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PL-15-432 (2) Miami Shores Village SB ' RrvF 13 Building Department292015 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 20/1-,,- BUILDING 0/1rBUILDING Master Permit No. —i:2 PERMIT APPLICATION Sub Permit No./?/ S,2 ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP D CONTRACTOR DRAWINGS JOB ADDRESS: LSO � �I 0l - City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: \\ 3-Z OCt, --¢) \4 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): ` ��Gc�� Cc=���.5� Phone#: Address: ern `�►�1 City:_ State: `�\ zip: Tenant/Lessee Name: Phone#: Email: x CONTRACTOR:Company Name: Jp�WA�V �� Lvf 1-7'4>;v Phone#: Address: & '0 (/u C= I City: "5 A A f Stater Zip: ;Qualifier Name: ;- Phone#: State Certification or Registration#: G FG O�P `>3/ Certificate of Competency#: DESIGNER:Architect/Engineer: �_y�C.�1 ^Tr-n.V1 CSS Phone#:-laG -2-Lc)-�Sz Z Address: 2?_L� Sc� �`� Qy� City`_,c^ c-c)L\ Gja6\etate:2t�= Zip: 3�lSS Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: �C-1—� Specify color of color thru tile: Submittal Fee$ Permit Fee$ �S '`y 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 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 approv and a reinspection fee will be charged. �� Si nature ° Signature g OWNER or A NT CONTRACT (R The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 1� by day of 20 Lc,-.) by L1, 40 � ,who is personally known to ���cA�e9.Qo�gS ,,who is personally known to me or who has produced off (.as me or who has produced as identificatiop and who did take an oath. identificati an who did take NOTAPLIC NOT RODOt FO E SOsAPublic StatealFI2p17otComm.ExpY 4,RODOLFO E SOSA ' * Y E 873648 Sign: c% Notary Public-State of Florida SignCommissihN Nolary AssnMyComm.Expires May 4,2017Print ;= Commission#EE 873648 Print: Bonded Through National Notary Assn. Seal: Seal: APPROVED BY Z-L f'45 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Report Viewer Page 1 of 1 • a i �&a r e JEFF ATWATER •^4pe�t�� CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION "CERTIFICATE OF ELECTION TO BE 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: 7/12/2015 EXPIRATION DATE: 7/11/2017 PERSON: ROJAS ED`NARDO FEIN: 453073611 BUSINESS NAME AND ADDRESS: EDWARD ROJAS PLUMBING CORP 880 NE 111 ST BISCAYNE PARK FL 33161 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pursuant to Chapter 440.05(14),F.S.,an omceraf a corporsOan who steels exemption from his cheptor byy fifNg o esrtihple of elagien under thb sectlon may not reeover benerds of compensation under this chapter.Pursuant to Chapter 440,05(12),F,:3.,lottleptos of-003fobeexomp6.,applyonly exempt antl vAthin the pprlirieales of eieeesrsronrlo Da oxade entlipf shall tr sonthenoucubject to revocatIon if,at any Ome after The IGn9 of0lhegnalko or thteeiissuanceaof the eM6 cafe, the poison named an the notke ar certlritate no longer meets the requirements of this socfion for issuance of a car,,tate,Tho department sholl revoke a h DFS-F2.OWC•252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 0&19 QUESTIONS?(850)4131609 S file:///C:/Users/RUTHL/AppData/Loca.I/Temp/5PNQSAIC.htm 6/30/2015% \�� Miami Shores Village 3 P -��i� Building Department FEB 015 i 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 $Y. INSPECTION LINE PHONE NUMBER:(305)762-4949 C2010 BUILDING Master Permit No. —I�v PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING REVISION EXTENSION RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: Z)L-�G E �1CA 5-C City: Miami Shores County: Miami Dade Zip: 33\3ri Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): V i (NcAt'n�c C,C— Phone#: Address: 160C t-A'E- CA01 4 A . City: W\aCYi, SMoret' Stater Zip: Tenant/Lessee Name: Phone#: `5\G - G'33C,, 3�L: Email: CONTRACTOR:Company Name: /V�w ��ie�' �M. C Phone# � Address: ���✓-� /PC City: /7 � %" State: Zip: 3511 Qualifier Name: Phone#: *b SS IlZdo 1�1 4jb State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer -P.0CX—_C% Phone#: :4 Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: _ Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: l�o.'\�►c��c�:�`a c6 Re, �oLC_1_- cvhno <ZY. Specify color of color thru tile: �'It!da 'toV 7 Adie ca ed'-, .� Submittal Fee$ Permit Fee$ %JCS •GL-) CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ •E5 (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 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 approv 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 �3 day of brL3Qsrc4 20 k'S by day of T'�C�rac-L'�cy.c 20 , by _1 'Std who i � V,C «k C-i%s� ,who is rsonlly kriown � e�oc1 E�S`�a r�'persoYlaf 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: Print: ?r°Pay Notar Public-State of Florida Seal: .'o�" , R '' My Comm. Expires May 4,2017 r* „`�; Notary Public Sta2NotaryAssn Seal: = ' `o;: Commission#EE 873648 • My Comm.Expires ''%°;,;;;;P Bonded Through National Notary Assn. P Commission#E °; Bonded Through Nation ********** ************************************************************** APPROVED BY ?% J'a Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) b e r J �� � a v r � Ln A k F 03F - - '�"t "{h1pI�U0Rt.�.{�fYf� x � , e s it er-Bl Awl'8'x'40' Sr OWNER m, SEC.TYp�E �AUSINEBE PAYMENT RECEIVED NEW NRM INC 198 $ $BUILQING BY TAX COLLECTOR P;C3NTRACTOR 45.00 09111@014 r(s) , 078w1w OUI-14-004648 oft This;LocattialaiM Tart o*eaa p 1.0"I ullTmm7f oLlm Raplipt is net tocerA . permit,ojaa �a oF11olows si Ammioaar MkN bmiasp.*mw meat compltwo any oftwormeml or aorgevdpl l►apah74il<Itiws aed rspaimmemb w th apply b*a btrsiruss. TholigoTNO.o"sppia be dhplarpMd on&#eommoreial vehMN- Lok tH: Sae 064 MUM - »ilknmmWL4vlw- C,TQB Board BUSINESS CERTIFICATE OF COMPETENCY MOM= NEW FORM INC D.B.A.: O SO HERNAN is Certified tinder the provisions of Chapter 10 of Miw&Dade Cw* tt�lt8 of Ful 4010 } say OWNER TYPI!btu�IiII�tNEfs PAYMENTAWCOWD NEW FORM INC 5U6 Ok��CONTRACT Qft 9Y TAX CgµE 100.00 09/11/ ,14 0221-14004849 ' RssttfObd to.Wt, y of mbl Bi" hun For mart+llMArfion,visit �' ►— r E:(1W7MEN LTri!'ttiU- NT9"'Tl RESOURCLT;'� 16115 SW 26 3,-gEET 11IRi+11 --',7175--,_474 78E a l ; ok"'le. MISCEL1_ONEOU', RECEIPTO9Y�9�:0:•i 3MOR, :} { DEsc ,.mo-jrt F rb�,0 .rig z ,4aa: a I CERTIFICATE OF LIABILITY INSURANCE °A02/224//15 PRODUCER Florida Bankers Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 7278 SW 8 Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami,FL 33144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305)266-6493 Fax (305)262-0679 INSURERS AFFORDING COVERAGE NAIC# INSURED New Form Inc INSURER A: FEDERATED NATIONAL INSURANCE INSURER B: PO Box 190934 INSURER C: Miami Beach, FL 33119- INSURER D: (305)926-1948 INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 OF MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD DATE(MMA) DATE MWDD/YY LIMITS GENERAL UABIUTY EACH OCCURRENCE _ 1,000,0_0_0.00 ©COMMERCIAL GENERAL LIABILITY ENTED GL-0504012412-00 08/09/14 08/09/15 PREM SES Ea occurence 100,000.00 ❑❑ CLAIMS MADE © OCCUR MED EXP(Any one person) 5,000.00 A © ❑ 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 ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS F-1 El SCHEDULED AUTOS BODILY rperson) ❑ HIRED AUTOS BODILY INJURY ❑ NON OWNED AUTOS (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE UABIUTY AUTO ONLY-EA ACCIDENT _ ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ OTH- EMPLOYERS'LIABILITYLIMIT ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS GENERAL CONTRACTOR 07B001020 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL MIAMI SHORES VILLAGE 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO BUILDING DEPARTMENT THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY 10050 NE 2 AVE OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. MIAMI SHORES, FL. 33138 AUTHORIZED REPRESENTATIVE w,305)460-7201 *� ACORD 25(2001/08)OF ®ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(20011'08)OF JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE 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: 3/20/2014 EXPIRATION DATE: 3/19/2016 PERSON: OSSO HERNAN FEIN: 383712606 BUSINESS NAME AND ADDRESS: NEW FORM INC P.O.BOX 190934 MIAMI BEACH FL 33119 SCOPES OF BUSINESS OR TRADE: CERAMIC TILE, INDOOR CARPENTRY WALLBOARD,SHEETROC PAPERHANGING AND STONE, MA INSTALLATION OF CA K,DRYWALL, P DRIVERS 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 only within the scope of the business or trade listed 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 be exempt shall be subject to revocation If,at any Ume after the filing of the notice 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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 SNORES 1loss f" Miami shores Village Building Department ��ORr1DA 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.. 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 Signature: i` ?` _ ature: State of Florida State of F o County of Miami-Dade County of Miami-Dade The foregoing was acknowledge before me this The foregoing was acknowledge before me this day of F��bciyEaS�p 20_N-:�- . day of 120v=---, . By I ' Qf By 0`.2f,0 wh '`s personally o me or has produced who is personally known to me or has produced as identificati ��� RODOLFO E SOSA as identificatio � RODOLFO E SCSA Notary Public-State of Floridat Notary Public-State of Florida Notary: - Comm. Expires May 4,2017 Notary. Aly cnmm.Expires May 4,20, SEAL: Commission#EE 873648 SEAL: N.. `o;: Commission # EE 873648 Assn. Banded Through National Notary As . "" Bonded Through National Notary P.O. Box 190934 Miami Beach, FL 33119 Tel: 305.926.1948 Email: office.newform@yahoo.com License No: 07B001020 February 26, 2015 State of Florida County of Miami-Dade Before me this day personal appeared, Hernan Osso,who being duly sworn, deposes and says: I, Hernan Osso, of New Form Inc. will personally perform the work at the location listed below for no more than a period of 30 calendar days: 860 NE 99 Street Miami Shores, FL 33138 Sworn to(or affirmed)and subscribed before me thin:7 day of e/A,%,1® 20 /S , by: r ELN• �' �� Personally known OR Produced Identification Type of Identification roduced 000LF0 E SOSA Y ?rowRof y Public-State of Florida 4411 * y m.Expires May 4,2017 mission#EE 873648 o. nry Assn. Pri pe of tamp Name of Notary