RC-14-2581 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-242350 Permit Number: RC-11-14-2581
Scheduled Inspection Date: August 28, 2015 Permit Type: Residential Construction
Inspector: Rodriguez,Jorge
Inspection Type: Final
Owner: BOEHNE, PATRICIA Work Classification: Alteration
Job Address:55 NE 94 Street
Miami Shores, FL 33138- Phone Number (202)262-2500
Parcel Number 1132060130560
Project: <NONE>
Contractor: CONCEPTS 21 INC Phone: (305)796-4913
Building Department Comments
REMOVE AND REPLACE CEILING DRYWALL. INSTALL Infractio Passed Comments
R-30 BATT INSULATION. INSPECTOR COMMENTS False
TO CLOSE PERMIT# RC-14-577
Inspector Comments
Passed
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
August 27, 2015 For Inspections please call: (305)762-4949 Page 11 of 30
MAY 2 2 2015
Patricia Boehne May 21, 2015
55 NE 94th St
Miami Shores, FL 33138
954-612-0217
RE: Permit Mo. RC-11-14-2581
To Whom It May Concern:
I, Patricia Boehne,would like to request a 90 day extension to our permit to ensure that our electrical
contractor has sufficient time to ensure all items are ready for a final inspection. Your assistance in this
matter is greatly appreciated.
Best Regards,
i�
Patricia Boehne
M AM
v
Miami Shores Village
Building Department
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 ' (�
BUILDING Master Permit No--K
PERMIT APPLICATION Sub Permit No.
OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION E]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 55 NE 94th Street
City: Miami Shores County: Miami Dade Zia:
Folio/Parcel#:11-3206-013-0560 Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Patricia Boehne Phone#:(202) 262-2500
Address:55 NE 94th Street
City: Miami Shores State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Concepts 21, Inc. Phone#: (305) 796-4913
Address: 333 NE 117th Street
City. Miami State: FL Zip: 33161
Qualifier Name: William Wever, Jr. Phone#: (305)796-4913
State Certification or Registration#: CGC1518023 Certificate of Competency#:
DESIGNER:Architect/Engineer: N/A Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$$1,500.00 Square/Linear Footage of Work: 380
Type of Work: ❑ Addition ❑ Alteration ❑ New FEW Repair/Replace ❑ Demolition
Description of work: Remove and replace ceiling drywall. Install R-30 batt insulation.
Request new permit to replace original Master Permit#RC-3-14-577 due to it expiring and for closeout of permit.
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
Bonding Company's Name(if applicable) N/A
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable) SuntruSt Mortgage, Inc.
Mortgage Lender's Address PO Box 79041
city Baltimoe State MD Zip 21279
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: 1 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 wtill be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was ackno ledged beforemethis
Zy day of n 'ONJ- �.tios n._ .20 14 by �_day of 1���M� .20 I l by
P or �-� T• �y�.k^+— ,who is personally known to (A)(l AM TB vl&k�yvho is personally known to
me or who has produced-L. 04-vi.off �!•, - L-�-• as me or who has produced EL (-A n) rJ as
identification andwho di oa . identification and who did take an oath.
NOTARY PUB NOTARY PUBLIC:
Sign. 4 Sign:
Print: Print: t*of Florida
1P
e
::°. , ;
Not Public-State of Florida !llndltlANa
Seal: „ , Seal: Mty 'a��FF 158750
•. . My Comm. Expires Jul 4,2015 1e
=;^ `�: Commission# EE 72698
F�,ii�•`�P`• Bonded Through National Notary Assn.
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
CGC1518023
The GENERAL CONTRACTOR
Named below IS CERTIFIED `
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
WEVER, WILLIAM B JR L
•
CONCEPTS 21 INC
333 NE 117TH STREET
MIAMI FL 33161
0
ISSUED: 08/03/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408030003794
W3877
Local Business Tax Receipt
Miami-Dade County, State of Florida
THIS IS NOTA BILL - DO NOT PAY
6996038
BUSINESS NAME/LOCATION RECEIPT NO.
CONCEPTS 21 INCEXPIRES
333 NE 117 ST RENEWAL 7271604 SEPTEMBER 30, 2015
MIAMI FL 33161
Must be displayed at place of business
Pursuant to County Code
Chapter 8A-Art.9&10
OWNER SEC, , .PE OF BUSINESS
CONCEPTS 21 INC 196 GENERAL BUILDING CONTRACTOR PAYMENT RECEIVED
Worker(s) 1 CGC1518023 BY TAX COLLECTOR
$75.00 09/30/2014
CREDITCARD-14-043388
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt
permit or a certification of the holder's qualifications,to do business. Holder must corn 1 wih is any
g a license,
or nongovernmental regulatory laws and requirements which apply to the business. P Y Y governmental
The RECEIPT NO.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 88-276.
For more Information,visit www,mtamidado aov rn�-+ie for
CERTIFICATE OF LIABILITY INSURANCE °11/14/20 4'
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
8250 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
INSURED CONCEPTS 21,INC INSURER A: ATLANTIC CASUALTY INSURANCE COMPANY
333 NE 117 STREET INSURER 8:
INSURER C:
�-
BISCAYNE PARK,FL 33161
INSURER 0:
INSURER E:
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. _
T POLICY R TYPE OF INSURANCE POLICY NUMBER r IMIDEDCTIVE PpATE EXPlRAT1 IMMI I LIMITS
GENERAL LIABILITY f EACH OCCURRENCE $ 1,000,000
I X COMMERCIAL GENERAL LIABILITY AC11225746PC j 04/16/2014 04/16/2015 FIRE DAMAGE(Anyone fire) S 50,000
CLAIMS MADE F OCCUR ( y P ) S 5,000
MED EXP An one arson
PERSONAL&AOV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000
X POLICY PRO- Ll
LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) S
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO ( OTHER THAN EA ACC S
I AUTO ONLY: qGG S
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR F CLAIMS MADE AGGREGATE 5
S
DEDUCTIBLE S
RETENTION S S
W STATU- OTH-
WORKERS COMPENSATION AND TORY LIMITS ER
EMPLOYERS'LIABILITY
E.L.EACH ACCIDENT S
E.L.DISEASE-EA EMPLOYEE S
i E.L.DISEASE-POLICY LIMIT 5
OTHER
I
DESCRIPTION OF OPERATIONSILOCATKINSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
GENERAL CONTRACTOR LICENSE#CGC1518023
CERTIFICATE HOLDER 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 INSU R ITS AGENTS OR
MIAMI SHORES,FL 33138 REPRESENTATIVES. /
AUTHORIZED REPRESENTATIVE
ACORD 25-S(7197) ACOptb CORPORATION 1988
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: 6/5/2014 EXPIRATION DATE: 6/4/2016
PERSON: WEVER WILLIAM B JR
FEIN: 651148467
BUSINESS NAME AND ADDRESS:
CONCEPTS 21 INC
333 NORTHEAST 117TH
IAITAUFT FL 33161
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 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 shag 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 oertgcate.The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609
St►�I
eggs Miami shores \
` Building Department
��ORNp 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.In these circumstances Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company.p y. 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
Print Name: -r i ` -( c F} O�L/ /P �����
Print Name: Ne ver-j,-.
1 J�-
Signature. � �y-�r� Signature:
State of Florida) State of Florida)
County of Miami-Dade) County of Miami-Dade)
Sworn to and subscribed before me this tJ Sworn to and subscribed before me this DA
day of v "-- ,201�_ , day of W3JLn4GR ,20 I y .
By GERALD LL By
(SEAL) "n
dz° Notary Public-State of Florida NotaryPublic State d Florid
jul 2015 (SEAL)
Type I rfication > -. ,98 T e of Identification rod
�i�F�oP`,`
Bonded Through National Notary Assn. of Expires Ot1103/2018 750