RC-15-303eJV� Miami Shores Village ;.6 ,":7°1-,
Building Department FEB 1 1 15
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
BUILDING Master Permit No.�
PERMIT APPLICATION Sub Permit No.
91F BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10544', Sj . # .:?) a
City: Miami Shores County: Miami Dade Zip: 3
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): L aAma Cc•a, nam. i 4,e *Ajo� a, 'fpl"kee Phone#: 7aO -amici �ro
Address: I?0b -1AA !S -V. TV a, -a'
City: M i&Wi, State: EL Zip: _33 ) 8 3S
Tenant/Lessee Name: Phone#:®S - 7,R6 -
Email: `u.14v1A(;/{rt 4VLUawl (P 6YK&%.: + C -6m
CONTRACTOR: Company Name:
Address: 3 4 0 S w
vcli^ & . eve_" �►� � C_�
B'l AV,
305-- 77r'O Ira
City: M I AV*1I State: r—L— Zip: 331 Lt 5�
Qualifier Name: �% r e Phone#: -30 9�'� 9' 3
State Certification or Registration #: C 15 C ® 108-3 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ q 2 o Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Is Repair/Replace ❑ Demolition
Description of Work:� � t� � �� �� �-p.� 411^(" ,1n
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ t2G • 0 0 CCF $ CO/CC $
Scanning Fee $ _
Technology Fee $_
Structural Reviews
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ • ULJ
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
Zip
City State Zi
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.
Signa re Signature c;2,2 Z<--IZZ
OWNER or AGENT CONT CTOR
The (foregoing instrument was acknowledged before me this
*\ day/oaf � . b(�-.k c 20 1 C—)• by
L V Ck l L' (06(:,k (n , who is personally known to
me or who has produced i-J(t (�'y elle , i c---�s
identification and who did take an oath.
NOTARY PUBLIC:
Print Z�U-k--y I
Seal: ,io»eYpOBi� JUDITH PEREZ
s Notary Public - State of Florida
?•. W.
;N . -,z My Comm. Expires Mar 19, 2016
Commission # EE 180865
APPROVED BY
(Revised02/24/2014)
59
The foregoing instrument was acknowledged before me this
day of �6A -AGir' 20 �� , by
who is personally known to
me or who has produced�ALX �G'G� l ei oeli `'\C-*41-a'S1-
identification and who did take an oath.
NOTARY PUBLIC:
ef
Sign: W�
Print: 1d
,`'- -'. JUDITH PEREZ
Seal: 02. . �:
* . Notary Public - State of Florida
is . cPc My Comm. Expires Mar 19, 2016
o'FOFv�o:d� Commission # EE 180865
/ Plans Examiner
Structural Review
Zoning
Clerk
VVOONJ �
1:
Local Business"Tax Receipt
r Mlam'i-pade Co�inty;: "State of; . Florida .
=THIS IS; >NOTA :BILL DO;NOTPAY`
ACORD CERTIFICATE OF LIABILITY INSURANCE626�o;MIDDIT
'r'
PRODUCER
COVERALL INSURANCE
5800 W. ATLANTIC BLVD.
MARGATE, FL 33063
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE 7NAIC
#
INSURED HUGH A. RYAN CONSTRUCTION COMPANY
1320 S.W. 13 TH AVE
MIAMI, FL 33145
FAX# 305-858.1$92
INSURER A: FEDERATED NATIONAL INSUREANCE
UN4T8
INSURERS:
701ENERAL
INSURER C:
GL -0504008T10 -D3
INSURER
0210112016
INSURER E:
DAMAGE TO RENTED $10%00
00
MED EXP one on SAP
P./ll ff 7MAnCft
vTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSURAWIF
POLICY NUMBER
POLICY EFFECTIVE
MfDDAIVI
POLICY EXPIRATION
UN4T8
701ENERAL
LIABILITY
MERCIAL GENERAL LIABILITY
CLAIMS MADE 5 � OCCUR
GL -0504008T10 -D3
0210112015
0210112016
EACH OC CE 30 4"
DAMAGE TO RENTED $10%00
00
MED EXP one on SAP
PERSONALS ADV INJURY 111300,100
GENERAL AGGREGATE sefto
N'LAGGREGATELWITAPPLIESPER:
PRODUCTS-COA�/OPACiG 600000
POLICY PRO -
11 LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea ®ardent)
ALL OWNED AUTOS
SCHEDULED AU70S
BODILY INJURY S
(Per person)
HIRED AUTOS
NON -OWNED ALITOS
BODILY INJURY
(Pef aa�dent)
PROPERTY DAMAGE
(Par accident)
GARAGE LIAMUTY
AUTO ONLY - EA CCIDENT S
OTHER THAN EA ACC
ANY AUTO
AUTO ONLY: AGG 8
EXCESSIUMBRELLALIABILITY
OCCUR CLAIMS MADE
EACH OCCURRENCE $
AGG EGATE $
DEDUCTIBLE
S
$
HF.TENTION $
WC STATU- OTH-
rg
WORKERS COMPENSATION AND
E.L. EACH ACCIDENT $
EMPLOYERS' LIABILITY
i
E.L. DISEASE - EA EMPLOYEE $
ANY PROPRIETORMARTNERIEXECUTIVE
OFFICERIMI-MBER EXCLUDED?
(
E.L. DISEASE. POLICY LIMIT S
Ka doscnbe under
PROVIS NS WIM
OTHER
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVM30NS
REMODELING
LIC# CBC?5^983
ktArdl SHORES VILLAGE
11. ,50 Northeast 2nd Avenue
Miami Shores, Florida 33138
w /.Ael'9 AC t'fR RA IRO\
SHDULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE =WHO INSURER WILL ENDEAVOR TO NAIL 10 DAYS WMMN
NOTICE TO THE HOLD ABED HE LEFT. BUT FAt TO DO SO SHALL
IMPOSE NO OBLI TIO OFA INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTATIVE
1988
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF :`:'.NP',NCIAL SERVICES
DIVISION OF W1°7�KGFS` COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT 17110 I F't'--]DA WORKERS' COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exemrt trcrr± Florida Workers' Compensation law.
EFFECTIVE DATE: 2/28/2014 EXPIRATIOdk LA J E: 2/28/2016
PERSON: RYAN HUGH A
FEIN: 562312507
BUSINESS NAME AND ADDRESS:
HUGH A RYAN CONSTRUCTION CO
1320 SW 13TH AVENUE
MIAMI FL 33145
SCOPES OF BUSINESS OR TRADE:
LICENSED BUILDING
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 bisinass 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 iotice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)113-1609
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. 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 pro-vided mlaffi4vit 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 verifrcat oo of
wor ecl—rs�compensafioninsurance coverage from
the contractor's company for day labor, part-time employees or subcontractors..
Therefore, You may 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
rni rr1Q rrc
County of Miami -Dade
The foregoing was acknowledge before me this 1 I
day of �Gb t'�t� y , 20 jig' .
BY Lgg&e n Cwt a., ,ZNL
who is pe onally known to me or has produced
as identifi 902op.;SAY Pie•. '�� MARIE FICUEROA
Notary Pubhe - State M Flori
. •e
Notary: es Mar 3 jo
Commission # EE119464
State of Florid/
County of Miami -Dade
The foregoing was acknowl ge before me this
day of VeN - --t– 920 I S .
BY t*,,, , P. Ki a.�o
who is personally known tome or has produced
t� r -,."o., , ,,,.;,,
as
Notary r'L,U„
My Comm. Expl-,
Commission # EE d i a4b
4
V
E xemption Affidavit ForWorkers' Compensation
Bate Received: -:7/ll l !r Agency: A4iA'k" o 5%�A�- J5'
t1)�
Job Address: /700 Alf— `�S` .S �'o ��f Z � kvh6k , 54-% �e S. �� -3 �r) 3 9
This will confirm that we shall not employ any workers other than and
properly licensed/insured subcontractors and myself
Hugh A. Ryan- CBC -059083
Signatdre
Notary State of Florida,
County of Miami -bade
Date
The foregoing instrument was acknowledged before me on this day of
/-- �o�.
�-- who is personally known or who produced
PL :.roa �a-i ?3 S for identification.
Signature of No_lary-R blic- State of Florida
MAOT. MOME8W0
M.
My commis �r�c
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L!
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t.
V,"'a j — ,
S -f
P, T NTL
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rev
Zl�
oset A, �6, 3,
a
Miami Sliores Village
APPROVED BY ATE
r.
ZONING DEPT
13LDG DEPT
SUBJECT TO COMPLIANCE WITH ALL FE AL
-TATF /\Nr) COUNTY RUL FS AND RFOU1.
169,
FEB -I 12015
LBY:
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FEB -I 12015
LBY:
PREMIUM ACOUSTICAL UNDERLAYMENT
WITH MOISTURE BARRIER
Use with laminate, engineered, bamboo and corm hardwood flooring
FLOOR (9
DECOR._
TILE • WOOD •STONE
Exclusively sold through Floor & Decor
11 eDown
Flooring",.;7
a
11 REDUCE THE NOISE!
STC 73 / IIC 73, Delta IIC 22
provides up to a 78% decible
sound reduction.
New revolutionary MOISTURE BARRIER
FILM for the best bond strength, durability
and moisture protection.
Resists indentation that enables your
floors to perform to its fullest potential
A
and last a lifetime.
Heavyweight HIGH DENSITY quality
underlayment. Made in the USA.
GO GREEN! Made with 100% post
consumer recycled granulated rubber tires
rol
and high-density polyurethane foam using
g$,
rapidly renewable resources (Agrol soybean
polyols and vegetable oils).
Up to 6 LEED credits for Green Building
certification, highest of any underlayment.
Contains ULTRA -FRESH °, an antimicrobial
protection that resists mold and mildew to
promote a healthier living environment.
#1 ,
Industry's best limited LIFETIME WARRANTY
covers the Eco -Ultra Quiet underlayment
and use under all brands of laminate and
wood flooring.
FLOOR (9
DECOR._
TILE • WOOD •STONE
Exclusively sold through Floor & Decor
11 eDown
Flooring",.;7
a
11 REDUCE THE NOISE!
STC 73 / IIC 73, Delta IIC 22
provides up to a 78% decible
sound reduction.
ECO -ULTRA QUIETTM MAINTAINS THE BEAUTY OF YOUR FLOOR LIKE NOTHING ELSE.
ECO -ULTRA QUIET TM UNDERLAYMENT CAN STAND UP TO THE PRESSURE.
ADVANTAGES
• Eco -Ultra Quiet"" is made with 100% post consumer recycled
granulated rubber tips and high-density polyurethane foam using
rapidly renewable resources (soybean polyols and vegetable oils)
• Suitable for floating, glue down, and nail down laminate,
solid hardwood, engineered wood, and bamboo flooring.
• New revolutionary moisture barrier film for the best bond
strength, durability and moisture protection up to 4 lbs. of
pressure. In geographic areas where concrete subfloors are
subject to excessive moisture, a calcium chloride moisture test
is required. Vapor emission readings in excess of 4 lbs. per
1,000 square feet in 24 hrs. will require additional protection
such as concrete sealant or polyethylene sheeting.
• Contains Ultra -Fresh', an antimicrobial protection that resists
mold and mildew
• Crushpruf" technology resists indentation that enables your
floors to perform to its fullest potential and last a lifetime
• Provides cushioned comfort under hard laminate flooring
• Eliminates minor subfloor imperfections
• Offers the industry's best limited lifetime warranty
• Suitable for radiant heat flooring systems
APPROVED SUBSTRATES
• Dry, completely cured concrete (at least 14 days old with
HVAC operating)
• 3/4' interior plywood, OSB flooring, gyperete (must be primed
before glue down)
• Waterproofing and crack -isolation membranes
• Cement backer units
• Existing wood and laminate floors
FLOOR PREPARATION
• Subfloor should be clean and dry
• Follow the wood manufacturer's installation instructions for any
additional preparation
QUICK AND EASY INSTALLATION
requires no additional seaming tape, cuts with a knife
1. Install Eco -Ultra Quiet'" Acoustical with film down against
concrete/subfloor.
2. For floating and nail down installations, roll out underlayment
with tape strip next to wall. Roll out next row in same manner
butting underlayment close to first row (do not overlap) and
covering the moisture barrier film. Remove the tape strip and
secure the overlapping moisture barrier film.
For double glue down installation for wood flooring, use
NA 8500 adhesive (based on the adhesive manufacturer's
recommendation) with a 1/16" — 3/32" trowel on the subfloor.
Trim off the excess overlapping film. Roll out underlayment
with tape strip next to wall. Roll out next row in same manner
butting underlayment close to first row (do not overlap). Roll with
a 75 -100 Ib. roller to smooth out any air pockets and to secure
a good bond to the adhesive.
3. Install flooring according to the laminate/wood manufacturer's
installation instructions.
PACKAGING
• Available in 3x 33.34' (100 sq. ft.) rolls and
6' x 75' (450 sq. ft.) contractor size rolls
TECHNICAL DATA
100% High -Density Polyurethane foam underlayment blended
with post consumer recycled granulated rubber tires and
bonded to a moisture vapor film.
Thickness.............................................................................070"
Density............................................................................ 25 LBS
Weight.................................................................... 2.35 oz/sq.ft.
Antimicrobial Treatment ....................................... ULTRA -FRESH T"
Thermal Resistance.................................................... R -Value .17
Compression Resistance ASTM D3676 ............................... 20 psi
Compression Set ASTM D3574 .......................................... 8.3%
Flammability Rating................................................Passes Federal
Flammability Standards DOC -FF -1-70
Smoke Density ...................................................Passes, 110 max
Product Emissions.....................................Exceeds VOC emissions
requirements, environmentally friendly
SOUND ABSORPTION PROPERTIES
Impact Insulation Class (IIC) This method is to measure
the impact sound transmission performance of a floor -ceiling
assembly (sound transmission through the floor)
IIC
Flooring
Sub -Floor
70
Laminate/Engineered
6" concrete with ceiling assembly
58
Hardwood
6" concrete with ceiling assembly
52
Laminate/Engineered
6" concrete with NO ceiling assembly
52
Laminate/Engineered
wood joist with ceiling assembly
Sound Transmission Class (STC) This method is to measure
the air -borne sound insolating property of a partition element
for effectiveness in blocking
sound
STC
Flooring
Sub -Floor
73
Laminate/Engineered
6" concrete with ceiling assembly
53
Hardwood
6" concrete with ceiling assembly
51
Laminate/Engineered
6" concrete with NO ceiling assembly
58
Laminate/Engineered
wood joist with ceiling assembly
Delta IIC The db rating difference between a floor measured
with an underlayment and with no underlayment
A IIC 22 (up to a 78% db sound reduction)
LEED CREDITS
MR 4.1 10% recycled content
MR 4.2 20% recycled content
MR 5.1 10% content manufactured within 500 miles of project
MR 5.2 20% content manufactured
within 500 miles of project FLOOR FO
MR 6 Rapidly renewable resource DECOR
EQ 4.3 low emitting VOC's , WrA
TILE • WOOD • STONE