Loading...
PL-14-1143 z, Miami Shores Village o� ( -- Building Department F03 NIS ` 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 ` Tel:(305)795-2204 Fax:(305)756-8972 BY INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 16 BUILDING Master Permit Now. jl� 5 PERMIT APPLICATION Sub Permit NoL- i y ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ®PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS YrCHANGE OF ❑ CANCELLATION ❑ SHOP M 1 CONTRACTOR DRAWINGS JOB ADDRESS: 571- N LP E 9-+ Ste( City: Miami Shores County: Miami Dade Zip: X31 3B Folio/Parcel#: 11- -V-6 Lo -o 1-+ - Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):_ gl Ljck-20K Nb xm- . Phone#: Address: n5Ro tam Cr-+ SA=re4-- �- City: """.Vwk ShcsyeC State: -:-kcx; c, Zip: 33135S Tenant/Lessee Name: Phone#: Email: i CONTRACTOR:Company Name: Ha4A"S LAMbI, 0 .S2rV(ckp Phone#: 3'�S- '41'1- S (-2 S Address: City: State: Zip: X34\Z Qualifier Name: CA— 7`\ti)o'.tiCs Phone#: GS- ZId-S�ZS State Certification or Registration#: C rL 1 41? moi 6 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ i U S60.O U Square/Linear Footage of Work: Type of Work: ❑ Addition YrAlteration ❑ New ❑ lace Re air Re p / p ❑ Demolition Description of Work: 11�`,�L�e Specify color of color thru tile: Submittal Fee$ Permit Fee$ �S`� CCF$ CO/CC$ Scanning Fee$3• C/� Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) r Bonding Company's Name(if applicable) 's 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) 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. Signature Signature —--G OWNER or AG T CONTRA TOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this dac10 y of Q J 20 15 by (0_day of �p �20 Iby ' lG1dia AbouciZk AsRawho is personally known to Acmuek �erCk-n^c) who is personally known to me or who has produced b L4 oV1-:Pe. as me or who has produced y--- 1` of-, as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sigh:- Sig a. Print, Print: ,2a Seal: ""`� REBECA M.PASTRANA Seal: " REBECA M.PASTRANA MY COMMISSION#07872624 EXPIRES:February 07.2017 MY CQMMISSION#00872624 or �,1, EXPIRES:February 07,2017 ************************************************************************************************* ****** APPROVED BY (� Plans Examiner Zoning L Structural Review Clerk (Revised02/24/2014) DEPARTMENT OF BUSINF-55 AND PROFE55IONAL REGULATIUN CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1'�,RIM 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 PERDOMO, MANUEL MANNY'S PLUMBING SERVICE INC 9850 NW 27TH STREET DORAL FL 33172 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 STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. `"� ` PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to CFC1428796i;�SUE"M 06/15/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more information CERTIFIED PLUMBING-CONTRACTOR about our divisions and the regulations that impact you, subscribe PERDOMO, to department newsletters and learn more about the Department's initiatives. SINANNY'S PLL�NGER (It' " C° 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, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! Expiration date: AUG 31,2016 0406150001271 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1428796 The PLUMBING CONTRACTOR Named below IS CERTIFIED. Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 PERDOMO, MANUEL MANNY'S (PLUMBING SERNA E INC, .. 1631 WEST 38 PLACE" �. BAY 1502A HIALEAH FL 33Q12 ISSUED: 06/15/2014 DISPLAY AS REQUIRED BYLAW SEQ# L1406150001271 001993 Local Business Ta l ec ipt Miami-made County, Mate of Florida -THIS IS NOTA 81Lt - 00.140T PAY 33591791 BUSIIVBtiS tMAMFJt Ora1►TION RECEIPT No. EXPIRES Mm"PLuan�lNc sE vrcE INCP&NOWA�L SEPTEMBER , X01 1631 W 38 PL 1542A 3502151 HIALEAH FL 33012 Must be displayed at place of businass Pursuant to County Code Chapter SA-Art.9&10 OWNER SEC.Ty"OF BUSINESS MANN"PLUMBING SERVICE INC 196 PLUMBING CONTRACTOR 13Y TAX YT LLECT @O CI'C142B796 BY TAX COLLECTOR Workers) 1 $45.00 09/10/2014 CHECK21-14-064922 ThsLwM Business Tax Receipt only aapfinns payment of the Local Business Tax.The Recaipt is not a fiosase, panalt ora certification of the hofAar`sqpualificatwos,to do business. Holder Ism iomply with any goveInangmcl Or aopgoperemental regulatory laws OW requiream"which apply to the boinaas, The RECEIPT 11110.above tma►t ha displayed on aR aoalnnrcial vehicles-fillaani-Dada Calle Sec 8a-276. For monisformation,Visit wtw.mlamidade ggzft o I9cwr OP ID: MIAC CERTIFICATE OF LIABILITY INSURANCE DA0211812015Y) 02/18/2015 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(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 lieu of such endorsement(s). PRODUCER CONTACT Allsafe Insurance Group dba NAME: ASI Florida PHONE A 7171 Coral Way#209 A�No. AIC No Miami,FL 33155 Jorge Pena,PIAM CPIA cusroMER ID#:NANNY-1 INSURE S AFFORDING COVERAGE NAIC# INSURED anny's Plumbing Service Inc INSURER A:Capacity Insurance Company 32930 Manny Perdoma INSURER B:Technology Insurance Compan 42376 1631 W 38 PI #1502 A Hialeah,FL 33012 INSURER C: INSURER D: INSURER E: 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. INSR TYPE OF INSURANCE ADDL OLICY F POLI X LTR POLICY NUMBER 616WDp/YYYy MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. A X COMMERCIAL GENERAL LIABILITY CLM01001559D 11/06/2014 11/06/2015 pREMISEs a occurtence $ 100,00 CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,00 X POLICY JECPRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION XWC STATU- TH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE TWC3438744 11/06/2014 11/06/2015 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 _L 1 -7 _7_ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Commercial Plumbing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Ave AUTHORIZED REPRESENTATIVE Miami Shores Village, FL 33138 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD SNORES D .� Miami shores Village Eb Building Department FBY OR,Dp` 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N L- f 4 1 143 Owner's Name (Fee Simple Title Holder): NADIA ABOURIZK ASAAD Phone#:1-240-988-8661 Owner's Address: 576 NE 97 STREET City: MIAMI SHORES State - FL -33138Zip Code Job Address (Of where work is being done):576 NE 97 STREET City: Miami,Shores State:_Florida Zip Code:33138 Contractor's Company Name: 1_ iC Ca,31clee1 Phone#: 195'1 7q3 2931 Address: _ 5\ W+11Mi \ City: T�--. Lci,s A, raa\e, State: a-L Zip Code: 37231 Z Qualifier's Name: Lic. Number: Q'Pc- ly 21,,852 Architect/ Engineer of Record Name: Phone#.- Address: City: State: Zip Code: Describe Work: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the ilynd. O ial and the Miami Shores harmless of all legal in ve t Signature Signature Owner or Agent Contractor or rchitect The foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me this -6 day of c ua( 12015,by�)c,4ia Qlxufi2V,A5..4 this k-�—day of 20M by & efL Who is personally known to me or who has produced who ff is personally known to meor who has produced ' as indencification. L -8f �c/ 1"�as indufiU� encation. No lic: Notary Public: Sign: Sign: Seal: =REBECA Seal: A 24 =REBECASTRMA17 #EE813624 07,2017 Miami Shores Village ��_ yv Building DepartmentJUN 0 2014 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 BY: INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 20 to BUILDING Permit No. RC 1 -' a`7 &5' PERMIT APPLICATION Master Permit No.-O I y— �� y Permit Type: PLUMBING JOB ADDRESS: 576 NE 97th Street City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: 11-3206-017-1510 Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder): Reda Asaad & Nadia Abourizk Phone#: (240)988-8661 Address: 3701 Jones Bridge Road City: Chevy Chase State: MD Zip_ 20815 Tenant/Lessee Name: N/A Phone#: Email: CONTRACTOR:Company Name: 7-4-L (6o\Afn Plvn%bi11y �Ac Phone#: 95V" a;3(0— (0?37 Address: $Sl Wyoming AveAoc_ City: Ir". (_q�ct+�ndalp State: F:L Zip: 3331 D Qualifier Name: Tr,e of s (9 of at Phone#: 4 Sq- a a(Q— (p 3 7 State Certification or Registration#: C Gt- 1 LA a(¢ 75 a Certificate of Competency#: Contact Phone#: Email Address: +&iakA*Y4�VrnbirA 0 A Ma I( . e-ew► DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ :5� 7 Sa Square/Linear Footage of Work: 1r66 Type of Work: ❑Address Alteration ❑New 51fiepair/Replace ❑Demolition Description of Work: KTimIr l �rp��ft� A( �•f tt P�yrHbii�., nPu> plant _ Submittal Fee$ Permit Fee .2Z)( . Xy CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ u TOTAL FEE NOW DUE$ / Bonding Company's Name(if applicable) 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 ELECTRICAL WORK,PLUMBING,SIGNS, WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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. Signature Signature Ell t Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 1S{- day of QL— ,206,by � day of °� 20)a' ,by_RMJ t S Ge'l 26-i'1 who is personally known to me or who has produced who is personally known to me or who has produced ►���2%S k6eA1As identification and who did ath. as identification and who did take an oath. NOTARY PUBLIC: W NOTARY PUBLIC: ,►x:►� • .°� NIOOLE W.M.SM :•�Qsres S �G * * MY COMMISSION t EE 133809 r c toy EXPIRES:September 27,2015 Sign: Ai4 a a v ,: C� Sign: Balled Thu Bo*NoWy Swim o Print:�X' C✓�� �E,(�, ��� ���, �� Print: J � C My Commission Expires: I ZI k3 H`-'(5_ { �'� �fi°0',,r My Commission Expires: L _ ;?7– )S APPROVED BY �� ` y Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET .�°�.. TALLAHASSEE FL 32399-0783 GOLDEN, TREVIS LAMAR T & C GOLDEN PLUMBING INC 851 WYOMING AVE FT LAUDERDALE FL 33312 sTaTE of O DwA ACS 6 3313-38 Congratulations! With this license you become one of the nearly one million DggAg OP .BUSINESS AND. Floridians licensed by the Department of Business and Professional Regulation. PROFRSSIQ»rL.,REGULATION , . Our professionals and businesses range from architects to yacht brokers,from boxers to barbeque restaurants,and they keep Florida's economy strong. = CFC142675 _ 09/01/1.2 128054144 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 C$RTIFIE#lsLUMBING CQN'rRACTOR There you can find more information about our divisions and the regulations that GOLDEN, TREYI S LAMAR impact you,subscribe to department newsletters and team more about the T & C GOLDEN PLUMBING INC, 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. IS_..CSRTIPISD under the provisions of M-489 rs Thank you for doing business in Florida,and congratulations on your new license! -piratsoa rotes AUG; 31, 207 4 L12o9o100888 V DETACH HERE AC# 6331338 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SE0#L12090100888 . LICENSE NBR 109/01/20121128054144 ICFC1426752 The. PLUMBING CONTRACTOR Named below IS CERTIFIED Under the 'provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 GOLDEN, TREVIS LAMAR T & C GOLDEN PLUMBING INC 851 WYOMING AVE FT LAUDERDALE FL 33312 RICK SCOTT REN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW .4co e� CERTIFICATE OF LIABILITY INSURANCE 05/14/2014 THIS CERTIFICATE 18 ISSUED AS A MATER OF INFORMATION ONLY AND CONFERS NO WG-,HTS UPON THE CEItTIFiCATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMBMD, ©LTEND OR ALTER THE COVERAGE AFFORDS BY TILE pOUCIES. BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CON1ISTITUTE A CONTRACT BETWEEN THE ISSUINt3 MNtIREi{8), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HELD IMPORTAWP-If fhe cert kmb holies Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SU8ROGATION IS WAPM,subject to the#cans and conditions of the policy,tarlain policies may require an ondorseevent.A statement an this ewd5caft does not confer rights to the cestfficate holder in peri of such )• PRODUCER k y@3208 THE MORGAN O(ECUTiVE GROUP PHONE pfi (954)5303755 IAP—W AMMDJ2 )W0-2414 6%)NORTH STATE ROAD 7 SUITE 5.4 DBUREM AIFoROBleCarOUM NM# PLANTATION FL 33317 00=11 BKA. TAPCO LAN-Lloyds of London 0 MISUREo : INSURER 13: T - T&C Golden Pkwftlg W- sdeaeR c: - 851 wyonting Ave moo: VISURN E: Fort Lsuderdale FL 33312 p_ COVERAGES CERI7FICATE NUNBER: REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF IMSUILANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWniSTANOM ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VaH.RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AUL THE TERMS. EKC1LU810NS AND CONW10M OF SUCH rOMM LIMI M SHOMMN MAY HAVE BEM REDUCED BY PAID CLANS. WPEOFROWN ME sum POUCY1a Poticrop UNITS W EACH occ 5. 300.000 i COMMERCIAL GE ERALUABLITY S 100.000 CLA4MOE El IM MM EKPas S 5.000 i4 ; GW R- 11/28/2013 11/28/2014 PB�1N.3ADV WARTf ±s 300.000 t ENERALAGGRBGJRE Is em,000 ciElll/1L gBf3l►TErLrkTAPPIl�P6t PRO0UCM-COM1VWAW S 300JM POLICY PRO' 1 EDC = ti AUTOMOBILE LL48a= 5 ANY AUTOALLOVBOD>L Y IN RJRY(Per p�rmn} S AIR DS _AVFIOS _inetfff S HRMAUTOS RUMS S $ UMBREL AUMOIx= EACH OCCUFFISCES _ E cm UAB HCL1 IMOE ABCiRLM7E S i DED I I mm m01rs S MIR 0711- ` YIN ER .OFFICIMPIMEMIMBtCUUO£DT VIA E-LEACHACGDBU S EL i7 -FJ1 3 R UIDMOFFOOPERATiOl1Sbelow I _.g=0IsEA$E-POI—UMrT1 S - DE$CRIP7IDN OF OPHI'A710r187i.00/1110rM1Mr3R11�( A>70�101,Al RsaoflosSChodtds,if 61101lfplC!r� Plumbft ConhBclpr CEQTIFICATE HOLDER CANCE r A70H . SHO"ANY OF THE ABOVE DEWRIBED POLICIES BE CANCELLED 884MM City of MianiShores THE EUPYtAIM DATE INEIMM. NOTICE WILL BE DEUVERED IN 10050 NE 2nd Avenue ACCORDAMEVM Tim POLICY PROVISION& Miami Shores Village,FL 33138 ACORD 25 PMMS) ®1809-2018 ACORD CORPORATION.AN r nerved. The ACORD nmw and logo am n1gataild nm tea of ACORD Report Viewer Page 1 of 1 75 -acs r c AM' - '7—'-�i.� �c ^�-�'t v4 :2 x 6 f a }I.as" Z uE ✓ Et' gSi`�c •S ts'-v"�. s+&S� s"Miu5...� . w�mssa z �yr . MR- _ - s -� .z+ € gm V `k.<1�' ��? a. 43k i %" Mu k Y .x - s,°yamR.z, 01 'q 3' s ^k"„ver 'NX '. ' S { y $} '� il Fi �{� 5 qa Ya' vsx. tF K^ �i 3`a �' WIN �.. b �'"•: MEN E. r ,amt ' �" .sed �€-s.t �. },...: � ��t �`��� � y � �....y �`'�Tv 'x'.�F-$'�,��f �.'�-�r4-✓f'�t''J'� S�''`i�N '�4 F }�' 7,77, ate: 4 https://apps8.fldfs.com/crreportviewer/reportViewer.aspx?data.=kdvpginc9D7Q3gH6TER6... 3/12/2014 -- - BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT-- --- 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2013 THROUGH SEPTEMBER 30,2014 DBA: 82-1325 T & C GOLDEN PLUMBING INC Receipt#:PLUMB NG/LWN SPRNKL/CONTRACTOI Business Name: Business Type:(CERTIFIED PLUMBING CONTRACTOI Owner Name:TREvIs LAMAR GOLDEN Business Opened:09/16/2005 Business Location: 851 WYOMING AVE State/County/CerUReg:CFC1426752 FT LAUDERDALE Exemption Code: Business Phone:954-931-6123 Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prror Years Collection Cost Total Paid 27.00 0.00 0.00 5.40 0.00 25.00 57.40 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature. You must meet all County and/or Municipality planning WHEN VAUDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: TREVIS LAMAR GOLDEN Receipt #02B-13-00003681 851 WYOMING AVE Paid 12/17/2013 57.40 FORT LAUDERDALE, FL 33312 w' 2013 - 2014 - DRIVER LICENSE CLASS E G435-812-69-403-0 TREVIS LAMAR GOl N 8551 WtOMING AVE FT LAUDERDALE,FL 33312-0000 DOE 11-03.1969 SEx M ISSUED,ll-W-2011 HCPT-5-03 rtxpwEs 11-03-2019 REST l E"OOR9£ OperMnxr nt x nrotrx velncM<txl4fitW�s<txtBsrx fn MY soMiefy teat retxxcriby law. SHORES l.,. Miami shores Village Building Department ORIDp' 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. 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 Contractor Print Name: Print Name: e-v i5 rr,olc1ey\ Signature: Signature: MOOIF W.M.SMITH NIOOLE W.M. MY COMMISSION#EE 13310! MY COMMISSION#EE 1 )609 State of Florida) r► * State of Florida) *�* EXPIRES-SepMeW27, 15 EXPIRES:September 27,2015 +�, 80"flw w County of Miami-Dade) �� brAWThatiu"N�YrySFMu County of Miami-Dade) 'earn a Sworn to and subscribed before me this Sworn to and subscribed before me this Ol day of M0.y 201. day of M 20 ti By By (SEAL) (SEAL) Type of Identification produced L Type of Identification produced FLtk