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RC-15-133 (2) Permit iva RC-1 15.133 s�!O!- Miami Shores Village Permit'ryj* R"Mon t con, mrixtiort 10050 N.E.2nd Avenue NE Work GJassiffcation:Alteration Miami Shores,FL 33138-0000 Per It Permit APPROVO Phone: (305)795-22048 Imm lam:gt,wv;� FExpiration: 12/19/2015 Project Address Parcel Number Applicant 485 NE 92 Street 1132060140280 Jordana Hart Miami Shores, FL 33138-3154 Block: Lot: Owner Information Address Phone Cell Jordana Hart 485 NE 92 Street 305 577-9977 Miami shores FL 33138 Contractor(s) Phone Cell Phone Valuation: $ 15,300.00 MGM CONSTRUCTION,CORP (786)838-6106 Total Sq Feet: 450 Approved: In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Window and Door Buck Date Denied: Fill Cells Columns Type of Construction:CONVERSION OF UNPERMITTED F Occupancy:Single Family Final PE Certification Stories: Exterior: Window Door Attachment Front Setback: Rear Setback: Framing Left Setback: Right Setback: Insulation Bedrooms: Bathrooms: Drywall Screw Plans Submitted:Yes Certificate Status: Review Mechanical Certificate Date: Additional Info: Review Building Review Building Bond Return: Classification:Residential Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Building CCF $9.60 Review Plumbing CO/CC Fee $50.00 Invoice# RC-1-15-54201 Review Plumbing DBPR Fee $6.89 06/22/2015 Check#: 1295 $827.38 $50.00 Review Plumbing DCA Fee $6.89 01/21/2015 Check#: 1270 $50.00 $0.00 Review Structural Education Surcharge $3.20 Review Structural Permit Fee $459.00 Review Structural Plan Review Fee(Engineer) $40.00 Review Structural Plan Review Fee(Engineer) $40.00 Review Electrical Plan Review Fee(Engineer) $40.00 Review Electrical Plan Review Fee(Engineer) $80.00 Review Electrical Plan Review Fee(Engineer) $80.00 Review Planning Plan Review Fee(Engineer) $40.00 Review Planning Scanning Fee $9.00 Review Planning Technology Fee $12.80 Total: $877.38 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: rtify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating co s uction ,I authorize the above-named contractor to do the work stated. June 22, 2015 Authorized Signa e:Owner / Applicant / Contractor / Agent Date June 22,2015 1 Miami Shores Village � Department �cFfl v20F5 U Building .UN 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 20' 0 BUILDING Master Permit No. PER IT APPLICATION Sub Permit No. UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ft/CHANGE OF CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 0 J" � 2 City: Miami Shores County: Miami Dade Zio 1 f% Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction T.yypee:� Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): 0 � rte► � -� Phone#:_ �✓l r J U'� Address: City:_ I�v�f bM S 1 ' `" State: C-t- Zip: -33 )'-3 Tenant/Lessee Name: Phone#: Email: �k � /�01 �L� ('t ' I 1.�,1''t✓l CONTRACTOR:Company Name: . r // �lr✓ �y ��d�J� (_Jxe %,� Phone#:_ Address: City: State:: ]r C Zip: 1.3 Qualifier Name: 111171—y'r- C2 Z15) Phone#: State Certification or Registration#: 4!1; �� 7 Certificate of Competency M DESIGNER:Architect/Engineer: �� I���� IU TQC- Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 1S 300•y'S quare/dtiear Footaga of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ ❑ Repair/Re lace Demolition Repair/Replace D4scription of Wbrk: beew V4­�' f . Lha myv- Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ JO•W Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ Lcm -oz) TOTAL FEE NOW DUE$ ?7,-7- 2 e (Revised02/24/2014) ( Bonding Company's Name(if applicable) % i 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signat - — - �f ► ' R orA'AW CTQR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this /l, day of ^�c1 �' 20 by day of SyfNX--- 20 1 S by who is personally kn wn to who is personally knowpo me or who has produced as me or who has producedI�Qins identification and who did take an oath. identification and who did take an oath. NOTARY PUPLIC: 1JMRY"Pti1wc: l� Sign: Sign: Print: ' ` ' Print: f i►a.'....W�; Seal: 'k c•' MY COMMISSION*FF084825 L�-G Notary Puoilo$tate of FloridaSeal:: SJanuary 21 ��S Sindia Zareizd, EXPIRE MY Commission FF 156750Notaryservice.com(407) -0153 mfida Expires 09/03/2018 APPROVED BY Z Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) MGM Construction Corp. 2740 SW 28th ter#803Miami FI 33133 Ph 786 838 6104 Lic#CGC 1552467 Date�D�16W State of Florida County of Miami Dade Before me this day personally appeared Marcelo G Martin who, being duly sworn,deposes and say. That he will be the only person working on the project at 485 Ne 92th St Miami Shore FI 33138 Sworn to and da V subscribed before me this Q 2015 b y of�_ y. Produce Identification' %351- Type of Identification Produce�k--VQA\P-fL Print,Typ ot a of Notary =oOW otic. c State of Florida rez aion FF 156750 �lpfHd°� 3/201 8 N... a,,,M Miami Shores Village Building Department ras RiDp' 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'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. I Signature: State of Florida County of Miami-Dade The foregoing was acknowledge before me this �� day of ,20 By F a who is personally known to a or has produced MARTIN �'"w'►�"•. RCELO G identification. 1 :. 4-Z201_8 Not er41- EA .(407)398-0' Floridallotary LocaLftsiness Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 7175444 SUSINESS NAME/LOCATION, RECEIPT NO. EXPIRES MGMCONSTRUCTION,-CORP N8WOUsINESS SEPTEMBER 30, 2015 2740 SW 28"TER 803 1 7454961 - Must be displayed at place of business MIAMI,FL 33133 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED MGM CONSTRUCTION,CORP 196 GENERAL BUILDING BY TAX COLLECTOR C/O MARCELO G.MARTIN CONTRACTOR 45.00 09/18/2014 Worker(s) 1 CGC1522467 0221-14-005031 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Raceipt is not a license, permit,or a cen fication of We holders qualification,to de business.Holder must comply with any governmental or nongovernmental regutarory laws and requirements which apply to the business. The RECEIPT N0.above meat be displayed on all commercial vehicles-Miami-Dade Code Sec 8"#. MI` For more infamutioa,vbk www miamidedLowAsMiksk IMPORTANT STATE OF FLORIDA Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation ICES who elects exemption from this chapter by filing a certificate of DEPARTMENT OF FINANCIAL SERV election under this section may not recover benefits or DIVISION OF WORKERS'COMPENSATION �' F compensation under this chapter. CONSTRUCTION INDUSTRY EXEMPTION O CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L Pursuant to Chapter 440.05(12),F.S.,Certificates of election to WORKERS'COMPENSATION LAW D be exempt...apply only within the scope of the business or trade EFFECTIVE DATE: 9/16/2014 EXPIRATION DATE: 9/1572016 listed On the notice Of election to be exempt. PERSON: MARTIN MARCELO G H Pursuant to Chapter 440.05(13),F.S.,Notices of election to be FEIN: 320438740 E exempt and certificates of electron to be exempt shall be BUSINESS NAME AND ADDRESS: R subject to revocation if.at any time after the fling of the notice MGM CONSTRUCTION CORP E or the issuance of the certificate,the person named on the ! notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke 2740 SW 28TH TER#803 a certificate at any time for failure of the person named on the MIAMI FL 33133 certificate to meet the requirements of this section. SCOPES OF BUSINESS OR TRA LICENSED GENERAL CONTRACTOR STATE OF FLORIDA DEPARTMENT OF FUSINESS AND PROFESSIONAL REGULATION CGC 1522467 ISSUED: 07/31/2014 CERTIFIED GENERAL CONTRACTOR MARTIN, MARCELO GUSTAVO SR MGM CONSTR IOK CARP° IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31.2016 L1407310000299 DATE(MM/DDNTYY) AccmO CERTIFICATE OF LIABILITY INSURANCEF 14.� 05/28/2015 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: N 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 endorsemen s). PRODUCER NONTACT AME. Mailluli Gonzalez Best Rate-Insurance Exchange Of America PHONE (866 616-0065 FAX N,), (305)403-0$01 8600 NW 17th Street E SSS: ieaunderwriting@bestrate4nsurance.com INSURERS AFFORDING COVERAGE NAILS Miami FL 33126 INSURER A: PREFERRED CONTRACTOR'S ASSOC INSURED INSURER 8: MGM Construction,Corp INSURER C: 2740 SW 28 Terrace INSURER D: 803 INSURER E: Miami FL 33133 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 POLICY NUMBER POLICY EFF Y EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ Li CWMS-MADE OCCUR PREMISES Ea E MED EXP(Any one person) $ A PC2608520-00 09111/2014 09/11/2015 PERSONAL&ADV INJURY $ GENT,AGGREGATE LIMIT APPLIES PER.. GENERAL AGGREGATE $ POLICY❑JPECOT F—]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE IJAB0.rrY Ea accident IN L § ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS P racddeM $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'LIABILITY y/N STAT IAUTE I I ER ANY PROPRIETORIPARTNERIEXECUTNE ❑NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE E If yesdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VBNCLES(ACORD 10l,Addilional Remarks Schedule,may be attached N more space Is ra pdred) MGM CGC1522467 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Ave AUTHORQED REPRESENTATIVE Miami,FL FL 33138 01988.2001444 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i Miami Shores Village -d �-_-;-k .- OV Building Department JAN 21 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 / lTel:(305)795-2204 Fax:(305)756-8972 = � NSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 !� BUILDING Master Permit No. q G15 -- I�� PERMIT APPLICATION Sub Permit No. �96 ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: jj FFE: c� OWNER: Name(Fee Simple Titleholder): "( V �� - ��vl Phone#: l4 (� ( 3 �3 a b Address: l I City: �"�� S �'� S State: Zip: "^3 31 3, Tenant/Lessee Name: Phone#: Email: ~I V� 1 (N�lbl/11 G)(� e fit Q - Cab CONTRACTOR:Company Name: C Z' Address: a 5 -Z City: � / State: Zip: �� Qualifier Name: J!�QO�4.1 / A A- W Phone#: �� 2 `� 'S 7 State Certification or Registration#: C G Q Certificate of Competency#: DESIGNER:Architect/Engineer. s�A �-��T� t-L- !1 Phone#: c3OJ 6 2- "' 61 40 C) Address: 3 3 O S Z '�v'�' SlW L� City: AAA`T'Q( State: L— Zip: 331 Value of Work for this Permit:$ /E—,�/�U U Square/Linear Footage of Work: Type of Work: ❑ Addition j Alteration ❑ New ❑ R pair/Replace Demolition Description of Work: WgWIIA kta deSpecify color of color thru tile: l a Submittal Fee$ S-® '� Permit Fee$ rr�155 CCF$ ` -( CO/CC Scanning Fee$ A-3 -RadonFee$ LD 10 W'9 DBPR$ (0• g Notary$ Technology Fee$ � Training/Education Fee$ 3 Double Fee$ Structural Reviews$ 1tO,0y 3 O•LL> '10-LO Lib-W �V-GO +V0 Bond$ -=C30G'_ TOTAL FEE NOW DUE$ O ` • +� I A�i��4hbt1S; r-f-. 33 f-Tg i 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 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 PROPERTY. IF YOU INTEND RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PR O 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 co o the notice o commencement and construction lien law brochure will be delivered to the person P 9 f PY f f 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 Signatures.If� `(/ O NER or AGENT CONTRACTO The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this _day ofCIC JVu-t- 2016- by 3 day of !4-\ _p20 `� by �OC_0 AA �'�ACr —,who is personally known to �7 la� IF 21 IJ w o is personally known to me or who has produced c.D " i L)6-7 . U QCVL,.�_ as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PU LIC: NOTARY PUBLIC: Sign: Sign: Print: M A 12.A A V ELL 2.- 14Q-C40&? Print: b � t�� Seal: Ea'a" iri�rl��r Seal: �.- Notary Public Stele of Florida MARIA YELE1-MUSKUS Dagoberto Martinez+� g My Commission EE 184086 Nowy Public•SfA1Q Of Florld� @ dR Expires 03/28/2016 Comm.E*mi Jill 26,20170.`�**'Ebili#!1�-IM►'/P"02451e**�Q TWogb Nft As". APPRO •Plans Examiner Zoning f/a Structural Review Clerk i , 1 ORE'#3 �I some p,,,� Miami Shores Village Building Department �toRiop 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDASUR 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 Affidavit) IF CONTRACTOR HAS A MIAMI DADt4QMW CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE 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: AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 r ��- BUSINESS NAME: 9221 f � BUSINESS ADDRESS: �� Y /l STATE ZIP 3 BUSINESS PHONE: (y ) FAX NUMBER(�� —� CELL PHONE V-�r) l �� QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: C I J L STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION F CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MARTINEZ, FERMIN A FAM CONSTRUCTION CORP 8340 SW 65 AVE#3 MIAMI FL 33145 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. PROFESS REGULATION Every day we work to improve the way we do business in order to CGCO19440 r Ur fi 07/02/2014 serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more Information CERTIFIED G F3N OR about our divisions and the regulations that impact you, subscribe MARTINEZ FF, to department newsletters and learn more about the Department's FAM CONSTR T, 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. 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 L1407020001234 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION.INDUSTRY_LICENSING BOARD CGCO19440 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date AUG 31, 2016 MARTINEZ, FERMIN A FAM CONSTRUCTION CORS h 8340 SW 65 AVE#3 MIAMI FL 33"5 ' icc1ian• n7in,)1')n1n niQoi av AQ RFr1i lipi=n RV I AIN 81700 1.1407020001234 Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOT A BILL-DO NOT PAY 5622130 LBT�/ BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES F A M CONSTRUCTION CORP RENEWAL SEPTEMBER 3O, 2015 8340 SW 65 AVE 3 1535062 MIAMI, FL .33143 Must be displayed.at place of business Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED F A M CONSTRUCTION CORP 196 GENERAL BUILDING BY TAX COLLECTOR CONTRACTOR 75.00 09/22/2014 Worker(s) 10 CGCO19440 0224-14-007070 This local Business Tax Receipt only con iron payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualifications,to do business.Holder mustcomply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec Se-276. w®! For more information,visit www.miamidade.govAaxcollector I DATE(MMIDD/YYYY) �..- CERTIFICATE OF LIABILITY INSURANCE 01/14/15 THIS CERTIFICATE IS ISSUED_ASA 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 Maikel Wong Franklin Insurance Group a/cO No Ext): (305)630-3923 ac No: (305)675-5964 8672 SW 72 Street ADDRESS: franklingroup@bellsouth.net Miami, FL 33143 INSURERS AFFORDING COVERAGE NAIC# Phone (305)630-3923 Fax (305)675-5964 INSURER A: COLONY INSURANCE COMPANY i INSURED INSURER B: FAM Construction Corp/Fermin A Martinez INSURER C: 8340 sw 65 ave Apt#3 INSURER D: MIAMI FL,33143 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 H POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE TY INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000.00 PREMISES Ea occurrence $ F1 F-1CLAIMS-MADE ❑ Y 03/12/2014 03/12/2015 OCCUR GL3655794A MED EXP(Any one person $ 5,000.00 A ❑ BI/PD DED 500 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COM IOP AGG $ 2,000,000.00 ElPOLICY ❑D PEC�RO ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ ALL OWNED ❑ SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED P OPER d4DAMAGE $ ❑ HIRED AUTOS ❑ AUTOS __ ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ �_._ ❑ DED ❑ RETENTION$ WC STATU- OTH- $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ❑TORY LIMITS [:]ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) F-1 E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) LIC. NUMBER CGCO19440 I I i II _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BLDG DEPT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE.2ND AVE MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE MAIKEL WONG-AGENT I — ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05)QF The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION *' CERTIFICATE OF ELECTION TO 13E 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: 9/17/2014 EXPIRATION DATE: 9/16/2016 PERSON: MARTINEZ FERMIN A FEIN: 201750462 BUSINESS NAME AND ADDRESS: FAM CONSTRUCTION CORP 8340 SW 65TH AVE#3 MIAMI FL 33145 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by 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...apply onty within the scope of the business or trade fisted on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to to exempt shall be subject to revocation if,at any time after the filing of the notioa or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 I 11 20" � •+�uh Miami shores Village Building Department �ORIDA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance 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: I. 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. to these circumstances.Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,You may 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 A, J Print Name: - ', Print Name: e- Signature: Signature: State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and subscribed before me this Sworn to and subscribed before me th' 1 day of 20 day o 20 By Arr1 '( V By 20 Notary Public Stabs of Florida (SEAL) _e6 _ _ - " - (SE `T e of Identification produceType of 164 a a Expires 03/26/2016 w MiamishoresVillage 5NORF►�' Building Departmalso 10050 N.E.2nd Avenue ti*4 Miami Shores, Florida 33138 �d Tel: (305) 795.2204 vOR> ► Fax: (305) 756.8972 1-5 Page 1 of 1 Permit No: Structural Critique Sheet 1�.. g�� ���i" � fir�-v� � �c�- �...�•(�. tsn ecw•k tXe leo w. w�a ti -Z) Ok- r 5t/�'dd v ty 4e -@A. U-,r w�-� 0- STOPPED REVIEW Plan review is not complete,when all items above are corrected,we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re-submittal drawings. WWI Asraf