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RC-15-884Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 VIVJ eLMUUFV?¢+ Parcel Number Applicant 320 NE 100 Street 1132060135460 Miami Shores, FL 33138-2421 Block: Lot: LEAH GROSSMAN owner mrormaaon Address Phone Cell LEAH GROSSMAN 320 NE 100 Street (786)342-8921 MIAMI SHORES FL 33138- 320 NE 100 Street MIAMI SHORES FL 33138 - Contractors) Phone Cell Phone CAIBAI CONSTRUCTION LLC (786)229-2770 (786)470-4207 In Review i Approved:: In Review i Denied: of Construction: BATHROOM REMODELING Occupancy: es: Exterior: t Setback: Rear Setback: Setback: Right Setback: 'ooms: Bathrooms: s Submitted: Certificate Status: ificate Date: Additional Info: Fees Due Amount CCF $4.90 DBPR Fee $3,22 DCA Fee $3,22 Education Surcharge $1.60 Permit Fee $214.50 Scanning Fee $9.00 Technology Fee $6.40 Total: $242.74 Valuation: $ 7,150.00 Total Sq Feet: 100 Pay Date Pay Type Amt Paid Amt Due Invoice # RC -4-15-55207 04/22/2015 Credit Card $ 192.74 $ 50.00 04/15/2015 Cash $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final PE Certification Window Door Attachment Framing Insulation Drywall Screw Fill Cells Columns Window and Door Buck Review Planning Review Electrical Review Building Review Plumbing Review Structural Review Mechanical 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 accurate and that all work will be done in compliance with all applicable laws regulating construction and 4oning. Futhermore, I authorize the above-named contractor to do the work stated. Signature: Owner / Agent April 22, 2015 Building Department Copy April 22, 2015 1 Miami Shores Village g J� 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 Pq BUILDING ❑ ELECTRIC ❑ ROOFING APR A 2015 FBC 20 (0 Master Permit No.�� ` I15 —�� Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: j 9- C% = City: Miami Shores County: Miami Dade Zip: 1313 R Folio/Parcel#: //-3;0 -0/3 -5-4&0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):f ��T� /,P �ei2a55 /1')�nl Phone#: 110AI &64 1033 Address: ;20IN� M- City: Tenant/Lessee Name: Email re S State: l=L Zip: '13/3 Phone#: AdA CONTRACTOR: Company Name: a A—,-8.4-,- O O»S 7,.e Al&r LLC Phone#: , Jac • 69-7' 015.31 Address: /o8 76 6W 5W 7�-, City: Mti2,01 State: f L Zip: 631 &,�- Qualifier Name: -'— rce- LQ� Phone#: 3®s • ,Sot 1 65M State Certification or Registration #: _ dd 05Z ®CDS Certificate of Competency #: Al 6A DESIGNER: Architect/Engineer: #j 117 Phone#: a 1A Address: hi City: ��� State: On Zip: Value of Work for this Permit: $ 1, &0.00 Square/Linear Footage of Work: SC`7® SSS. Ff Type of Work: ❑ Addition ❑ Alteration ❑ New RVRepair/Replace ❑ Demolition Description of Work: &Aravom ie -M& J e j Specify color of color tthru tile: Submittal Fee $ �( J ' "�-) Permit Fee $ 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 $ Bonding Company's Name (if applicable) I� , Bonding Company's Address /A City ,mla State N/j4 _ Zip �9 Mortgage Lender's Name (if applicable) Mortgage Lender's Address 1.4 City A JA State 91A 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. �n the absence such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature VAL ,tip Signature OWNER or AGENT V CON CTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this . a day of mar k . 20 16 , by a day of ltliC k , 20%� . by I -ea k 67EQ55" , who is personally known to J& Lo -so, , who is personally known to me or who has produced aAL> 6626 6739glnG�9 83 aOs me or who has produced FL as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: (" ( &r�Sign: Print: Print: 'AP Y°`���. CRISTHIAN GRILLO Seal: -'• '= MY COMMISSION # EE098903 Seal: *: MY COMMISSION # EE098903 EXPIRES May 31, 2015 EXPIRES May 31, 20.15 (407) 398 0153 Flcu tlallo '""``,` tarYse��e•com (407) 398-0153 FlondallotaryService.com APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 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.COPY OF QUALIFIER'S STATE LICENCES B. 7 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: 10I I & ;5w 34 %,9 CITY lMi STATE FL ZIP BUSINESS PHONE:c3( bS ) S27 -oS31 FAX NUMBER (_) CELL PHONE () QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER:4 (o'� ®SPE C & 0 PROFESSIONAL. CONTRACTORS INC. C & G Professional Contractors, Inc. 9254 NW 120 Terrace, Hialeah Gardens, FL 33018 Phone # 305-527-0581 or 786-295-8836 CCC # 1328983 Contract # 1754-0315 Name: Caibai Construction, LLC Date: 03-16-2015 Address: 320 NE 100th St. Total Costs: $3,500.00 City, State, Zip: Miami Shores, FL 1. Scope of Work: C & G Professional Contractors (Sub Contractor) will furnish all labor and equipment in order to remodel 1 bathroom of the property located at 320 NE 100th St. Miami Shores, FL (See # 16 for more Details). Work is to be performed in 2 to 3 Weeks. Caibai Construction, LLS (Contractor) must take into consideration unforeseen delays for example rain and other weather that does not allow Contractor to continue work, any legal discrepancies that the Contractor may go through with the property not allowing work to proceed. 2. Plans and Specifications: Work is to be performed in compliance with FL Building Code 2010, C & G will provide a sketch of existing condition and of proposed condition in order to pull building and plumbing permit. (Contractor will be responsible for all permit fees) (If village request plans done to scale Contractor will be responsible to pay for a drafter/architect in order to submit plans required by Village) 3. Commencement of Work: Sub -contractor will supply all needed documentation, drawings, and applications within 10 days of execution of contract and Sub contractor will commence work within 10 days of the issuance of the Village of Miami Shore Permit. 4. Compliance with Codes and Laws: In the performance of the work, Contractor and all Sub Contractors will comply with the requirements of all applicable building codes and other laws and regulations. 5. Inspection and Testing: Sub -Contractor will make all portions of the work available at all times for inspection and testing by inspectors required and or requested by the Contractor. Inspection and testing will be at the expense of the Contractor. 6. Change Orders: Should Owner, any public agency, or inspector direct any discretionary changes from, or modification of or addition to the work, the cost shall be added to the contract price. A contract addendum will be provided to owner with a separate payment schedule if this is to occur. 7. Correction of Work: Sub -Contractor will immediately, upon written orders of Owner, Architect, and or Inspector, correct any defect or deficiency in their work, equipment, or materials at no additional cost to owner. 8. Concealed Conditions: If Sub Contractor encounters underground or concealed conditions that were unknown to Sub Contractor before the execution of this Contract and that could not reasonably have been anticipated, the Contract price will be equitably adjusted to compensate Sub Contractor for the cost of dealing with such conditions. 9. Clean Up: At all times during the progress of the work the Sub Contractor shall keep the project and immediate surrounding area free form unreasonable or unsafe accumulation of waste material or rubbish. 10. Dumpsters: All Dumpsters and or dump trucks will be paid for by the Sub Contractor. 11. Limitations of work as per price given includes and is limited to: 11.1. Demolition and Disposal: 1. Provide all labor in order to demo and dispose of all construction debris that comes from the demolition process. 11.2. Tile work: 1. Provide all labor and material in order to install file to 40 square feet of floors, 70 square feet of tub walls and 72 square feet, to go up 4 feet on the 3 walls beyond the tub walls. 2. C & G to pick up tile, thin set, mastic, mortar mix and grout, contractor will be responsible to reimburse C & G for the purchase of any of these materials. 11.3. Drywall, Duroc and Mud work: 1. Provide all labor and material in order to install duroc to walls where tub is as well as to the floors in preparation for tile. 2. Provide all labor and material in order to install new green board to wall where vanity is in preparation for tile. 11.4. Painting: 1. Provide all labor in order to paint ceiling and walls that do not have tile. 2. Contractor to provide all paint. 11.5. Bathroom Accessories: 1. Provide all labor in order to install all bathroom accessories provided by owner. Please Print Name Q3 / /& / 2015 X� epared by Juan Cata LOSA, JOSE ANTONIO JR CAIBAi CONSTRUCTION LLC 10876 SW 24TH TER MIAMI FL 33165 is e�ou Wwmeomte of needy one mil�on Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yadit brokers. from boxers to bwbeque r ants, and theykeepFlorida's economy strong. Every day we work to improve the way we do business In order to serve you better. For hibml Son about our services. plem log onto www mytloridaticenoo,com. There you can find more infomrattnn about our divisions and the regulafions That impact you, subscribe to deparktont newsletters and team rrrore about the Depa WWWs init�tives. Our mission at the Department Is: Ucerm Ellidentiy, 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 kwtsel RICkC SCOTT,_G0V RNOR'" - - STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFEESMONAL.RE..GU .ATION CGC068065 ISSUEP;-<`: 07/01/2014 CEFMF1ED t3ENERAL.CON'TE;ACTOR LOS& JOSE ANTONIO t R `:.' CNEW CONSTRt1CTlON Is CERTIFIED Under the provisions of Ch.489 FS. 6 ►dge: nuesr,ars L1401010001488 DETACH HERE .. ............. .... __..____�_...._.___.-. :. .....- t r::Wi. +W30Nt SEML AM- STATE M STATE OF FLORIDA DEPARTMBff OF BUSINESS AND PROFESSIONAL. REGULATION . CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUR1BER'' IlI7 \ I Z7.1 1PLO]e " Named below IS CERTIFIED Under the- provisions of Chapter 489 FS. Expiration.date: AUG 31, 2016 LOSA; JOSE ANTONIO JR .: CAiBAI CONSTRUCTION LLO . . 10876 SW 24TH TER MIAMI F03165 I Ft U O"m Local Business Tax Receipt Miami -Dade County, State of Florida "S IS NOTA BILL — DO NOT PAY 6543749 BUsWWW NAMWWCATON CAWAI CONSTRUCTION LLC 10876 SW 24 TM MIAMI FL 33165 rage 1 oI 1 REC,HPT No. EXPIRES RemOVA . SEPTEMBER 30#2015 "4.11" Must be cfoayW at place of business Pursuantto County Code Chapter 8A — Art 9 & 10 SM TYPE OF BUSIKOW PAYMENT RECEIVER ovmBp 19S GENERAL BUILDING CONTRACTOR BY TAX COLLECTOR CAI&V CONSTRUCTION LLC CGC058065 $75.00 07/17/2014 Worker(s) 1 CREpTTCARRD-14--028362 of the I= W 80laess'I'm Tba Reeaipt � rmta license. ThIsLoweasiaessTaxReasipteslli!ma6� mdoboslaoss. �doro�tcmoplgwitheaYfieuammeelel pomd4 are =Mllca enoltbe holders wbWb op*to We business. or iiig mwawrt laws o re�iren anon bdvehloles— W�nade Code Soc 8"IL 'I�f1I�EIPTp(0,aboaamast bodiaplaYod oa aQ oamoterc �+� �v xcaileaNr Fora►aretcformetioe.��` _ _� _._timer about -.blank 7/25/2014 4 ,4 CERTIFICATE OF LIABILITY INSU NCE DATE 4/11ai1°s PRODUCER Ramallo Assurance Inc. THIS CERTIFICATE S ISSUED AS A MATTER OF INFORMATION 12955 S.W. 42nd Street ONLY AND CONFE S NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CE TIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33175 _ALTER THE COVE AGE AFFORDED BY THE Phone (305)207-1332 Fax (305)207-1343 INSURERS AFFORDING COVERAGE _INSURER A: Essex Ins O INSURED Caibai Construction LLC 10876 SW 24 Ter INSURER_e_ INSURER C: Miami, FL 33165- INSURER D: INSURER E: MAIC # COVERAGES ----- — -- --- ----- INSURER F: -- - — - -- THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLI Y PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO AtHICH 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. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER LTR__INgR�_GENERALLIABIUTY POLICY EFFECTIVE POLICY EXP DATE(MM/DDIYY)-DATE(M__DlYY) TION LIMITS EACH OCCURRENCE 1,000,000' Q COMMERCIAL GENERAL LIABILITYDAMAGE 3DV4549 08/29/14 08/29[ TO RENTED 5 PREMIS-ES.(Eaoccurence) 100,0001 LIE] CLAIMS MADE 0 OCCUR MED EXP (Any one person) 5,000: A ❑ ❑ PERSONAL 8 ADV INJURY 1,000,000 ❑ i GENERAL GREGATE 2,000,000 PRODUCTSGCOMP/OP AGG 1,000,000: GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT [] ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑ SCHEDULED AUTOS - (Per person) ❑ HIRED AUTOS BODILY INJURY ❑ NON OWNED AUTOS (Per accident) ❑ _ - --- --- PROPERTY DAMAGE (Per accident) -- - -_--❑ — GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC AUTO ONLY: _AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE ❑ OCCUR ❑ CLAIMS MADE AGGREGATE - -- ------ - -- - ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND T ❑ WC STATU- ❑ EMPLOYERS'UABIUTYIUTY Tommy-uM1TS__-_ ER _ ANY PROPRIETOR / PARTNER / EXECUTIVE E.L. EACH ACCIDENT _ OFFICER I MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE!] If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIA LICENSE NUMBER CGC058065 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOI EXPIRATION DATE THEREC MIAMI SHORES VILLAGES10 DAYS WRITTEN 1 10050 NE 2nd AVE THE LEFT, BUT FAILURE T( MIAMI SHORES FL 33138 of ANY KIND UPON THE IN AUTHORIZED REPRESENT ACORD 25 (2001108) QF . PROVISIONS E DESCRIBED POLICIES BE CANCELLED BEFORE THE THE ISSUING INSURER WILL ENDEAVOR TO MAIL )TICE TO THE CERTIFICATE HOLDER NAMED TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY URER, ITS AgfENTS OR REPRESENTATIVES. TIVE40 - 1� - © ACORD CORPORATION 1988 JEFF ATWATER CHIEF FINANCIAL OFFICER "" 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 lair. EFFECTIVE DATE: 10/17/2013 PERSON: LOSA FEIN: 800429597 BUSINESS NAME AND ADDRESS: CAIBAI CONSTRUCTION LLC EXPIRATION DATE: 10/17/2015 JOSE 10876 SW 24 TER MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR A JR Pursuant to Chapter 440.05(14), F.S., an oflia®r of a corporation who elects enffq on from this chapter by tiling a certificate of election under this section may not recover benefits or comparsration under tits chapter. Purscrant to Chapter 440 05(12), F.S., Certificates of election to be exempt... apply only within the scope of fire bustrrgsp or trio Holpd on thp MUM of elpom 10 bo Purstror># to Chapter' 4 0.05(13), F.& 140mololegligmto bo exempt end WKwatas Of election to be exempt Shap be subject to revocation If, at any time atter the lV of the notice or the Issuance of the cerdfica#e, the person named on the notice or certificate no khW meals the requkamerb of this section for Issuance of a certillcate. The deparbTwd shall revoke a cerpRc ate at arry time for failure of the person maned on the W1111cafie to meet the mgftmw is of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 Migwc�yo ��i.coM QUESTIONS? (850)413-1609 '°�'�' `' ' CERTIFICATE OF LIABILITY INSURANCE °"' 0411,5115"`' 04/15/15 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 pollcy(les) 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 Rau of such endorsement(s). PRODUCER Accurate CONTACT NAME: Lucia Estrella PHONE, (305)226-8727 (305}226-8767 IF No 8300 West Flagler Suite 114RE-MAIL ludaestreila@bellsouth.net INSURER(S) AFFORDING COVERAGE MAIC # Miami, FL 33144 INSURER A: United Specia)tylnsuranceCompany Phone (305)226-8727 Fax (305)226-8767 INSURED INSURER 8 INSURER C: C & G Professional Contractors Inc INSURER 0: 9254 NW 120th Terr INSURER E: Miami, FL 33018- (305) 527-0581 AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ❑ AAUTOWNED SS L-1 AUTOSSCHEDULED ❑ HIRED AUTOS ❑AUTOS ❑ ❑ INSURER F: 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. ILTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MIRIUDCO MPO MIIDD EXP LIMITS A GENERAL LIABILITY © COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE 9 OCCUR ❑ CGD00001868 12/14/2014 12/17/2015 EACH OCCURRENCE $ 1,000,008.00 PRAEMGES Me RENTE�nce $ 100,000.00 MED EXP (Any one person) S 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER R POLICY ❑ PRO- ❑ LOC PRODUCTS - COMWOP AGG 1 S 1,000,000.00 Is AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ❑ AAUTOWNED SS L-1 AUTOSSCHEDULED ❑ HIRED AUTOS ❑AUTOS ❑ ❑ OMBI &DD SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident S PParr ardent GE $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE I EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' U ABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMSER EXCLUDED? (Mandatory in NH) It yes describe under DESdRIPTION OF OPERATIONS below N / A ❑ WC STAB T ❑ OTFI EL EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space is required) General Contractor CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2 Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shares, FL 33138 AUTHORIZED REPRESENTATIVE 305.756.8972 Lucia Estrella ©1988-2010 ACO C O�ION. All rights reserved. ACORD 25 (2010105) OF The ACORD name and go are registered marks of ACORD 3/2612015 .TEFF ATWATER CHIEF FINANCIAL OFFICER Report Mewer Fitt s}�y STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION } ` CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW. CONSTRUC71ON INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers` Compensation law. EFFECTIVE DATE: 2/26/2015 EXPIRATION DATE: 2/2512017 PERSON: CATA JUAN C FEIN: 204752688 BUSINESS NAME AND ADDRESS: C & G PROFESSIONAL CONTRACTORS INC 9254 NW 120TH TERRACE HIALEAH GARDENS FL 33018 SCOPES OF BUSINESS OR TRADE: ROOFING - ALL KINDS CONTRACTOR -PROJECT AND DRIVER MANAGER, CO Prreuai1DChaPW440.OSC14I,F.S,aidkerdaca wdmvAwdeMwwrdanfran1b DFSF2-DWC 212 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 06-13 QUESTIONS? ($W)413 -1W9 Crit{sJ/ap3s8.fldis.c /Crr Mewer/reps Mewer.aspx?data=kdvpginc9D703gH6TER6ePIKMZ%2fSz5bXKYfBxkrOwE—gWW1v4NPOPN42XeirDRGXWV... 1/2 Report Viewer ODDDD=ii DDo IEri Image JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * 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: 2/26/2015 EXPIRATION DATE: 2/25/2017 PERSON: GRILLO JUAN B FEIN: 204752688 BUSINESS NAME AND ADDRESS: C & G PROFESSIONAL CONTRACTORS INC 9254 NW 120TH TERRACE HIALEAH GARDENS FL 33018 SCOPES OF BUSINESS OR TRADE: ROOFING -ALL KINDS CONTRACTOR -PROJECT AND DRIVER MANAGER, CO Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapterby 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 applyy 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 elecfion 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, ertificate the person named on the notice or cno longer meets m the requireents 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)4131609 0 Page 1 of 1 u file:///C:/Users/alvarers/AppData/Local/Microsoft/Windows/Temporary%20Internet%20F... 4/15/2015 I BANA00M RECEPTACLE ON 20 AMP CKT AND Gh PROTECTED A 0 K E/GA F,, j JN' J-20 Alj� Z,00 r I;SaQ p-r2s: ® -0 m m -71 1W I 177�bl 41 �;x �cs k ! XXZ&r-WJ&i PAM 0;0 VAj:r-ry 4o RoPLAc s OMS :tAl SAME CZ CD m > 0 1-�t A v4x4-c, J&Fe �o 9. -14AXN IE xxs -rxm 30" boog -ro �w 7-.q' b W4 6 LIRE OIAM DU 'rub TI --- 4 :v! AY �4 All -r;lr-, Its AOL y 11 77 �,`r :�dTA pr?"41, UT hu or .4 KI LVS Wr J4LL w4a� Lit Ve 1 0 0 '40 000 OF M, O Bearing, if any, shown based on N/A (reference) N/A REVISIONS: 08/30/12 Field date corrected. O N.E. 3rd AVENUE o I NOTES: CBS Wall encroaches into the adjacent property (East R) No platted easements in these lots FLOOD ZONE COMM. No. PANEL No. SUFFIX: X 120652 0302 1 L F.I.R.M.DATE F.I.R.M.INDEX BASE ELEV. 09/11/09 09/11/09 + N/A N.G.V.D. Z in j ULMOU40 PLAM Approved DM ' '� S Disapproved Da— F/x This property described as: Lots 9 and 10, Block 40, AMENDED PLAT OF MIAMI SHORES SECTION No. 1, according to the Plat thereof as recorded in Plat Book 10, Page 70, of the Public Records of Miami -Dade County, Florida. CERTIFIED TO: Ethan S. Grossman and Leah Z. Grossman City First Mortgage Services, L.L.C., its successors and/or assigns, ATIMA Pardo Gainsburg, PL First American Title Insurance Company 320 N.E. 100th Street, Miami Shores, FL 33138 ELEVATION NOTE: (IF APPLICABLE) Not valid unless L.F.Elev.= N/A (lowest habitable floor elevation). it bears the Elevation shown hereon refer to N.G.V.D. 1929. signature and the adjacent grade elevation= N/A . original raised seal Lowest ad 1 of Florida licensed BM. N/A Elev.= N/A . Surveyor and Garage Elev.= N/A . Erp= N/A Mapper_ 'THIS SURVEY DECLARATION IS MADE ON THE FIELD DATE INDICATED, TO THE OWNER(S) LISTED. IT IS NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS BOUNDARY SURVEY. I HEREBY CERTIFY: that this survey meets the minimum technical standards as set forth by the FLORIDA B��ESSI L SURVEYORS AND MAPP RS in pter 5J-1 lon( Administrative Code, pursuan o Section 027 Florida Statutes. IVES 08/27/12 P70F=ESSON�0A2>SURVEYOR AND MAPPER No. 4327. State of Florida. V a W a�2nib °- w v o W Q C V w .92 w v E ° W 0 3 m W m Hi m ° mW�E;E o =Zo 8t& °c�'m�Eaw Coo C 0 W Y W m E o `o 0n L0,.'W 'Co W c0W p m 8 Oy W o WW WCro E° CE 2 oacE 8012O.S oo I!!'oWw °E>. loo L� CL m W = c o.o .mccci'oo�mm W 2`c 0 C .c n— cccc F.o CL CM WQ0 ° o E? Sr mII = W C aZNi]�roa:o rsVJ3 !A t = Y o� o E E a v v ° o W • � !c m•••e m • a ••• o d y ••�� T 1 .'°.. • • r'aH.'C C m i��s m ° • E � o E m o ° m D W n �t0o v C C v W> W 0 W ao v r >W E£ W m F Z M a m a w in �—°-M o`o W O W€ mW m om+ C r- CO � O W E ° CL m o v z E C� y W C N G m 0-0-0 E W E L m m= m E E -S ° m m so ° W m 0 C W° W C C O Q C $ U G° zW a civet c LEGEND A = Arc ASPH = Asphalt BM = Bench Mark BRG = Bearing CAN = Catch basin CB = Catch basin CBS = Concrete Block Structun CH = Chord Chatta = Chattahoochee CL = Center Line CLF = Chain Link Fence CL. = Clear CONC.= Concrete D = Delta 0 = Diameter DH = Drill Hole DME = Drainage & Maintenano Easement E.B. = Electric Box Enc. = Encroachment F.F. = Finish Floor F.H. = Fire Hydrant F.I.R. = Found Iron Rebar FPL = Florida Power & Light F.I.P. = Found Iron Pipe FD. = Found L.P. = Light Pole M = Measured M.F. = Metal Fence M.H. = Manhole I = Monument Line MON. = Monument N/A = Not Applicable MID = Nail & Disc NTS = Not to Scale O/S = Offset O.U.L. = Overhead Utility Lines • = Overhang Pee Plat •••••• Pie = Plat Book a • P Point of Curva�c3e t!C. = Point oftompound • Curvatum • PCP = Permanirit t' M4 Pot :g • iiPage P.I. = Point of lh?eWgp , • • +Propefty"o • • PL • gPlanter _. • • • • • 9.8.B. = Point of Begin nirlg P.O.t.= Point of Commenceme P.P. w Power PAO • • • • i0i=.0-'Permanept Reference MonumeNt• • • • • • §.R.Joint of Reverse • ;urvature Pel =Point of Tangency R = Radius R/R = Railroad PSM = Professional Surveyor Mapper RNV = Right -of -Way SWK = Sidewalk Sec. = Section Crypt = Typical T - Tangent U.E. = Utility Easement W.F. = Wood Fence W.M. = Water Meter W.V.�.= Water Valve 4 - Denotes Spot Elevations Taken Alvarez, Aiguesvives and Associates, Inc. Surveyors, Mappers and Land Planners 5701 S.W. 107th Avenue #204, Miami, FL 33173 Phone 305.385.0385 Fax 305.385.0623 L.B. No. 6867 / E-mail: fastsurveys@aol.com Field Date Scale: Drawn by: Drwg. No. 08/24/12 1 1 1 = 20' D.( 1 12-19430