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PL-04-370 R� ` Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL F�Rte' Phone: (305)795-2204 Fax: (305)756-8972 r spedion Number: INSP4.482 : Perm ,NumW- P .. U�437 . Inspection Date: 04/02/2007 Permit Type: Imported Permit Inspector: Levrack,James Inspection Type: Final Owner: CONESCU,JEREMY Work Classification: <NONE> Job Address: 161 105 Street NE Miami Shores Village, FL Phone Number Parcel Number 1121360080110 Project: <NONE> Block: Lot: Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: 305-661-6633 Building Department Comments INSTALL NEW DRAINFIELD AND SEPTIC � Ins r omments Passed EO Failed Correction Needed Re-Inspection Fee ($7`) No Additional Inspections can be scheduled until re-inspection fee is paid. Friday, March 30, 2007 Page 2 of 2 Miami Shores Village Plumbing Permit 10050 NE 2nd Avenue ":.. RIM" Phone: 305-795-2204 Permit Number: PL2004-370 OR Printed: Printed: 1/10/2005 Page 1 of 1 Applicant: EDGAR PALACIOS Owner: CONESCU JEREMY JOB ADDRESS: 161 NW 105 ST Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26 Local Phone: 305-661-6633 Parcel # 1121360080110 Legal Description: DUNNINGS MIAMI SHORES EXT 4 PB 48-20 LOT 11 BLK 204 Fees: Description Amount FEE2004-13177 CCF $1.20 Total Fees:$663.97 FEE2004-13178 Notary Fee $5.00 Total Receipts:$488.97 FEE2004-13179 Scanning Fee $3.00 FEE2004-13180 Training and Education Fee $0.40 FEE2004-13181 Technology Fee $4.37 FEE2005-251 Building Fee $350.00 FEE2005-252 Builders Bond $300.00 Total Fees: $663.97 Permit Status: APPROVED Permit Expiration: 6/26/2005 Construction Value: $2,100.00 Work: INSTALL NEW DRAINFIELD AND SEPTIC TANK Signed: (INSPECTOR) 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 responisibility for all work done b either myself,m agent,servants or employes. Y Y Y 9 Signed: (Contractor or Builder) BY: Miami Shores Village Plumbing Permit2I" 10050 NE 2nd Avenue ""' 370 PL2004 b Permit Number: - Phone: 305-795-2204 P Printed: 1/10/2005 Page 1 of 1 Applicant: EDGAR PALACIOS Owner: CONESCU JEREMY JOB ADDRESS: 161 NW 105 ST Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26 Local Phone: 305-661-6633 Parcel # 1121360080110 Legal Description: DUNNINGS MIAMI SHORES EXT 4 PB 48-20 LOT 11 BLK 204 Fees: Description Amount FEE2004-13177 CCF $1.20 Total Fees:$663.97 FEE2004-13178 Notary Fee $5.00 FEE2004-13179 Scanning Fee $3.00 Total Receipts:$488.97 FEE2004-13180 Training and Education Fee $0.40 �j�, `� FEE2004-13181 Technology Fee $4.37 FEE2005-251 Building Fee $350.00 FEE2005-252 Builders Bond $300.00 Total Fees: $663.97 Permit Status: APPROVED Permit Expiration: 6/26/2005 Construction Value: $2,100.00 Work: INSTALL NEW DRAINFIELD AND SEPTIC TANK Signed: (INSPECTOR) 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 responisibility for all work done by either myself,my agent,servants or employes. Signed: (Contractor or Builder) BY: OR Miami Shores Village Plumbing Permit 10050 NE 2nd Avenue ---- Permit Number: PL2004-370 ` may` Phone: 305-795-2204 a>atin ttaR Printed: 1/10/2005 Page 1 of 1 Applicant: EDGAR PALACIOS Owner: CONESCU JEREMY JOB ADDRESS: 161 NW 105 ST Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26 Local Phone: 305-661-6633 Parcel# 1121360080110 Legal Description: DUNNINGS MIAMI SHORES EXT 4 PB 48-20 LOT 11 BLK 204 Fees: Description Amount FEE2004-13177 CCF $1.20 Total Fees:$663.97 FEE2004-13178 Notary Fee $5.00 FEE2004-13179 Scanning Fee $3.00 Total Receipts:$488.97 FEE2004-13180 Training and Education Fee $0.40 / r75, r-19 FEE2004-13181 Technology Fee $4.37 FEE2005-251 Building Fee $350.00 FEE2005-252 Builders Bond $300.00 Total Fees: $663.97 Permit Status: APPROVED Permit Expiration: 6/26/2005 Construction Value: $2,100.00 Work: INSTALL NEW DRAINFIELD AND SEPTIC TANK Signed: (INSPECTOR) 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 responisibility for all work done by either myself,my agent,servants or employes. Signed: (Contractor or Builder) BY: Miami Shores Village Plumbing Permit 10050 NE 2nd Avenue -.•r Permit Number: PL2004-370 Phone: 305-795-2204 OR�p► Printed: 1/10/2005 Page 1 of 1 Applicant: EDGAR PALACIOS Owner: CONESCU JEREMY JOB ADDRESS: 161 NW 105 ST Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26 Local Phone: 305-661-6633 Parcel# 1121360080110 Legal Description: DUNNINGS MIAMI SHORES EXT 4 PB 48-20 LOT 11 BLK 204 Fees: Description Amount FEE2004-13177 CCF $1.20 Total Fees:$663.97 FEE2004-13178 Notary Fee $5.00 FEE2004-13179 Scanning Fee $3.00 Total Receipts:$488.97 FEE2004-13180 Training and Education Fee $0.40 /�7 ` fv FEE2004-13181 Technology Fee $4.37 FEE2005-251 Building Fee $350.00 FEE2005-252 Builders Bond $300.00 Total Fees: $663.97 Permit Status: APPROVED Permit Expiration: 6/26/2005 Construction Value: $2,100.00 Work: INSTALL NEW DRAINFIELD AND SEPTIC TANK Signed: (INSPECTOR) 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 responisibiliity for all work done by either myself,my agent,servants or employes. Signed: (Contractor or Builder) BY: TL ,�9 00 3�7D STATE OF FLORIDA PERMIT Na. DEPART29F T OF HEALTH DATE PAID: i_, ONSITE SEWAGE TREAT2=T AND DIPOSAL SYSTEM FSM PAID: wrl CONSTRUCTION INSPECTION AND FINAL APPROVAL NIECSIPT ft APPLICANT: AGENTt SSG �`'F C PROPERTY ADDRESS t All A1W' JQJ 3/,�'-`, G LOT: /I BLOCK: C7(),/ SDBDIVISION4 ! Nr�►•A 1�'(ITa t1y� PROP.z ID ift CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATOTB OR AOLZ AM MST HE CORRECTED. TANK INSTALLATION //�� SNLTB1lCK8 I [oil- TAMC-SIZE (1]�t� V [2 . [N ] [27] SORFACNL iOMR'�-- - FT [ I IO2] TANK MATERIAL Pr GSf [ ] [28] DITCHES FT I I [03] OUTLET DEVICE (g or [ I I291 PRIVATE WELLS FT [ I [04] MULTI—CWWBZRZD /.N [ ] [30] PUBLIC WBLLs. FT [ I [05] OUTLET FILTER e's �(�1 � [� ] [31] IRRIGATION' WEXIA FT [ I 1061 LEGEND [A l [32] POTABLE WATER LINES _ _ FT. I I [07] FLIGHT , [ ] 133.1 BUILDING FOUNDATION FT [ ] 1081 LEVEL [ ] [34] PROPERTY LINES `7 FT [ 1 1091 DEPTH TO LID [ l [35] OTHER FT DRAINMFIELD 134STAT1.A7�on FILLED / MOUND SYSTEM [ I 110] AREA [ly x 3(- (2]±_Z_sQFT [,J l I36] DRAZN1=0 COVER [ ] [11] DISTRIBUTION BOX HEADER Lel [) ] [37] SHOUIIMS 1 I 1121 NUMBER OF DRAINDLINES _�_ I/ l [38] SLOPES I I (13) DRAINLINE 8NZPARATION 3 �P Ii l 1391 STABILIZATION I I 114) DRAT umat S1iOPE I ] [15I DEPTH OF COVER ADDITIONAL INFORMATION I I [16] ELEVATION [ABOVE/BELOW] BM [ l [401 nNnimmT1tUCTZD AREA [ l [17] UTSTEK LOCATION [ ] [411 STORMKATER RUNOFF [ I [18] DOSING PUMPS 4A [ ] t421 ALUM [ l [191 AGGREGATE SIZE W• INDzB�0.d7, [ l [43] N NCS AGREEMENT [ l [20] AGGREGATE EXCESSIVE [ l 1441 BUILDING AREA I I (211 AGGREGATE DEPTH I I 145] LOCATION CONFORMS WITH SITE PLAN -- — MATERIAL [ l 1461 FINAL SITE0� nju FILL EXCAVATION MA [ I 1417) COINTNZACTOR .�1.. n [ I 122j FILL AMOUNT [ l -[481 022m I l [23] FILL TEXTURE [ I [24] EXCAVATION DEPTH [ l 1251., AREA REPLACED [ l [491 TANK PUMPED /_� 1 l 126] REPLACEMENT MATERIAI Xr: �,, So �� 1 l (SO] TANK CRUSHED is FILLED EXPLANATION OF VIOLATIONS / REIMARKSt [ I . [ I [ I � r . CONSTRIICTION [APPROVED/DISAPPROV®]t �. CBD `� DAA' FINAL SYSTEM (APPROVED/DISAPPROVED]: J a ,!L CED =2fyt a � DH 4016, 10/97 (Previous Editions may be Used) page 2 of 3 Miami Shores Village Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 BUILDING FEi^;_ Permit No. �� , PERMIT APPLICA I6 Master Permit No.FBC 2001 - Permit Type (circle): Building Electricallumbing Mechanical Roofing Owner's Name(Fee Simple Titleholder) 0%ry A Pa 1016 o S Phone# Owner's Address N 10 < ,:X� CityKSW1ore5 State FL- Zip 513 Tenant/Lessee Name Phone# Job Address(where the work is being done) City Miami Shores Village County Miami-Dade Zip Is Building Historically Designated YES NO V Contractor's Company Name on# (301 � Contractor's Address `P® e) City c, I/*J0 0 State r L Zip ?2 S(9 Qualifier (ere5 -q !So I State Certificate or Registration No. 5%502-t 011+ Certificate of Competency No. Architect/Engineer's Name(if applicable) pd Phone# $Value of Work For this Permit Square Footage Of Work: 300 Type of Work: ❑Addition ❑Alteration ❑New Ej�Repair/Replace ❑Demolition Describe Work: 1,1021( Ora in A4 V + 5.1cottc tci h IG Submittal Fee$ Permit Fee$ CCF$� 60 - CO/CC Notary$ n -00 Training/Education Fee$ U Technology Fee$ Scanning$ Radon$ Zoning Bond$�� .CXD d Code Enforcement$ Structural Plan Review. $ TotalFee Now Due$ (Continued on opposite side) �� Bonding Company's Name( applicable) Bonding Company's Addres Nix City State Zip Mortgage Lender's Name(il applicable) Mortgage Lender's Address City State Zip Application is hereby made I obtain a permit to do the work and installations as indicated. I certify that no work or installation pp y p rtlfy mstallatio 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 jun'sdicti n. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING, SIGNS, WELLS,POOLS,FURNAC 'S,BOILERS,HEATERS,TANKS and AIR CONDMONERS,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 co truction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR ROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YO R LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: Asa co dition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a opy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to ttachment. 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 inon will not be ap r d and a reinspection fee will be charged. Si:. a Signa e" Owner r Agent Contractor The foregoing instrument was acknowledged before me this The for in ent was acknowledged before me this day ofc , 20 G`f,b day of 2017y1` � ( ho is personally known to me or who has produced who is personally kno to me or who has produced sYi>�1(�ld take oath. as i entifiEPSid aAY CpMMISS10N#DD 255050 - _ Pii"ailion VP 1 yg4 NOT Y PUBLI �*� „ p�pber1,2007 NOTARY PUBLIC: �'k'•, ' l.'Qe Expires;Jr�I 1 2007 XpIRES: Sign: r- 60:rAA'mrut;40 €t nd ru Sign: t" le 80 Co. In, Print: et Print: My Commission Expires: My Commis 'on Expir s: RL :*: r;l.''" �i(:<SIt?UffbD256459 f APPLICATION APPROVED Y: / Plans Examiner Engineer Zoning Chc 05/13/03 — - Miami Shores Village Building Department i M_ 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 ,3y: 7 Tel: (305)795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER: (305)762.4949 FBC 20 BUILDING Permit No. PERMIT APPLIC_A_ TION Master Permit N Permit Type: UILDING� ROOFING JOB ADDRESS: N L I City: Miami Shores County: Miami Dade Zip: _33)3 2 Folio/Parcel#: P l —3Lc)(6 —6 0 — 05-6c) Is the Building Historically Designated:Yes NO ✓ Flood Zone: OWNER:Name(Fee Simple Titleholder): ��" �:P'"� � � N Ph ne#: C2-®Z) g(o.Z')'5-,Dc) Address: -S S N &- City: A;4 i-A i Sit®ye-.5 State: /�� Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: ®,,.j c e '� Phone#: 3 6 S 7 9 b _ Address: 3 3 N 6— IL r City: s t State: Zip: 3 3 Qualifier Name: �a ��/ uc A*'V-e ✓r Phone#: 65— -716 — ��713 State Certification or Registration#: C d-c /S/ i®a- Certificate of Competency#: Contact Phone#: .3®S- 79 6 09/ 3 Email Address: C® ov c e J'5 AA a r l� . 94— DESIGNER: Architect/Eiigineer: .lam/A- Phone#: ' o0 Value of Work for this Permit: $ �T Square/Linear.Zair/Replace of Work: J� Type of Work: ❑Addition OAlteration ONew 015eemolition Description of Work: X, ave C A7 OL, 'P, /, d a>--- / Color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ WV . s Bonding Company's Name(if applicable) Bonding Company's Address City State zip Mortgage Lender's Name(if applicable) c� 1 r t) ,� Mortgage Lender's Address 13 i -7610 e City 6 q /fr ,1, ®r-,-- State 1440 zip I 7 Application is hereby made to obtain a permit to do the work and installations as indicated. I certifyno work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the t at dards 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 PAYINq 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 exceedi g$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 Iust be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absende of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contra for The foregoing instrument was acknowledged befo2Le_me is The foregoing instrument was ackno ledged before me this day of MgeJo 20 ,by 17 p,�� peKyL+e day of ,20 by who is personally known to me or who has produced who is personally known to me or w o has produced FL As identifier.. ..nc i ke an oath. as identific nth. •; 1.91 '.::=R"'• NOTARY PUBLIC: S6OZ'60 tPAW 83MIdX3 NOTARY PUBLIC: 14A MY comm;6; 3 93 £&L t 33 N NWS81WN00 AW � EXPIRES Match 04.iv16 1`1aVd OM38R13H ' Sign: Sign: Print: AiC k ,4V rZ.L4, Print: �"/t , Y p 3/ `� G y p *.34M ERIBMTO PADILL, M Commission Expires: /� M Commission Expires: My S " EXP�ES Arch 04.200 APPROVED BY 3 LGTc. Plans Examiner zoning Structural Review Clerk (Revised 5/2/2012)(Revised 3/12/2012)XRevised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) MAR 2 6 2014 DURABLE POWER OF ATTORNEY MAR State of Florida �,, Countyof MiAN1.l — '. Vle �h lrA/'a� — t KNOW ALL MEN BY THESE PRESENTS,that 1, ftT'(?► G'A Joe✓tIINc; 'Of (name) (county) Florida,as authorized by Florida law,do hereby appoint. I�-rT r16 W 306f- 0G_ (name) To manage and conduct my affairs. This power of attorney shall be non-delegable except as otherwise provided in Florida Statutes, and shall be valid and effective from date hereof until such time as I shall die or revoke the power. This durable power of attorney is not affected by subsequent incapacity of the principal except as provided in Florida Statutes. The property subject-to this durable power of attorney shall include all real and personal property owned by me, my interest in al property held in joint tenancy, my interest in all non-homestead property held in tenancy by the entirety, and all property over which I hold power of appointment and shall also include authority to sell, mortgage or convey my homestead property. Without limiting the broad powers intended to be conferred by the preceding provisions,I expressly authorize my attorney acting hereunder in a fiduciary capacity to do and execute all or any of the following acts, deeds, and things for my benefit and on f my behalf. I 1. COLLECTION POWERS: To ask, demand, sue for, recover, collect, receive all sums of money, bank deposits, chattels and other real or personal property, tangible or intangible, of whatsoever nature or description that may be due, owing,payable or belonging to me,and to execute and deliver receipts,releases,cancellations or discharges. 2. PAYMENT POWERS: To settle any account or reckoning whatsoever wherein I now am or at any time hereafter shall be in any way interested or concerned with any person whomsoever,and to pay or receive the balance thereof as the case may require. 3. SAFE DEPOSIT BOXES: To enter any safe deposit or other place of safekeeping standing in my name with full authority to remove any and all the contents thereof and to make additions, substitutions and replacements, specifically including any safe deposit box in my name jointly with my spouse or any other person. 4. BANKING POWERS: (a) To borrow any sum or sums of money on such terms and with such security,whether real or personal property belonging to me, as my attorney may think fit, and to execute any and all notes, mortgages and other instruments which my attorney may deem necessary or desirable. (b) To draw, accept, make, endorse or otherwise deal with any checks, promissory notes, bills of exchange or other commercial or mercantile instruments, specifically including the right to make withdrawals from any savings account or building or loan deposits. (c) To redeem or cash in any/or all bonds issued by the United States Government or any of its agencies, any other bonds and any certificates of deposit or other similar assets or securities belonging to me. j (d) To sell all or any bonds, shares of stock, warrants, debentures, or other securities belonging to me, and to execute all assignments and other instruments necessary or proper for transferring the same to the purchaser j or purchasers thereof,and to give good receipts and discharges for all monies payable In respect thereof. (e) To invest the proceeds of any redemptions or sales aforesaid, and any other of my monies, in such, bonds, shares of stock and other securities as my attorney shall think fit, and from time to time to vary the said Investments or any of them. Page 1 of 3 i I S. MANAGEMENT POWERS: To vote at all meetings of stockholders of any company or corporation,and otherwise to act as my attorney or proxy in respect of my shares of stock or other securities or investments which now or hereafter shall belong to me,and to appoint substitutes or proxies with respect to any such shares of stock. 6. TAX POWERS: To sign and execute in my behalf any tax return, state or federal relating to income, gift, ad valorem, intangible or other taxes, state or federal, and to act for me in any examinations, audits, hearings, conferences or litigation relating to any such taxes,including authority to file and prosecute refund claims,and to enter into an effect any settlements. I 7. TRUST POWERS: (a) To execute a revocable or irrevocable trust which provides that all income and principal shall be paid to me or the guardian of my estate, or applied for my benefit in such manner as I or my attorney hereunder shall request or as the trustee shall determine,and that on my death any remaining assets,including income,shall 1 pass according to my will or intestate succession if I have no will. j (b) To make additions of funds and assets,real and personal,to any trust established by me. j 8. BUSINESS INTERESTS: I (a) To sell, rent, lease for any term,or exchange, any real estate or interests therein,for such considerations and upon such terms and conditions as my attorney may see fit;specifically including the power and authority to execute acknowledge and deliver deeds, mortgages, leases and other instruments conveying or encumbering title to property owned by me and my spouse jointly. (b) To commence, prosecute, discontinue or defend all actions or other legal proceedings touching my estate or any part thereof,or touching any matter in which I or my estate may be in any way concerned. (c) The powers herein conferred upon my attorney shall extend to and include all of my right,title and interest in and to any real and personal property,tangible or intangible, In which I may have an estate by the entirety, joint tenancy,tenancy in common,as trustee or beneficiary of any trust,or in any other manner. 9. PERSONAL INTERESTS: (a) To make gifts, outright or in trust, in an amount not greater than $10,000.00 per donee per year or the amounts allowed without gift tax consequences under the appropriate Internal Revenue code provisions (including my attorney hereunder appointed). (b) To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home, retirement home or similar institution. (c) To renounce or disclaim any interest acquired by testate or intestate succession or by inter vivos transfer. 10. HEALTH CARE POWERS: (a) To authorize,arrange for,consent to,waive and terminate any and all medical and surgical procedures on my behalf(including any election or election and agreement under the Life-Prolonging Procedures Act of Florida with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a declaration hereunder)and to pay or arrange compensation for my care. (b) To make health care decisions for me and to provide informed consent if I am incapable of making health care decisions or providing informed consent. (I) To be the final authority to act for me and to make health care decisions for me in matters regarding my health care during any period in which I have the incapacity to consent. (ii) To expeditiously consult with appropriate health care providers to provide informed consent in my best interest and make health care decisions for me which my said Surrogate believes I would have made under the circumstances if I were capable of making such decisions. (iii) To give any consent in writing using the appropriate consent form. (iv) To have access to appropriate clinical records regarding me and have authority to authorize the release of information and clinical records to appropriate persons to insure the continuity of my health care. Page 2 of 3 i (v) To apply for public benefits,where necessary, such as Medicare and Medicaid,for me and have access to information regarding my income and assets to the extent required to make such application if necessary. (vi) To make all health care decisions on my behalf including but not limited to those set forth in F.S. Chapter 765. 11. GENERAL POWERS: (a) In general to do all other acts, deeds, matters and things whatsoever in or about my estate, property and affairs,or to concur with persons jointly interested with me therein in doing all acts,deeds,matters and things herein particularly or generally described, as fully and effectually to all intents and purposes as I could do myself. (b) This instrument is executed by me in the State of Florida but it is my intention that the powers and authority herein conferred upon my attorney as authorized by the laws of Florida now or hereafter in force and effect shall be exercisable in any other state or jurisdiction where I may have any property or assets. I hereby ratify and confirm, and promise at all times to ratify and confirm all and whatsoever my duly authorized attorney hereunder shall lawfully do or cause to be done by virtue of these presents, including anything which shall be done between the revocation of this instrument by my death or in any other manner and notice of such revocation reaching my attorney; and I hereby declare that as against me and all persons claiming under me everything which my said attorney shall do or cause to be done in pursuance hereof after such revocation as aforesaid shall be valid and effectual in favor of any persons claiming the benefit thereof who,before the doing thereof,shall not have had notice of such revocation. IN WITNESS WHEREOF,I have executed this Durable Power of Attorney. 03/zy�o/y 03 Witnes Signature Date Signature Date 3 �( a0�� 'T•�rTZ�Gt AH{l/G' Witness Signature Date Print Name State of Florida County of 1,AitA'1^pero E.. Before me the undersigped authority, duly authorized to take acknowledgements and administer oaths, personally appeare &6nc 'XJAAnfi--- ,personally known to me to be the person described above,who being by me first duly sworn states that(His or Her)is the person who executed the foregoing instrument for the reasons expressed therein. I Dated this 2�"` day of r -V��- GUEU TH MERCEMEB OMRAMITO MY COMMISSION 8 EE187748 NOTARY PUBLIC EXPIRES/1prp22.2018 My Commission Expires: �2Z) t'O i I I Page 3 of 3 �5�uREs G loss aMiami shores V - too �` Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. �r COPY OF LIABILITY INSURANCE* DCOPY OF WORKERS COMPENSATION INSURANCE* IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. C. COPY OF LIABILITY INSURACE* D. COPY OF WORKERS COMPENSATION INSURANCE* *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: o ou C' e /P BUSINESS ADDRESS: '3-3 3 N 1 7`-- CITY /1?®� , STATE % ZIP CODE -3 3 1 & I BUSINESS PHONE: ( 3 05 ) 716— /-/7 13 FAX NUMBER( ) CELL PHONE( ) QUALIFIER'S NAME: *I Ne ver jr. QUALIFIER'S LIC NUMBER: f- -- 15 1 $ 0 d- 3 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 -�°� `• 1940 NORTH MONROE STREET TALLAHASSEE L32399-0783 WEVER, WILLIAM B JR CONCEPTS 21 INC 333 NE 117TH STREET MIAMI FL 33161 S7 ATE 60 FLb10A' AC# Congratulations! With this license you become one of the nearly one million DRF BISINES Floridians licensed by the Department of Business and Professional Regulation. PgOFE , EaEGt�iTION Our professionals and businesses range from architects to yacht brokers,from , boxers to barbeque restaurants,and they keep Florida's economy strong. CiC1518 02 � . 12$66"6 8 6 Every day we work to improve the way we do business in order to serve you better. For information about our services,please log onto www.myfloridalicanse.com. CLR'I'IFI _. TQ�t There you can find more information about our divisions and the regulations that TA?VER, W impact you,subscribe to department newsletters and learn more about the COiCEPTS'a �hE) Department's initiatives. Our mission at the Department is:License Efficiently, Regulate Fairly.We &' ` constantly strive to serve you better so that you can serve your customers. =S:s��g�yF,. ; air tt� Sxoviioas ch �# 9 �; Thank you for doing business in Florida,and congratulations on your new license! Ssp*ratioa dat8e30D3340- 1 DETACH HERE 6 T AT OFL �bA:; DEPARTI EN'3' OF H ; T S D P l77FESSI AIS 1 LGUL' ,T16� OtIStT�tC�C:TIDI%fiTSTRY LIUENBINC Bt1ARD + Q �a120'8303Q LI'CN$ ppv _:. The + }gxttbT. C `— 6T- NdQW I;S1 CEaIFI$D 3.er: ns o� Ch°apt r Xat2 date A`i�G .31, 2014iO T +� �{�•yy: "rip -. ,s� �. S `'��r r°�z' `,�"�- N`. , _. TY��.c7r l; `•1�F?.1J2 B �.1:,R : + h � ..,. � �j �,;..x€�.A �.�k! r CO�lC TS 2:i Ib C 13 3 NX 117TA TRE RICK 16'OTT ItT.: S >O GOINOR S�CR 'T3i' . DISFkLAY AS REQUIRED BY LMt/ s � �9 ��'fi a ��-z� `� f'��,,. { �r•z �� '� ,�Ee,� -7"��M�`4`��.u. Y� t S gU,2ya�i�,rt;.� �+.♦ �,y"�� _lam' �Y� �, :fi s r ' x 3P OWN SEC.TOF ESS s � y 1 INC 6 GE ONTRA P Tax OR C1518D EDIT 1 373 p� This usln ecel o e Locil Business OR is R or clam hal to d r o arm mply with a � ental gave I rag. f ry requlr 3 ply to O.a must 1 com al vehl a Code For m n, .mlawl > D 121,. ffI910 PRODUCER 305-227-0082 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CAROLINA INSURANCE CONSULTANTS, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 5250 W FLAGLER STREET,STE 116 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MIAMI, FL 33144 INSURERS AFFORDING COVERAGE --------- ---- ---...---•----...---- - ------ --------..._.. ------------------ r INSURERA: ATLANTIC CASUALTY INSURANCE COMPANY _ INSURED CONCEPTS 21, INC __. _ 333 NE 117 STREET INSURER B: SISCAYNE PARK, FL 33161 INSURER C: tN_SURER ENSURERF.: ._-_...._.._._.—._._.._.........._.-.._...----- ------•-- COVERAGES - --- 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION TR� TYPE OF INSURANCE _ POLICY NUMBERI DATE iMPo1100fYYl� DATE fNI;n4D07YY1 -^ - LIMITS _ 1-4--z- NERAL LIABILITY EACH OCCURRENCE _ _ S 1,000,000 COMMERCfALGENERAL LIABILITY ACH 225746PC 04/16/2014 04/16/2015 FIRE DAMAGE(Any One fire) S50,1}b�-- -. ! CLAIMS MADE JC;OCCUR MED An EXP _ �...-, I —.(Any one person) S 5,000 _ -• _ _ -.. PERSONAL&ADV INJURY S- 1 000 000 GENERAL AGGREGATE ~-I S 2,000,000 GEN'LALLGREGATELIMIT APPLIES PER: I ) rPRODUCTS.COMP/OP AGG S 2,000,000 X�POLICY PEO —1 LOC IAUTOMOBILE LIABILITY !II COM1i01NEDSIMGLELIAi1T S accident) ANY AUTO (Ea a ALLOWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Par person) i HIRED AUTOS 8004LY INJURY S NON-OWNED AUTOS (Per accident) I -• --` I PROPEP.TY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT S ANY AUTO OTHER THAN EA ACC SS_ I AUTO ONLY: AGG I S -_-M-- EXC LIABILITY RRENCE T CLAIMS MADE ' AGGREGATE E 3 DEDUCTIBLE S { RETENTION S j - _-~•—• g -- -�_ WORKERS COMPENSATION AND WC STAT U- TH- EMPLOYERS'LIABILITY ) TORY LIMITS I-,,,,I ER - E.L.EACH ACCIDENT S E.L.DISEASE•EA EMPLOYEE S j E.L.DISEASE-POLICY LIMIT S OTHER i DESCRIPTION OF OPERATIONSILOCATIONSNEFMCLE$iEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS GENERAL CON"T"RACTOR LICENSE 9 CGC1518023 CERTIFICATE HOLDER I X ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN MIAMI SHORES VILLAGE BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 10050 NE 2ND AVE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR MIAMI SHORES, FL 33138 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE , ACORD 25•S(7197) (DACORD C PORATION 1988 06-05-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 06/05/2012 EXPIRATION DATE: 06/05/2014 PERSON: WEVER WILLIAM B JR FEIN: 651148467 BUSINESS NAME AND ADDRESS: CONCEPTS 21 INC 333 NORTHEAST 117TH STREET MIAMI FL 33161 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR IMPORTANT: 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 time 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. O.UESTIONS? (850) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDAL under this section may not recover benefits or compensation under this y WORKERS'COMPENSATION LAW D chapter. EFFECTIVE: 06/05/2012 EXPIRATION DATE: 06/05/2014 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be PERSON: WILLIAM B WEVER JR H exempt.. apply only within the scope of the business or trade listed on FEIN: 651148467 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt CONCEPTS 21 and certificates of election to be exempt shall be subject to revocation MIAMI, NORTHEASTT 117TH STREET if, at any time after the filing of the notice or the issuance of the IAMI, FL 33161 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 SCOPE OF BUSINESS OR TRADE:- person named on the certificate to meet the requirements of this I- LICENSED GENERAL CONTRACTOR section. QUESTIONS? (850) 413-1609 CUT HERE Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11