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RF15-820 J Miami Shores Village Building Department APR ° 9 ?D1� 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 ►O BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC F(ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP � CONTRACTOR DRAWINGS JOB ADDRESS: �O,f�a /�� Z ,/ f/ City: Miami Shores County: Miami Dade zip: jr—?136 / Folio/Parcel#: /�"Z Z 3��»/J?'C 3 ` 449 Is the Building Historically Designated:Yes NO Occupancy Type: J-I; Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): S IP73' 518 46c— Phone#: /S4— 6�71'1*p Address: Z7-00 At' C� .C�c/ D^//8 City: F�LQua/1✓�4 1�- State:�� Zip: ZS�� !q Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: L.40+ ce—*' 4re ,S c—: Phone#: t' Z.?4'gT)C> Address: 4/te E d City: SWte. / Zip: Qualifier Name: Phone#: j7/'234-qy-7`d State Certification or Registration#: e-'4 C A fig ificate of Competency#: DESIGNER:Architect/Engineer: I Phone#: Address: City: State: Zip: Value of Work for this Permit:$ �5�]2-6' � Square/Linear Footage of Work: /� P Type of Work: ❑ Addition ❑ Alteration ❑ New �C Repair/Replace ,/. ❑ Demolition Description of Work: �J lt.t ✓" �i✓� �v��/� c/! +� rs�+ / 07— tN7 Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address _ City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City SnZte 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 S by 6 day of S 20 by )-ar ' fSQu yn whoisis p `\Gm�PS ��y�C� ersonall know o me or who has produced as me or who has produced identification and who di$(tee tiifitid ke ar� �t7, _ `* �.�SP e• NADINE AUSTERFIELD NOTARY PUBLIC: o p<. NADINE AUSTERFIELD a* # .`_ Notary Public State of Florida NOTARY PUBLIC: Notary Public-State of Florida ;9' ao` My Commission Expires Nov 7,2017 - C mmission Expires Nov 7,2017 �( Commission#FF 55651 nn,,II,, mission#FF 55651 Sign:�'^^^^Ik Sign: Print: Print: Seal: Seal: APPROVED BY (J Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) KEN LAWSON, SECRETARY RICK SCOTT,GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGCA02737 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date; AUG 31, 2016 FLUKE, JAMES M LANCE CONSTRUCTION, INC. 3248 BERMUDA ROAD PALM BEACH GARDENS FL 33410 ISSUED: 06/18/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406180001244 ANNE M. G AN N O N P,O, Box 3353,West Palm Beach,FL 33402-3353 "LOCATED AT** CONSTITUTIONAL TAX COLLECTOR www.pbctax.com Tel:(561)355-2264 3248 BERMUDA ROAD Serving Palnl Keach County PALM BEACH GARDENS, FL 33410 Serving you. TYPE OF BUSINESS OWNER I CERTIFICATION p RECEIPT A/DATE PAID AMT PAID BILL k 23-0102 CW GENERAL CONTRACTOR FLUKE JAMES M CGCA02737 U14.670183.08108114 $369.80 F840104397 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2014/2015 LOCAL BUSINESS TAX RECEIPT LANCE CONSTRUCTION INC LBTR Number: 200005929 LANCE CONSTRUCTION INC EXPIRES: SEPTEMBER 30, 2015 3248 BERMUDA RD PALM BEACH GARDENS, FL 33410-2423 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. ANNE M. G A N N O N P.O.Box 3353,West Palm Beach,FL 33402-3353 "LOCATED AT** Lr CONSTITUTIONAL TAX COLLECTOR www.pbctax,com Tel:(561)355-2264 3248 BERMUDA ROAD Serving Palm Beach County Serving you. PALM BEACH GARDENS, FL 33410 TYPE OF BUSINESS OWNER I CERTIFICATION 4 RECEIPT B/DATE PAID AMT PAID BILL N 23-0051 GENERAL CONTRACTOR FLUKE JAMES M I CGCA02737 U/4.670183.08108l14 $27.50 840104398 This document iS valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2014/2015 LOCAL BUSINESS TAX RECEIPT LANCE CONSTRUCTION INC LBTR Number: 200005928 LANCE CONSTRUCTION INC EXPIRES: SEPTEMBER 30, 2015 3248 BERMUDA RD PALM BEACH GARDENS, FL 33410-2423 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. AnoRrY CERTIFICATE OF LIABILITY INSURANCE DATE 04//09/209/201155 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 CONTACT KIMBERLY M ADAMS NAME: Pyramid Insurance,Inc. PHONE (561)842-8868 aC No: (561)842-8161 700 Old Dixie Hwy Suite 104 E-MAIL kimberly@mypyramidinsurance.com Lake Park,FL 33403 INSURERS AFFORDING COVERAGE NAIC# Phone (561)842-8868 Fax (561)842-8161 INSURER A: ARCH SPECIALTY INSURANCE COMPANY INSURED INSURER B Lance Construction,Inc. INSURER C 3248 Bermuda Road INSURER D: INSURER E: Palm Beach Gardens FL 33410 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 CONTRACTOR 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 ADD UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM D (MM/DD/YY" GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 © CDAMAGE TO RENTED 100,000.00 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ F-1 F-1CLAIMS-MADE © OCCUR MED EXP(Any one person $ 5,000.00 A F-1AGL0011063 01 03/27/2015 03/27/2016 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 ❑ POLICY ❑ PRO- ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ❑ SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ ❑ ❑ HIRED AUTOS NON-OWNED FIR PER DAMAGE $ ❑ AUTOS Per accident ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION STEARTUTE ❑OTH- AND EMPLOYERS'LIABILITY Y/N FR ANY PROPRIETOR/PARTNER/EXECUTIV E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CGCA02737 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ATTN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES,FL 33138 sz } ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01)OF The ACORD name and logo are registered marks of ACORD Rusines v Charlie Crist,Govemor Professional Regulation ° Holly Benson.Secretary Division of Pmfensions Phone: 850.487.1385 Construction Industry Licensing Board Fax! 850.921.4216 1940 North Monroe Streeter»�•�v1�Flri a.=oiTdLi. Tallahassee,Florida 32399-1039 www_.MyFloridaLicrnse.com February 23, 2007 James M. Fluke Lance Concrete, Inc. 3248 Bermuda Road Palm Beach Gardens, FL 33410 Dear Mr. Fluke, Thank you for your correspondence of February 2, 2007, regarding your initiallicensure date and the "pre-1973" roofing exemption. G.W."Harrell, the Board's Executive Director, has asked that I respond to your request. f Pursuant to Section 489.113(3)(g),Florida Statutes, "no general,building;or residential contractor certified after 1973 shall act as,.hold`himself/herself out to be, or advertise himself or { herself to be a roofing contractor unless he or she is certified or registered as a roofing contractor." However, any Division I.contractor who was licensed by the Florida Construction Industry Licensing Board prior to 1974 may perform all manners of roofing and repair, as referenced in Section 489.105(3)(e), Florida Statutes. Your original license, number CG C002737, was issued on October 17, 1973. This license is now null and void. As you remain licensed under license number CG CA02737 today,the Board still considers your licensure date to be October 17, 1973. As such, you may perform roofing work under your current license. If you should have any adgitionai questions regarding this matter, please feel free to contact me at 850.922.2887. Sincerely, At Andy Janecek Government Analyst I Construction Industry Licensing Board Licensure & Education Report Unlicensed Activity Toll--Free at 1.866.532.1440. f 14 NO, . ORfSy l `.s�` Miami Shores Village P81T1?l T 10050 N.E.2nd Avenue NEin W- '41 l slip Miami Shores, FL 33138-0000 Phone: (305)795-2204t �xe Expiration: 10/13/2015 Project Address Parcel Number Applicant 10540 NE 2 Place 1122310130540 SRP TRS SUB LLC Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell SRP TRS SUB LLC FL (954)671-1400 Contractor(s) Phone Cell Phone Valuation: $ 500.00 LANCE CONSTRUCTION, INC. (561)626-2603 (561)236-4470 _. Total Sq Feet: 100 Type of Work:Repair Available Inspections: Additional Info: Inspection Type: Classification: Residential Roof Repair Scanning:3 Final Roof Review Roof Fees Due Amount Pay Date Pay Tffi6nA Amt Paid Amt Due CCF $0.60 Invoice# RF-4-15-55 DBPR Fee $2.00 04/09/2015 Check#:7063 $64.60 DCA Fee $2.00 Education Surcharge $0.20 04/16/2015 Check#:7069 $0.00 Permit Fee-Repairs $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 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 above-named contractor to do the work stated. April 16, 2015 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy April 16, 2015 1