RC-15-1385 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-236301 Permit Number: RC-6-15-1385
Scheduled Inspection Date: August 11, 2015 Permit Type: Residential Construction
Inspector: Rodriguez,Jorge
Inspection Type: Final
Owner: MORRIS, MICHAEL J AND MELISSA Work Classification: Repair
Job Address: 120 NE 91 Street
Miami Shores, FL Phone Number
Parcel Number 1131010190020
Project: <NONE>
Contractor: ARCO CONSTRUCTION Phone: 305-892-6507
Building Department Comments
REPLACEMENT OF STUCCO DETAIL UNDER THE Infractio Passed Comments
EXISTING BALCONY INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
August 10, 2015 For Inspections please call: (305)762-4949 Page 7 of 35
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�snO1s y,{ Miami Shores Village E�YfIt� I � Ctf)tl
10050 N.E.2nd Avenue NE �tlrft@fir
Miami Shores,FL 33138-0000
PefrrZs OVED-
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Phone: (305)795-2204 ` � � �
ISs e � 3 I2f 1a Expiration: 12120/2015
Project Address Parcel Number Applicant
120 NE 91 Street 1131010190020
I Mlallll ShOreS, FL Block: Lot: MICHAEL J AND MELISSA MORI
Owner Information Address Phone Cell
MICHAEL J AND MELISSA MORRIS 120 NE 91 Street
MIAMI SHORES FL 33138-2810
120 NE 91 Street
MIAMI SHORES FL 33138-2810
Contractor(s) Phone Cell Phone Valuation: $ 2,400.00mmrvW�yy
ARCO CONSTRUCTION 305-892-6507
Total Sq Feet: 6
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved: : In Review Final
Date Denied: Review Building
Type of Construction:REPLACEMENT OF STUCCO DETA Occupancy:Single Family
Stories: Exterior:
Front Setback: Rear Setback:
Left Setback: Right Setback:
Bedrooms: Bathrooms:
Plans Submitted:Yes Certificate Status:
Certificate Date: Additional Info:
Bond Return : Classification:Residential
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.80
Invoice# RC-6-15-55885
DBPR Fee $2.00
DCA Fee $2.00 06/08/2015 Check#: 1033 $50.00 $67.80
Education Surcharge $0.60 06/23/2015 Check#: 1038 $67.80 $0.00
Permit Fee $100.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $117.80
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 zoning. Futhermore, I authorize the abe-nam�d contractor to do the work stated.
June 23, 2015
Authorized Signature:Owner '/ Applicant / Contractor / Agent Date
Building Department Copy
June 23,2015 1
t I �
Miami Shores Village PF,C D
Building Department JUN 08 2015
10050 N.E.2nd Avenue, Miami Shores,Florida 33138 BY'
Tel:(305)795-2204 Fax:(305)756-8972 '
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 IO
BUILDING Master Permit No& /Y-1
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL FPUBLICWORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: � - CE V/ j .
City: Miami Shores County: Miami Dade Zip: `;j 7 1-,,? g
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: qqii Construction Type: Flood Zone: BFE: FFE:b
OWNER: Name(Fee Simple Titleholder): f--,u Cx& LOEI )Qi ( ( 1� e#
�_ ho
Address: 12-c> N 4-:-- !e2±ytx—,t-
City: State: Zip: ` _
Tenant/Lessee Name:_ �� Phone#:
Email:
CONTRACTOR:Company Name:i �C�� _ ��- Phone#: - v
Address: z0q �E / ® V kizz.
City:_ /I.^ �/� State: _ Zip: 33i
Qualifier Name: :j mme�E " Phone#:
State Certification or Registration#:CCI-f /`5-0 i5�7 6 a Certificate of Competency#:
DESIGNER:Arch itect/Enginee r: UvCL-f i,, e E,d- Phone#:
Address: City: ..id i f}R State:
Value of Work for this Permit:$_ 'CA0 O 4-10Square/Linear Foo�of Work:—
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work:
I V
Specify color of color thru tile: �Mc�
Submittal Fee$� .eh�_Permit Fee$ ��• JU CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$0. tjO
(Revised02/24/2014)
Bonding Company's Name(if applicable) a � "
Bonding Company's Address _
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
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.....
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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7 ays after the building permit is issued. In the absence of such posted notice, the
inspection wWwot bee approved and a reinspe ton Ne will be charged.
t
Signature Signatur
OWNER or AGENT CON RA OR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
4 day of 20 _, by _day of )fl 20 by
who is personally known to jg k/ �✓oe2 ,who is personally known to
me or who has produced as me or who has produced �� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: �, '� Prin
Seal: ';::!; CYNTM8ALILM Sea Nwery Public State of Florida
*M
* COtYBYIISSI�N11F8 '4
MyCOmmissionlF 082753
EXPIRES:November 23,2017 e. Expires 01!12/1018
tor nd ' Bonded TW Budge)Notary SrJ,,
APPROVED BY (� 16 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
A RFU° CERTIFICATE OF LIABILITY INSURANCE � DA,�,��D�YYY�;
o&04/15
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT; If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of time policy,certain policies may require an endorsoment A statement on this certificate does not confer rights to the }
certificate hotder in lieu of such endorsements).
PRODUCER i NTACT
H.G.Hcidam insurance E (561)434-4451
3830 Road tA/C.Nam: 561)434 3505
Jog A�Ess_ cra;gG gholdam.cen i
Lake Worth,FL 33467 1NSURER(S)AFFORDING COVERAGE MAIC 4
Phone (56')434-4451 Fax (561)4343505 i fNSURERA: Federated National Insurance Co I
INSURED !
INSURER B 1i
Arco Construction Caporatcrl L{NSLlRER C
1665 NE 37th Ter PNSURER D: I
N Miami,FL 33181 561 i INsvt_ RER E: N
1 ENSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES CF INSJRANCE LISTED BELOW HAVE BeEN ISSUED TO THE':NSURED NAMED ABO'+1E FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REC:UIREIVIENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO Wr}CH THIS
CERTIFICATE MAY BE ISSUED OR MAY PEP.TAIN.THE INSURANCE AFFORDED BY THE POLICIES D_SCR BED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLLSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIC CLAItn. j
RRT TYPE OF INSURANCE �DtsuBR ! POLICY EFF { POLICY EXP
Pt�LiCY NUMBERi(MM/DDM'YYI (Nt!!lDDIYYYYI: UMtTS
GENERAL LIABILITY
INC
CURRECE
$ 300,000!00
k A A OC11 NNT
i EV
CCl7PAERCI L GENER AR•,L:`:Y ! PRE:JISES(Ea ocwnence' S 100,Onoo
A — CLAIMS-MADE !;I o:GUR N N GL-0000022583 OQ MED ExP(Any 0,--e wson $ 5,000.00
0810512015 ;06!05!2015 ; PERSONAL&AD'J INJURY st 300.000.00
i GENERAL AGGREGATE ; S 600.003.00
i GErrlAaGREGATELEPRITA?P IES PER i PRODUC7S-COMP/0PAGG S 600,000.00
PD''ICYLOC
AUTOIAO64LE LIABILITY COfJBI D 34ICs1 E LIMIT
4 �_ I G iS ECtader ji '
= ANY PUTO { ; 6001y`.N1URY(Par roman) { 6 t
I — A L OWNED �-
- A 'GSA.�TCS 1 ! i 800;LY NJURY(Per-agtlantpi S
I— NON-CWNED PRO'ER'Y QnMACE
HIREC A-TCSA.tfTC3 S
i — Per acdaen'I
i UMBRELLA UAB4
OCCUR i EACH OCCURRENCE S
EXCESS UAS _CLAIMS-MA40E i AGGREGATE $
DED _ RETErdi'iON$ S ?
WORKERS COMPENSATION yc
WC C STAT'- OTr-
AND EMPLOYERS LIABILITY Y/N ' I -T6fcY L MSS
i ANY PROPRIETO,4/PARTNERIEXECe,1 r j --�
OFFIC=RAI:IEMBER EXCLUDED? r—+.N/A, E L.EACH ACCIDENT a
i --+
L 1SEA
j t es..descibeNunder
E_ SE-EA_EA4PLOYE, S
DESCRIPT ON OF OPERATIONS b&Cpw I E.L.DISEASE-POLICY LIMIT S
j
DESCRIPTION OF OPERATIONS J LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remafks Schedule,If more space k3 required)
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C43CI505163
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCfES BE CANCELLED BEFORE
Kami Shores Vll?age Bldg Dept i THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
10050 NE 2--d ke I ACCORDANCE WITH THE POLICY PROVISIONS.
Miami Shores,FL 33138 I ---
AUTHORIZED REPRESENTATIVE
®1988-2010 ACORD CORPORATION. All rights reserved."
ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD
�s�oREs y
„ , Miami Shores Village
L4P,�-- � Building Department
ORiD 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner,must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if
1. The officer owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State,Division of Corporations;and
3. The corporation is registered and listed as active with the Florida Department of
State,Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use
day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of
workers' cofu!!ppensation insurance coverag from the contractor's company for day labor,part-time employees or subcontractors.
BY StGNI1 G\BELOW YOU ACKNEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENT/ �-4 0_,,->
-
Signature:_Al Len t_(d.__
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day ofC� '20I't-) .
By \�46—L k who is personally known to me or has produced
------- -----
as identification.
-- — ro�►sv 1uk. CYNTHIA SAIALW
MY FF 06M
Notary: '� * EXP RES ISSIONNovember 23
,2017
SEAL: +"e.OF nom° Bonded Thru Budget Notary Services
Arco Construction Corporation
June 8, 2015
State of Florida
County of Miami Dade
Before me this day personally appeared Lester Jensen who, being duly sworn, deposes and
says:
All work to be performed by Lester Jensen or licensed and insured subcontractors.
Sworn to ( r meds and subscribed before me thiis day of U f�t=r , 20 ,by
Personally know
Or Produced Identificatio e
Type of Identification Produced
Print, Type or Stamp Name of Notary
g,J)! Nota,y Public State of Florida
Joanna M Fe►icieno
MY�ommiaaion FF 082753
EVora&01/12/2018
General Contractors✓CGCI50516311665 N.1:. 137`h TerraceIN. hfiami, FL 33181
305.892-6307
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