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DS-15-2608 Permit tV 4,.J'r' 726 �sN°SES o,� Miami Shores Village Perm f rype:'0rhr'49 * 111 10050 N.E.2nd Avenue NE 1fflork G,awlff l i ( (t3Y1 A f t at)Qt1 Miami Shores,FL 33138-0000 Pelf:Sfa OVER Phone: (305)795-2204 � �YORII� ' .tlasuebito: 10120126115 Expiration: 04/17/2016 Project Address Parcel Number Applicant 230 NE 107 Street 1122310130670 gENJELLOUN HASSAN Miami Shores, FL 33161- Block: Lot: Owner Information Address Phone Cell BENJELLOUN HASSAN (305)207-0606 Contractor(s) Phone Cell Phone Valuation: $ 5,900.00 TRUE STAMP CONCRETE LLC (305)494-4465 Total Sq Feet: .0 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:REPLACE EXISTING DRIVEWAY WITH PL Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning:3 Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Owners Bond $500.00 Invoice# DS-10-15-57422 CCF $3.60 10/20/2015 Credit Card $647.60 $0.00 DBPR Fee $2.00 DCA Fee $2.00 Bond#:2884 Education Surcharge $1.20 Permit Fee $125.00 Scanning Fee $9.00 Technology Fee $4.80 Total: $647.60 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 me responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRIC L,l?LUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AF T• I gerhfy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction nd zoning. utherm uthorize the above-named contractor to do the work stated, �_ October 20, 2015 Autho ized nature:- Applicant / Contractor / Agent Date Buil Department Copy October 20,2015 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-245708 Permit Number: DS-10-15-2608 Scheduled Inspection Date: November 03, 2015 Permit Type: Driveways/Sidewalks/Slabs Inspector: Rodriguez,Jorge Inspection Type: Final Owner: HASSAN, BENJELLOUN Work Classification: Addition/Alteration Job Address:230 NE 107 Street Miami Shores, FL 33161- Phone Number Parcel Number 1122310130670 Project: <NONE> Contractor: TRUE STAMP CONCRETE LLC Phone: (305)494-4465 Building Department Comments REPLACE EXISTING DRIVEWAY WITH PLAIN Infractio Passed Comments CONCRETE DRIVEWAY INSPECTOR COMMENTS False Inspector Comments Passed 0 13 Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. November 02,2015 For Inspections please call: (305)762-4949 Page 20 of 50 Miami Shores Village --_ � zo1�� i Building Department � . ,. OCTC 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. DS 15` 26Dq PERMIT APPLICATION Sub Permit No. (BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: d (6-7 S 7— City: City: Miami Shores County: Miami Dade Zia: F Folio Parcel#: -© 06Z2 Is the Building Historical) Desi ated:Yes NO >C Occupancy Type: Load: Construction Type Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): &2 ,; 5,q/L-/ 14e1L, :jgZ( 2,,z•�./ Phone#: �1 "� J Address: 231a f✓/� �c� `7 S7` City: t-11 IL6!�o�5 State: T/�'zf Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: r2,00, C,2avo.,t_{f-CPLhone#: Address: City: Pi✓i l �' State: iC (L Zip: Qualifier Name: !� (.�� __��'L&a Oft Phone#: _3 -0_5' State Certification or Registration#: C—(9 Y[O0 Z Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ ��fD o Square/Unear Footage of Work: 2-O 5X Type of Work: ❑ Addition ❑ Alteration' ❑ New Repair/Replace ❑ Demolition Description of Work: c 2. e X i Z�.� A vQ� •4�Z tv"/ T� ��� e:►< eoi►'c'R P� 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$ _0 I � - G0 `{� ' &D 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 nowork 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 fJ'rst inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be ap roved and a reinspection fee will be charged. Signature Signature c OWNER or AGENT CONTRACTOR The f egoin strument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 0 �` .20 /� A by ("0 day of e9 C7— .20 �� .by L 4DUw6vho is ersonally known o G✓/CC/ �., c�!S�1 .who' personally known)o 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: illZ Seal: Seal: Seal: ARANMY COM MISSM#FF 913306 MY i4tirWELlB 60NIAlQ . •rL COMMISSION#FF 913M �- EXPIRES:September 18,2019 EXPIRES:September 18,2019 TW"P+MC U wwftm eo„ded ThmMV Pub¢c uncle to a r*wss��•*a��:sear• +rr**�**sa��r*r*�sssss�e w**a+rru�r APPROVED BY Plans Examiner Zoning. Structural Review Clerk CTOB f ;. � �� Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY E0800748 'TRUE STAMPED CONCRETE LLC 4TEiA WILLIAM Is certified under the provisions of Chapter 10 of Miami-Dade County QUALIFYING TRADE(S) 0008: CONCRETE ENGINEER y ll wk& P.E Semxmag / WAWW a0m � Ndade.povfecammy relaft f Municipal Contractor's Tax Receipt Miami—Dade County,State of Florida -THIS IS NOT A BILL-DO NOT PAY CC NO: E0800748 BUSINESS NAMEILOCATION RECEIPT NO. TRUE STAMPED CONCRETE LLC EXPIRES 8320 SW 38 ST 7a�o�28 SEPTEMBER 30, 2016 MIAMI,FL 33155 Pursuant to County Code See 10-24 OWNER TYPE OF BUSINESS TRUE STAMPED CONCRETE LLC SPECIALTY ENGINEERING PAYMENT RECEWED CONTRACTOR BY TAX COLLECTOR 175.00 08/06/2015 0237-15-000074 This receipt Is not valid in the lollowiq MmdaipaRtles:Montoya,Beat Hialeah,Key Biscayne, Miami Barden,Mind Lakes,Palmetto gay,Roacrest Sum l isles Beach.Town of Cotler Bay. MIAM ® � For more bdomxuioa,visit mamwgda y Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 6314843 BUSINESS NAME/LOCATtON TRUE STAMPED CONCRETE RECEIPT No. EXPIRES LLC RENEWAL SEPTEMBER 30, 2016 8320 SW 38 ST 6581289 MIAMI,FL 331M Must be displayed at place of business Pursuant to County Code Chapter 8A-Art.9&10 r OWNER SEC.TYPE OF BUSINESS TRUE STAMPED CONCRETE LLC 186 SPECIALTY PAYMENT RECEIVED ENGINEERING BY TAX COLLECTOR Worker(s) 1 E0800748CONTRACT 75.00 08/06/2015 This Local Bmhlw Taxnas 0237-15-000074 permit ora cartilmatim WR Receipt mem of the Local Business Tex.The Receipt Is not a Won$% . or o1�afetory laws.tea,to do business.Holder mast comply with any Baventmostal The RECEIPT N0.strove amst be regafmmems width apply to the btatir M displayed M aR comtroreial wobbles-Mlaml.,0aae Code Sec 88 -276• Farmore hdormatlon, ..rmiamta,.a a..-� AC4OkVCERTIFICATE OF LIABILITY INSURANCE DAT 10/1415 10/14/15 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS j 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,thpol e icy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to 1 the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the j certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Madeline Estrada Yes Insurance Agencies, Inc. PHo No Ext:_-(305)225-5757 _ �� No): (305)223-8158 9507 Bird Road ADD LESS• madeline@yesins.com Miami,FL 33165 INSURERS)AFFORDING COVERAGE NAIC# Phone (305)225-5757 Fax (305)223-8158 INSURERA GRANADA INS CO. INSURED INSURER B: True Stamped Concrete Llc. INSURER C: 8320 SW 38 St INSURER D Miami,FL 33155- (305)494-4465 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—P L(MM/LIIID��L CLAIMS. _POLICY NUMBER - - - AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY P -� INSR ADD lSUBR' LTR TYPE OF INSURANCE MMIDD/YYYY LIMITS GENERAL LIABILITY -- — T COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE - -_ t_$- 500,000.00 _ DAMAGES(RENTED 100,000.00 CLAIMS-MADE ❑ ❑ ! L.PREMISES(Ea occurrence—�$_._ _— OCCUR L00020506 0185FMED EXP An one person) 5,000.00 N 08/01/2015 08/01/2016 PERSONAL&ADV INJURYT$ 500,000.00 Ll - GENERAL AGGREGATE $ 1,000,000.00 GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG! $ 1,000,000.00 ❑ POLICY 11PRO- ❑ LOC - - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ - L accl _ $ _ - - -- -i ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED -- - ---- — -- ❑ AUTOS AUTOS BODILY INJURY(Per accident $ NON-OWNED - - ❑ HIRED AUTOS AUTOS PROPERTY MAGE $ ��Per_accident ❑ UMBRELLA LIAB OCCUR EACHOCCURRENCE - r ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ �- - - -L - TORYTLLMITS $ AND EMPLOYERS'LIABILITY OTH- DED RETENTION$ WORKERS COMPENSATION ANY PROPRIETOR/PARTNER/EXECUTIVE/N _� - - -- OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT j $ (Mandatory in NH) If [- l E.L.DISEASE-EA EMPLOYEE$ - F OPERATIONS below - - E.L.DISEASE-POLICY LIMIT; $ yes,describe under DESCRIPTIONO I I i -� -- - --- DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CONCRETE PAVING I - I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BUILDING DEPT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2 ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE MADELINE ESTRADA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05)QF The ACORD name and logo are registered marks of ACORD .� WE 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: 7/18/2014 EXPIRATION DATE: 7/17/2016 PERSON: TRUEBA WILLIAM FEIN: 203060130 BUSINESS NAME AND ADDRESS: TRUE STAMPED CONCRETE l 8320 SW 38 STREET MIAMI FL 33155 SCOPES OF BUSINESS OR TRADE: CONCRETE WORK CONCRETE OR CEMENT INCIDENTAL TO TH WORK-FLOO 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 Boom Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner- Workers' Compensation Insurance Exemption =YT 7 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. Signature: State of F] County of Miami-Dade The foregoing was acknowledge before me this L� day 20jE. By #CAS&4 J who i personally known to me or has produced as identification. Notary: ARPML18 GOVALEZ MY SEAL: EXP C0MW8S10N#FF91s= k), 1RES:September 18 2019 6 d 7bru*try PU*Uudenvrilers True Stamped Concrete LLC 8320 SW 38th Street, Miami, FL, 33155 October 15, 2015 State Of Florida County of Dade Before me this day personally appeared Mr William Trueba who,being duly sworn, deposes and says: That he will be the only person working on the project locatded at 230 NE 107 street, Miami shores, 33161. Sworn to (affirmed) and subscribed before me this 15 day of October.2015,by Personally know Type of Identification Produced: Driver license ARANEUS GONZAM ¢ MY COMMISSION#FF 913306 s, j:,� EXPIRES:September 18,2019 Boeded Thru Notary PubGe undewiws SORES S K _ ^�Z)7 Miami Shores Village ell ,.... OCT 1 2015 Building Department 10050 N.E.2nd Avenue L--- �-- - Lp ��` �}oma - � Miami Shores, Florida 33138 OR Tel: (305) 795.2204 Fax: (305) 756.8972 COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY Whereas, (owner) Ar/44 4 4-l-, ZG®,/,1.m hereinafter referred to as the owner of the following described property(address): Legal Description LotTA`r Block _ Subdivision,4scST *?�/i'3 Folio#;P.1 22�f;PL - 670 �'��� ....•IRequeWal:missign to ipstall(describework):�L.�„`, ®,�� ���� ,�n��`�,�C� • ...... .. .. .. .. •••'@Within tDpjoL:blic rig 0ofway of(address) &1_;': IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said items within public right of way including restoration of street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from any and all liability,which may rise by virtue of permitting the installation of these items within the public right of way. 1 3. The Owner does hereby agree to remove or relocate their facilities at their own expense,within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village(or his fully authorized representative). SIGNED, SEALED, EXECUTED AND ACKNOWLEDGE on this day of 6 C , 2015- wn ignature) . .. . . ... 6666. SIGNED, SEALED, AND DELIVERED in the presence of: :*ease 666.. • 6666•. 6666.. 00 .. of •. 6• 600000 . . 66660 ARANELIS OON7AI Gl 060•6•• EXPIRES:Sep~18,2019• 0 0666.• Bonded Thm N*W WuV*W de=brs • • • •• • i.. .6•..• • . • .. • 0060 • 00 • • • • • 000000 0 0 2 o MAP 4F BOUNDARY SURVEY `_tel t�'- j � Ti '$ v_ ply ��✓j 1 7 1 1. .. r; o 10 zo OCT a 20 ' tR6DAt1d te�ARrx m,COMs"°•" .I..i 6 ..^.. _.' 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