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DEMO-15-2297 (2) Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-243167 Permit Number: DEMO-9-15-2297 Scheduled Inspection Date: October 01, 2015 Permit Type: Demolition Inspector: Rodriguez,Jorge Inspection Type: Final Owner: , Work Classification: Building Job Address:9055 BISCAYNE Boulevard Miami Shores, FL 33138- Phone Number Parcel Number 1132060110051-55 Project: <NONE> Contractor: CAM CONSTRUCTION SERVICE, INC. Phone: (813)626-8643 Building Department Comments INTERIOR DEMO FOR TENANT IMPROVEMENT FOR Infractio Passed Comments DOLLAR TREE INSPECTOR COMMENTS False Inspector Comments Passed -vm_ Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. September 30, 2015 For Inspections please call: (305)762-4949 Page 16 of 32 � tj Miami Shores Village SEP 092015 Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138Y'— Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2oly s BUILDING Master Permit NoL,)= z 22/'j"--7 PERMIT APPLICATION Sub Permit No. FE-IBUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION RENEWAL F-IPLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9055 Biscayne Blvd. City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO X Occupancy Type: M Load: 345 Construction Type: I I Flood Zone: +'f BFE: FFE: OWNER: Name(Fee Simple Titleholder): IMC Property Management & Maintenance Phone#:305-893-9955 EXT-107 Address:696 N.E 125 Street North City: Miami State: Florida Zip: 33161 Tenant/Lessee Name: Dollar Tree Stores Phone#:757-321-5218 Email: cgomez@dollartree.com CONTRACTOR:Company Name: CAM Construction Services Inc. Phone#: 813-626-8643 Address: 8109 E. Martin Luther King, Jr.-Blvd. Cit,: Tampa State: Florida Zip: 33619 Qualifier Name: Christine Lemons Phone#: 813-626-8643 State Certification or Registration#: CGC1505471 Certificate of Competency#: DESIGNER:Architect/Engineer: RRMM Architects Phone#: 757-622-2828 Address: 1317 Executive Blvd. Suite 200 Cit,. Chesapeak State: VA Zip: 23320 Value of Work for this Permit:$ 14,800 Square/Linear Footage of Work: 12,477 Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑■ Demolition Description of work: Interior demo for tenant improvement Specify color of color thru tile: F Submittal Fee$ Wil)uO/ ) 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$ 2-0 (Revised02/24/2014) Bonding Company's Name(if applicable) N/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 certifylthat no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the sitandards 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 exce$ding$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 commencemebt must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absince of such posted notice, the inspection will not be approved and a reinspection fee will be charged. ~ature SignaZregoing OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The f instrument was acknowledged before me this — 10 day of '57PSP7C-A.BE'2 20 15 by � day of g e& �f'✓,20 f� , by who is personally known to 40 U422�3 who is personally known to me or who has produced /'L. dL as me or who has produced as identification and who did take an oath. identification and who did take an oath. NQWY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: 400 y C 1 G)L 1 O Print: .-l/ C/'0- Ale,-!!n, WY Seal: +°` 'P e`er WCYCICILIO Seal: fid" Notary Pudic State of Florida * * MY COMMISSION p EE 164923 Duc Pha EXPIRES:April 19,2016 a My Com awn FF 232517 "OF F°e° Bonded Thru Budget Notary Services 0r w Expires tl'11912019 A. .j APPROVED BY • 1 rlans Examiner Zoning / Structural Review Clerk (Revised02/24/2014) f t NOREs 5 SNC.1931 �! ,.9. j�� ..... Miami Shores Village', - �� Building Department �LORIIDA 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. 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 form and Contractor 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 form and Contractor 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: �011 ruGfi 0o ('tf e2 BUSINESS ADDRESS: 8101 E.Maffin I eY X111 f Od clTyTamm STATE—ZIP BUSINESS PHONE: ( 61 ) (pZle- SLOgS FAX NUMBER 9 CELL PHONE( ) QUALIFIER'S NAME:Umisbne N. temons QUALIFIER'S LIC NUMBER: L�JS ' M - 7 0 ` U Lf q — STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 LEMONS, CHRISTINE ANN CAM CONSTRUCTION SERVICES INC 3115 TOSCANA CIRCLE TAMPA FL 33611 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and !9 Professional Regulation. Our professionals and businesses range . from architects to yacht brokers,from boxers to barbeque restaurants, STATE OF.FLORIDA I, and they keep Florida's economy strong., h DEPARTM, �T zBUSINESS AND PROF I' ULATION Every day we work to improve the way we do business in order to - CGC 1505471 r 07/31/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more information t - `= about our divisions and the regulations that impact you, subscribe CERTIFIED y t to department newsletters and learn more about.the Department's IsEMON$, CH + initiatives. CAM CONST , C Our mission at the Department is:License Efficiently,Regulate Fairly. td' s 6L1 We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, ` al$.CERT.LFIED udder the prov�sl'ohs of Ch .488 FS% and congratulations on your new license! �Xpi(auoddatdAUG 31;2016 w --040131.0001§04 DETACH HERE ................................._.................................... _. ... ... ....................._..._._...... ....... .. RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY ::':.'STATE-OF PRFLORIDA DEPARTMENT OF BUSINESS AND OFESSIONAL REGULATION + CONSTRUCTION INDUSTRY LICENSING BOARD l .. - ...... .✓yy .._ �r CCtiC15D5471 _ �' ` - ;~The GENERAL CONTRACTOR 5 Under the provlslons of Chapter 48g EkPir-Mion date AUG_31' 2016 {x ; '"LEMONS CH:RISTIIVE Af 2 ,,,(.3AM`CONSTI3UCTIbG� �;it `x - 8109 .E MARTIN T x L ,fir✓ r '` ' .. ', r �` �� ; �t 2015 -2016 HILLSBOROUGH COUNTY BUSINESS TAX RECEIPT EXPIRES SEPTEMBER 30,2016 232948counrNo. OCC.CODE RENEWAL 090.010000 Contractor 2 Employees Receipt Fee 18.00 Hazardous Waste Surcharge 40.00 Law Library Fee 0.00 CGC1505471 BUSINESS LEMONS CHRISTINE ANN 8109 E DR MARTIN L KING JR BLVD TAMPA, FL 336192 0' 1 2 U0` 1 6 NAME LEMONS CHRISTINE ANN MAILING CAM CONSTRUCTION SERVICES INC ADDRESS 8109 E DR MARTIN L KING JR BLVD Paid 14-625-072455 TAMPA, FL 33619 07/22/2015 58.00 BUSINESS TAX RECEIPT DOUG BELDEN,TAX COLLECTOR HAS HEREBY PAID A PRIVILEGE TAX TO ENGAGE 813-6355200 IN BUSINESS,PROFESSION,OR OCCUPATION SPECIFIED HEREON THIS BECOMES A TAX RECEIPT WHEN VALIDATED. ' 1 i DATE(MMIDD/YYYY) ' ,a►C�oma® CERTIFICATE OF LIABILITY INSURANCE 9/1/2015 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 CONTNAMEACT Laurie Sack : _ Stahl & Associates Insurance, Inc. PHONE (727)391-9791 A/C No:(727)393-5623 110 Carillon Parkway Vk10tss:laurie.sack@stahlinsurance.com INSURERS AFFORDING COVERAGE NAIC N St. Petersburg FL 33716 INSURERA:Southern Owners Insurance Co 10190 INSURED INSURERBOwners Insurance Co 32700 CAM Construction Services Inc INSURERC:COmmerce & Industry Ins Co 8109 E Martin Luther King Jr INSURERD: INSURER E: Tampa FL 33619 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1561625972 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 ADD SBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MWDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR PREMGE TO RENTED—ISES SES Ea occurrence) $ 50,000 20160037 6/14/2015 6/14/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY[:]JECTPRO-- F�LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS 4919725302 6/22/2015 6/22/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE -J HIRED AUTOS R AUTOS Peraccidenl J $ BFCGL $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ PER WORKERS COMPENSATION x STATUTE EERH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? ❑Y N/A C (Mandatory in NH) 020735706 6/22/2015 6/22/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,00 000 Leased Rented Eqpt 20160037 6/14/2015 6/14/2016 Leased/Rented $75,000 i i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Contractor - Christine Lemons, License #CGC1505471 I I 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 BLDG DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Kelly Petzold/SACK ��� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I N S025 19014011 i