forth by the "4111 al land aurveyn,s putauant to Set tion 472.027, Fla. �tatutct. Thrra art - m, ent niat•hrrirntt. o, artapt, rarrmrntt aplMarigtt r>n the Pled, of e than at LANNES and +GARCIA, INC, ENGINEERS - LANG SURVEYOR" - LAND PLANN0". 359 Alcazar Avenue:, Coral Gables, i i •, Office adc(rams: 9f�itltSiYlbcft hctit�trAaai i�a�ixjil•+cuto %.' Mailing address; P.A. 90x 561131, Miami, Flnridia 331 . 310 5) 666-7909 11.1. Its -16. land S;11#" te,r No. ' d,---tf; $C/�LE - PRAWN aY DRWC*-. 7 :;3ZI: 1i e:d ' O i't < <s L1ni iJtUC �1::\f l.�t•te , J lff Y - t11 N r7 . ;�f ;Lia •ii � ce I fi3,EF' i� `• i't ' TATE Ah9 1 if ell l ,d4 ftEQF1� H13 — - ' Layag, 11ar.ilou A., PROPERTY OF: 1 136 tI. C . 1100 5tl'00t, ;=Naini. Not valid un►e6s ambo secs Willi Su, ix Seal. ii—':,�+Y'°tt (tt:Ct,t•isi. A BOUttDARY SURVEY I horFby entity Ihbt iltt• w(yoy reltre- tented hrrean merit the Met-JiMim teehnital trandar.la tet forth by the "4111 al land aurveyn,s putauant to Set tion 472.027, Fla. �tatutct. Thrra art - m, ent niat•hrrirntt. o, artapt, rarrmrntt aplMarigtt r>n the Pled, of e than at LANNES and +GARCIA, INC, ENGINEERS - LANG SURVEYOR" - LAND PLANN0". 359 Alcazar Avenue:, Coral Gables, i i •, Office adc(rams: 9f�itltSiYlbcft hctit�trAaai i�a�ixjil•+cuto %.' Mailing address; P.A. 90x 561131, Miami, Flnridia 331 . 310 5) 666-7909 11.1. Its -16. land S;11#" te,r No. ' d,---tf; $C/�LE - PRAWN aY DRWC*-. 7 :;3ZI: 1i e:d ' O i't < <s L1ni iJtUC �1::\f l.�t•te , J (o'X(o' C -NC. EDGE CURB ERVIOUS $RICK PAVERS OVER 2' SAND FILL (o' LAYER OF WELL FCOMPACTED LIMEROCK 11-1 11-1 I. i -1 11=1 I I-1 I I-1 I I-1 I i-1 I I-1 11--1 I I-1 I I-1 I'' f3RlGK PAVER DETAIL Miami shores V 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 f: 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.o�y 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 Print Name: Signature: State of Florida) County of Miami -Dade) Sworn to and subscribed be e day of , 20 By V (C-tvkZ LAY (SEAL) Tvpe of Identffication !, G/ Print Name: Ca/' `q„.5 »Y 060S4 BARBARO SOBRINO` , •# EItPlREB: Jent�y 2'r. X115 WOMCOh EMRMt�S3ljanu # EE 059A35 27.2015 State of Florida .a: f r eo'�anaut�en'�u� um'„"stere eoaded Tlw wocrey Punk uanMbm County of Miami ade ) 1s Sworn to and subscribed before me this 3 U Cir day of 7' 9201 By CA QjS %cO 5 of Identification