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DS-15-1542Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-237766 Permit Number: DS -6-15-1542 Scheduled Inspection Date: June 29, 2015 Permit Type: Driveways/Sidewalks/Slabs Inspector: Rodriguez, Jorge Inspection Type: Final Owner: MCHALE, EDWARD Work Classification: Repair Job Address: 9500 NE 12 Avenue Miami Shores, FL 33138- Phone Number Parcel Number 1132060143640 Project: <NONE> Contractor: TCS EMPIRE INC Phone: (305)234-8355 Building Department Comments REPLACE 1 SQUARE OF SIDEWALK INSPECTOR COMMENTS False June 26, 2015 For Inspections please call: (305)762-4949 Page 21 of 28 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. June 26, 2015 For Inspections please call: (305)762-4949 Page 21 of 28 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number Applicant 9500 NE 12 Avenue 1132060143640 EDWARD MCHALE Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell EDWARD MCHALE 9500 NE 12 Avenue MIAMI SHORES FL 33138-2543 Contractor(s) Phone Cell Phone TCS EMPIRE INC (305)234-8355 In Review Date Approved:: In Review Date Denied: Type of Work: REPLACE 1 SQUARE OF SIDEWALK Additional Info: Bond Retum : Classification: Residential Scannina: 3 Fees Due Amount CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 Valuation: $ 500.00 Total Sq Feet: 25 Pay Date Pay Type Amt Paid Amt Due Invoice # DS -6-15-56064 06/23/2015 Check #: 600492 $ 114.60 $ 0.00 Ayaname 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 certify that all the foregoing information is accur d that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above-named cerffrpctor to cjb tqpAVrk stated. June 23, 2015 Authorized Signature: Owner / Building Department Copy �� 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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑PLUMBING ❑ MECHANICAL [—]PUBLICWORKS JOB ADDRESS: 9500 NE 12 Avenue FBC 20 fC:D Master Permit No.y SH Sub Permit No. ❑ REVISION ❑ EXTENSION []RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County Miami Dade Zip: Folio/Parcel#: 11-3206-014-3640 Is the Building Historically Designated: Yes NO XXX Occupancy Type: Resdenbal Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Edward F Mchale Phone#: (305) 812-0876 Address: 9500 NE 12 Avenue City: Miami State: FL Zip: 33186 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: TCS Empire, Inc. Phone#: (305) 234-8355 Address: 14629 SW 104th Street, Suite 518 City. Miami State FL Zip; 33186 Qualifier Name: Angel M Pareja Phone#: (305) 234-8355 State Certification or Registration #: CGC 1504111 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 500 Square/Linear Footage of Work: 25 sq. ft. Type of Work: ❑ Addition ❑ Alteration ❑ New 7 Repair/Replace ❑ Demolition Description of Work: Replace 1 square of sidewalk Submittal Fee $--)L-J ° Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ `` 11 t 4+. //''`` TOTAL FEE NOW DUE $ l\ . 60 (Rev(sed02/24/2014) City State Zip City 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... : 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. RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FIN LING-.-aMSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING Notice t. Appli a c ndition to the issuan of a building permit with an estimated value exceeding $2500, the applicant must promise 'n good fait th of the notice of mmencement and construction lien law brochure will be delivered to the person whose perty is s ject ac nt. Also, a cert ied copy of the recorded notice of commencement must be posted at the job site for the r st inspecto curs s n (7) dayser the building permit is issued. In the absence of such posted notice, the inspecti will ne appro, d a d a reins ctic fee t/ be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this day of 20 15 by DWfi40 F' who is personally known r,oe or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: APPROVED BY (Revised02/24/2014) # EE 198416 28,2D16 as The foregoing instrum��ery was acknowledged before me this day of. 1,2e— , 20 /�, by ��1-1'✓�� who is personally known to me or who has produced L as identification and who did take an oath. NOTARY PUBLIC: Sign: Seal: �ft � Notary Public State of Florida Joanna M Feliciano My Commission FF 082753 orw Expires 01/12/2018 '04011 � Plans Examiner Structural Review Zoning Clerk Miami Shores Village Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. XXXX COPY OF QUALIFIER'S STATE LICENCES B. XXXX COPY OF LOCAL BUSINESS TAX RECEIPT 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor 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 form and Contractor 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. ■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■ BUSINESS NAME: TCS Empire, Inc. BUSINESS ADDRESS: 14629 SW 104 St. #518 BUSINESS PHONE:3(, 05 ) 234-8355 CELL PHONE31 05 ) 979-4561 CITY Miami STATE FL Zip 33186 FAX NUMBER3( 05 ) 675-0342 QUALIFIER'S NAME: Angel M Pareja QUALIFIER'S LIC NUMBER: CGC 1504111 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD ' 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 PAREJA, ANGEL M TCS EMPIRE INC 14629 SW 104 STREET SUITE 518 MIAMI FL 33186 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE RICK SCOTT, GOVERNOR (850) 487-1395 3STATE OF FLORIDA 3 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CGC1504111 'ISSUED: 08/14/2014 CERTIFIED GENERAL CONTRACTOR PAREJA, ANGEL:M TCS EMPIRE INC IS CERTIFIED under the provisions of Ch.489 FS. Expirationdate AUG31,2016 L140814000IB64 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1504111 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 o a PAREJA, ANGEL M TCS EMPIRE INC 14629 SW 104 STREET SUITE 518 MIAMI FL 33186 ISSUED: 08/14/2014 DISPLAY AS REQUIRED BY LAW SEQ IN L1408140001864 0001126 Local Business Miami -Dade County, -THIS IS NOT A SILL 6519871 BUSINESS NAMEMOCATION TCS EMPIRE INC 14629 SW 104 ST 518 MIAMI FL 33186 Tax Receipt State of Florida - DO NOT PAY j tt 1 RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2015 6790209 Must be displayed at place of business Pursuant to County Code Chuptor 8A -Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED TCS EMPIRE INC 196 GENERAL BUILDING CONTRACTOR By TAX COLLECTOR Worker(s) I CGC1504111 $75.00 09/29/2014 ECHECK-14-145295 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 Ba -276. For more information. visit wwwAlln pffidQ.yov/taac0110C191 TCSEM-1 OP ID: SD CERTIFICATE OF LIABILITY INSURANCE COVERAGES 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, 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. DATE06/19/2015Y) 06!19/2015 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 Kahn -Carlin & Company, Inc. 3350 S. Dixie Highway Miami, FL 33133-9984 CONTACT PHONE FAX A/c No Fd); 305 A No: 305-448-3127 ADoliEss: processing@kahn-carlin.com INSURER(S) AFFORDING COVERAGE NAIC # 11/15/2014 INSURERA:Arch Insurance Company 11150 EACH OCCURRENCE $ 1,000,00 INSURED TCS Empire, Inc. 14629 SW 104 Street, #518 Miami, FL 33186 INSURERS: INSURERC: GENERAL AGGREGATE $ 2,000,00 INSURER D: INSURER E: $ INSURER F : AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COVERAGES 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, 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 ADDL UBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADEI OCCUR �AGI_000649401 AUTHORIZED REPRESENTATIVE 11/15/2014 11/15/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occu encs $ 100,00 MED EXP (Any one person) $ 5>00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 1,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea .,dent)S BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PER ERTY DAMAGE $ — _ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N f A WC STATU- OTH- TORY LIMIT ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) General Contractor - License CGC1504111 CFDTIGICATG 1-1(11 nr-O rANrFI I ATION MIAM-03 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village Building Department 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 U 19BI1-ZU1 U ACUKU UUKFUKA I IUIV. All rlgnis reserVeo. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACCMD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/19/2015 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 FrankCrum Insurance Agency, Inc. 100 South Missouri Avenue Clearwater, FL 33756 CONTACT NAME: PHONE A/C, No, Ext): 1-600-277-1620 x4800 FAX A/C, No): 727 797-0704 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Frank Winston Crum Insurance Co. 11600 INSURED FrankCrum L/C/F TCS Empire, Inc. 100 South Missouri Avenue Clearwater FL 33756 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: CnVFRAGFS CFRTIFICATF NI)MRFR: 319420 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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. INSRTYPE LTR OF INSURANCE ADDL INSRD SUBR WVD POLICY NUMBER POLICY EFF (MWDDYYY) IY POLICY EXP (MWDDNYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ GE TO RETED PREMSES Ea occurrence $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ $ POLICYf—I PROJECT F7LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE Per accitlent $ HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAR OCCUR EACH OCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N WC201500000 01/01/2015 01/01/2016 I WC X STATUTORY LIMITS O ERR E.L. EACH ACCIDENT $1.000.000 ANY PROPRIETOR/PARTNERIEXECU'rIVE OFFICERIMEMBER EXCLUDED? Q N/A E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks, Schedule, if more space is required) Effective 04/06/2015, coverage is for 100% of the employees of FrankCrum leased to TCS Empire, Inc. (Client) for whom the client is reporting hours to FrankCrum. Coverage is not extended to statutory employees. General Contractor - License CGC1504111 ® 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 ® 1988-2010 ACORD CORPORATION. All rights reserved. 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