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DS-15-1169 �c \ _ a��\ \ \ \ c Miami Shores Villagez 771-w ` 10050 N.E.2nd Avenue NE \ \ "t \ Miami Shores,FL 33138-0000 y \ \u\ Phone: (305)795-2204 boom \\� Expiration: 11/3012015 11� .r. Project Address Parcel Number Applicant 912 NE 95 Street 1132060010010 RICHARD EFFS BARCLAY GRAI Miami Shores, FL Block: Lot: Owner Information Address PhoneCell RICHARD EFFS BARCLAY GRAEBNER 912 NE 95 Street (305)490-3299 i MIAMI SHORES FL 3338- 912 NE 95 Street MIAMI SHORES FL 3338- Contractor(s) Phone Cell Phone LValuation: $ 500.00 HOME OWNER Feet: 175 Approved: In Review Available Inspections: Comments: Inspection Type: Date Approved: :In Review Final Date Denied: Foundation Type of Work:REPLACE EXISTING WALKWAY Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# DS-5-15-55597 DBPR Fee $2.00 DCA Fee $2.00 06/03/2015 Credit Card $ 108.60 $0.00 Education Surcharge $0.20 Permit Fee $100.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $108.60 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFF VIT: I certify t I the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction n oning. Futherm re,Yauthor a the above-nam for o do the work stated. 11 June 03, 2015 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy June 03,2015 1 �b i � 3 Miami ShoresVillage �-. g M1AY Building Departments, 4 - 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 t-� BUILDING Master Permit No,'D,5 I S— " Cc PERMIT APPLICATION sub Permit No. U11-DING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder) C:,.)---CAQ-k-A - Phone#:LI Address: c�\ 2— "�'2 �^ City: , LC�/"�^, ;�y` .'"F' State: Zip: ' Tenant/Lessee Name: Phone#:-- Email: CONTRACTOR:Company Name: Phone#: Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration#: Certificate of Competency M DESIGNER:Architect/Engineer: Phone#: Address: , \ City: State: i Zip: Value of Work for this Permit:$ y U 0 ' v Square/Linear F otage of Work: 1� S Type of Work: E:1 Addition EJ Alteration `Repair/Replace ❑ Demolition De ription of Work: �� �{1f\cNi<-- <. -t-N%�`-\ 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) 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 nota pproved an a reinspection fee will be charged. SignatureSignature g OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this CS day of M Fkt- 1201S by day of 20 by IPmAk3►"" w is per y know to who is personally 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: \���� rlenls ��, NOTARY PUBLIC: iEP/- Sign: Sign: Print: Print: Seal: '�,r OF ............ Seal: F�ORIDP ***************************** ****************************************************************************** APPROVED BY cs Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) `5 0 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT NAME: DATE ADDRESS: cjlz_ C�_- CA Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,F.S 489.103(7).And I have read and understood the following disclosure statement,which entitles me to work as my own contractor;I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor.You have applied for a permit under an exception to the law.The exemption allows you,as the owner of your property,to act as your own contractor even though you do not have a license.You must supervise the construction yourself.You may build or improve a one-family or two-family residence.You may also build or improve a commercial building at a cost of$25,000.00 or less(The new form states 75,000).The building must be for your own use and occupancy.It may not be built for sale or lease.If you sell or lease a building you have built yourself within one year after the construction is complete,the law will presume that you built for sale or lease,which is a violation of this exemption.You may not hire an unlicensed person as a contractor.It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances.Any person working on your building who is not licensed must work under your supervision and must be employed by you,which means that you must deduct F.I.C.A and with-holdings tax and provide workers'compensation for that employee,all as prescribed by law.Your construction must comply with all applicable laws,ordinances,buildings codes and zoning regulations. Please read and initial each paragraph. 1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner-builder permit under an exemption from the law.The exemption specifies that I,as the owner of the property listed,may act as my own contractor with certain restrictions even though I do not have a license. Initial 2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. , L Initial 3. 1 understand that,as an owner builder,I am the responsible party of record on a permit.I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name.I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. Initial 4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding.I may also build or improve a commercial building if the costs do not exceed$75,000.The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease.If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete,the law will presume that I built or substantially improved it for sale or leas ,which violates the exemption. Initial 5. 1 understand that,as the owner-builder,I must provide direct,onsite supervision of the construction. Initial 6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence.It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance. Initial- 7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner-builder permit that erroneously implies that the property owner is providing his or her own labor and materials. I,as an owner-builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property.My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner-builder and am aware of the limits of my insurance coverage for injuries to workers on my property. Ini ' 8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done.Any person working on my building who is not licensed must work under my direct supervision and must be employed by me,which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act(FICA)and must provide workers compensation for the employee.I understand that my failure to follow these may subject to serious financial risk. Initial 9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide by all applicable laws and requirement that govern owner-builders as well as employers.I also understand that the Construction must comply with all applicable laws,ordinances,building codes, and zoning regulatio s. Initial 10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,the United States Small Business Administration,and the Florida Department of Revenues.I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http://www.mvfloridalicense.com/dbpr/pro/cilb/index.htmI Initial 11. 1 am aware of,and consent to;an owner-builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: Initial- 12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the information that I have provided on this disclosure. Initial Licensed contractors are regulated by laws designed to protect the public.If you contract with a person who does not have a license,the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court.It is also important for you to understand that,if an unlicensed contractor or employee of an individual or firm is injured while working on your property,you may be held liable for damages.If you obtain an owner-builder permit and wish to hire a licensed contractor,you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued,this disclosure statement must be completed and signed by the property owner and returned to the local permitting agency responsible for issuing the permit.A copy of the property owner's driver license,the notarized signature of the property owner,or other type of verification acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this �Lee day of d` , 20 15 BY '��b -ZF_b`6"r'fZ--who was pers96llikno to me or who has Produced there Lic\ $'{�31b1S %, as identification. n O"ER'°°•. °� say`.•' �J� NOTARY m Drdered By: i5 We nee(i Co take ever-y opportunity t pxossible to thank our C .. •' < ; rt �� �� �.�. amazing clients �< P» for their support... = s me ; Thank You!!! N. E. 95th STREET I 20'ASPHALT PAVEMENT 0 i 26.5' PARKWAY i v r Ft.P,r 2 11 : 0 P 7bl _ COKC.'WALK p9 © CONCRETE wAu 3 ' �9�'ryg963 ?aO�` d 2 Tib c. RECII V7-4,0 JAN 19 2014 4.15 v - ri 24.28' 015.35 p 24.15 0 <.10' N N a^ 16.80 31.11' 0. O 1.55' TWO STORY ~ O RESIDENCE O t{, N ,/912 0 m QT N h 27.70016.25' 5.60' i 22.73' 19.75' 20.25 A S P H A L T 0 R I V E W A Y 00 y `r'._20.30'.-\ ZO m 5 2.50' 20.2 O.lt' 26 o E� 127J0'P (411 ALL FEDERAL • •• • • • • •••••••••••••• Airo�e•r�•y Ada•dtses•c:` 1•2iE_R9•`5ro`SReETcRrroE x.ETxTs,c.piFLEsrxtxT.x.NE•NRN •._,_. _.�tS..,.�E.._UT N� CHES OUTH LO T UNE. Dli:Ml!FL 33138 ESATMMA SnMGELE$f1NOSALAND SURVEYING,INC. TFlZ1 x RYGOOR uTMmW,rioMSTATUTM 10665 SW 190TH StW eaSuite3110 • • • • ` MIAMI,FL 33157 • • FOR THE FIRM NI-IONE;(305)740-3319 S'7- STATE OF 3 P.&M.Na 5101 FAX#_(305)6693190 rio ��{" TVAiow TVAUR TuxE,wuemx�nceM E�eTRarMSURVEYOR LB#6463 W{P6NDT VALq� I�UlD NEgtK'MAL AAL9FL:F.ALOFALICERSEO SUPVEYOR ,. • • *in- iA 35793• •Client File#. SCHA121312 Page 1 of 2 Not valid without all pages. ••• • • • ••• • • Surveyors Legend end Y PROPERTY LINE ' STRUCTURE FIND FOUND MON PIPE R.R. BEARING REFERENCE TEL TELEPHONE FACILITIES / r� CONC.BLOCK WALL PIN AS NOTED ON PIAT L CENTRAL ANGLE OR DELTA U.P. UTILITY POLE —X—X— C"M-LRW FENCE OR WINE FENCE LBj LICENSE j-BUSINESS R RADIUS OR RADIAL E.U.B. ELECTRIC UmLmr BOX fit'--Yl— WOOD FENCE LSj LICENSE#-sURMEYOR RAD. RADIAL TIE SEP. SEPTIC TANK IRON FENCE CALC CALCULATED POINT N.R. NON RADIAL D.F. DR/JIOIELD EASEMENT SET SET PIN TYR. TYPICAL. A/C AIR CONDITIONER —-— CENTER LINE A CONTROL POINT I.R. IRON NOD S/W SIDEWALK WOOD BECK W CONCRETE MONUMENT I.P. .IRON PIPE DWT DRIVEWAY lit BENCHMARK TURD NAN t DISK SCR, SCREEN �.' CONCRETE ELEV ELEVATION PK NAD PARKER-KALON NAIL GAR GARAGE ® ASPHALT P.T. POINT OF TANGENCY D.H. BRILL HOLE ENCL ENCLOSURE P.C. PONT OF CURVATURE ® WELL N.T.S. NOT TO SCALE BRICK/TIE P.R.M. PERMANENT REFERENCE MONUMENT FIRE HYDRANT FF. nNNrHED FLOOR WATER P.C.C. POINT OF COMPOUND CURVATURE ® Y.H. MANHOLE T.O.B. TOP OF RANK P.R.C. PRINT OF REVERSE CURVATURE 0-M.L. OVERHEAD LINES E.O.W. EDGE OF WATER APPROXIMAXE EDGE OF WATER P.O.R. POINT OF BEGBNNNG TX TRANSFORMER E.O.P EDGE OF PAVEMENT _. COVERED AREA P.O.C. POINT OF COMMENCEMENT CAP/ CABLE TV RISER C.V.G. CONCRETE VALLEY BUFFER x y P.C.P. PERMANENT CONTROL POINT W.M. WATER METER B.S.L. BUILDING SETBACK LINE i TREE YFIELD MEASURED P/E POO EQUIPMENT S.T.L. SURVEY TIE TIE UNE T} POWER POLE P PLATTED MEASUREMENT COMIC. CONCRETE SLAB ¢ CENTER LINE CATCH BASIN 0 DEED ESOT EASEMENT R/, RIGHT-OF-WAY C.U.E. COUNTY UT1U1Y EASEMENT C CALCULATED D.E. DRAINAGE EASEMENTP.U.E. PUBLIC UTILITY EASEMENT INGRESS/EGRES-.i EASEMENT L.M.E. LAKE OR LANCSC41E MAINT.ESM q E LANOSCAPE BLFFER EASEMENTC.M.E. CANAL MAINTENANCE EASEMENT U.E. UTIUry EASEMENT R.C.E. RQOF OVERHANG EASEMENT L.A.E. LIMITED ACCESS EASEMENTaE. ANCHOR EASEMENT Property Address: General Notes: 1. The Legal Description Used to PEITform thus sLuvey was supplied by others. 912 N.E.95 STREET This Bey does not determine or is riot to imply ownership. 2. This survey only stows above ground improvements. Underground MIAMI,FL 33138 utilities,footings,or encroachments are not located on this survey map_ 3. tf there is aseptic tank,well.or drain field on this survey,the location of such items was shown to us by others and the information was not verified. Flood Information: 4. Examination of the abstract of title win have to be made to determine recorded instruments,if any,effect this property. The lards shown herein Community Number. 120652 were not abstracted for easement or other recorded encumbrances not shown Panel Number: 12086CO306L on the plat. 5. Wall fies are done to ft face of the wall. Suffix: L 6. Fence ownership is not determined. Date of Finn index. 9/11/2009 7. Bearings referenced to fine noted B.R. 8. Dimensions shown are platted and measured unless otherwise shown. Flood Zone: X 9. No identification found on property comers unless noted. Base Flood Elevation: NIA 10. Not valid unless sealed with the signing surveyors embossed seal- 11. Boundary survey means a drawing andfor graphic representation of the Date of Field Work: 12r2112012 survey work performed in the field,could be drawn at a shown scale andror Completion: 12/26/2012 not toDate of Com P 12. Elevations if stows are based upon NGVD 1929 unless otherwise noted. 13. This is a BOUNDARY SURVEY unless otherwise noted. 14. This survey is exclusive for the use of the parties to whom it is certified. The certifications do not extend to any unnamed parties. Legal Description: LOT 1,OF SUBDIVISION MARILYN HEIGHTS,ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK 41,PAGE 8,OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY,FLORIDA Gertified ro:KATHERINE E.SCHAFER;CLEAR TITLE PRINTING INSTRUCTIONS: GROUP LLC;CHICAGO TITLE INSURANCE COMPANY;;. While viewing the survey in any Acrobat Reader,select the Its successors and/or assigns as their interest may appear. File Drop-down and select`Print7 Select a color printer,if available,or at least one with 8.5'x 14'paper. Select ALL for Print Range,and the If of copies you would like •• Wit ing please make sure you have AFFILIATE •• 04Do no#che*th6.°AetolaQ4te and Center"button. ' � Check the"Choose Paper size by PDF'checkbox. F L„TA MEMBERS Click OK to Print. . . • M.E. LAND SURVEYING, INC. ... ` •` ;' ••• 10665 SW 190TH Street,Suite 3110 MIAMI,FL 33157 PHONE:(305)740-3319 FAX#:(305)669-3190 LB#6463 ..• 0C . WWW.MELANDSERVICES.COM ' SuniWiA- 93• •Client Filet SCHA121312 Page 2 of 2 Not valid without all pages. • • • • • • • • • • • •• •• • • • •• •• ••• • • • ••• • • t Miami Shores Village i4 zd14 s Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 1 INSPECTION'S PHONE NUMBER: (305)762.4949 FBC 201J BUILDING Permit No. PERMIT APPqCATION master Permit No. Permit Type: BUILDING ROOFING JOB ADDRESS: C' l City: Miami Shores County: Miami Dade Zip: I Folio/Parcel#: Is the Building Historically Designated: Yes NO V Flood Zone: OWNER:Name(Fee Sim e Titleholder): ���� ✓ U1 Phone#: Address: City: & k C/­e-� State: Zip: �- Tenant/Lessee Name: Phone#: Email: \C V'6 -r— C. C-yvk C'i. C 1, CONTRACTOR:Company Name: ufl) cnS , J'-�6 Phone#: S -7 � Address: 7/> 1�h`�ti't lt>y z . City: State: 1'2_-_ Zip: r �eZ_ Qualifier Name: v=<-Z Phone#: 3 0SCJ 3 fJ State Certification or Registration#: L t S 2. Certificate of Competency#: ------- Contact Phone#: Email Address: T�>. Cry.&a-6 t b.& "_PUtq h 1 S .w M DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ 6 c_�)c square/Linear Footage of Work: Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ODemolition ` Description of Work: Z. ,r,.1 �/ � ;�� Lj I 1 X—a 0. c � TT 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$ LL TOTAL FEE NOW DUE$ �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 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 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 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first ins a tion which occ seven (7) days after the building permit is issued. In rabse ofsuch posted notice, the inspection will v�ot e approved a a,reinsp ction fee will be charged. 1 Signature Signature Owner or Agent ctor The foregoing instrument was acknowledged before me this The foregg instrument was acknowledged before me this /1� day of;gre ,20 L�/,by/3l�C19,—(f7 ra day of r4 / ,20�,by �Glriie� �'raictc.� who is personally known to me or who has produced�L `fdls who is personally known tome or who has producedF/ Q 6/ 7013-1 As identification and who did take an oath. /6 ( 13t-0 as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: P , nt: CommissiLrdf' Notary Public$tate of Florida CommI io �rewary Public State of Florida Joanna M Feliciano Joanna M Feliciano My Commission FF 082753 • My Commission FF 082753 Expires01H2/2018 OF Expiresoi/12/2018 � fir. � APPROVED BY Plans Examiner �k Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/21/14 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: 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 NAME: Ariel Ajo InterAssurance PHONE 305 7 FAX A/C No Ext: ( ) 58-8322 A/C No: (305)758 4456 9190 Biscayne Blvd.,Suite#201 AE-MAIL David@interassuranc.com Miami Shores,FL 33138 INSURERS AFFORDING COVERAGE NAIC# Phone (305)758-8322 Fax (305)758-4456 INSURER A: ATLANTIC CASUALTY INSURANCE COMPANY INSURED INSURER B: DVG Builders,Inc. INSURER C: 260 Payne St. INSURER D: Miami Springs,FL 33166 INSURER E: (305)506-7308 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. ILTR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DA AGE F-/ COMMERCIAL GENERAL LIABILITY PREMS SESOEa olccu ence $ 100,000.00 ❑ ❑ 10/03/2013 10/03/2014 A CLAIMS-MADE © OCCUR L040002129-0 MED EXP(Any one person) $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000.00 © POLICY ❑ PR? ❑ LOC $ AUTOMOBILE LIABILITY EOMaBIINdEDtSINGLE LIMIT $ ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED❑ AUTOS AUTOS BODILY INJURY(Per accident) $❑ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ ❑ ❑ AUTOS Per accident ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑T/RY L TU ❑�RH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) ❑ E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) GENERALCONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 N.E.2ND AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FLORIDA 33138 AUTHORIZED REPRESENTATIVE Ariel Ajo ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)QF The ACORD name and logo are registered marks of ACORD DEPARTMENT OF BUSINESS AND PROFESSIONAL KLGU1AXX-LQN CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET v ` TALLAHASSEE FL 32399-0783 GARCIA, DANIEL DVG BUILDERS, INC 260 PAYNE DRIVE MIAMI SPRINGS FL 33166 ;. STX of FLOWA A m Congratulations! With this license you became one of the nearly one millionDPAT � 01r BSI-SS AND Floridians licensed by the Department of Business and Professional Regulation. ��agSS , QU1AI4N Our professionals and businesses range from architects to yacht brokers,from boxers to barbeque restaurants,and they keep Florida's economy strong. CGC152923 f 1.2 126005030 Every day we work to improve the way we dobusiness in order to serve you better._ � , For information about our services,please lag canto�r.myflmidalic€snse.c©m, C'ERTX-Fi . TSR There you can find more information about our divisions and the regulations`that GIARCIA. Ak impact you,subscribe to department newsletters and learn more about the BUIL Department's initiatives. � s, Our mission at the Department is:License Efficiently,,Regulate Fairly.We constantly strive to serve you better so that you can serve your customers. IS CaRTIPT x;489 rs Thank you for dating business in Florida,and congratulations on your new licensel 2014 12024b2111 ; DETACH HERE THIS DOCOWNT HAS A COLORED SAC ROUND-MICROPRiNTING UNEMARK 'PATENTED PAPE R ONS ST St z,�24� st2'r x f f LIC H OS 9 20 212fi00x0'30 C0Cinsl 3 '. E The GENERAL CONTRACTOR" 4 tl Named below ,IS CERTIFIED Utider this Chtg � FH� Exp iretion date: AUG 31, 203.x; GARC:IA, DANIHL 3 D'E'C tUILDERS, INC 260 PAYNE DRIVE MIA SPRINCxS FL 331.66 i z t RI{ SCOTT R XN LA+T3N zGOVERNOR SERO_ DISPLAY AS REQUIRED BAY LAW F ......... ME, A, F77 'N 7K 'a w z � � S—r, HPP", '. ot# SEC pe of ImESS PAY EtVF1 O t3Et2S IP3C 196 � 6tNG t1laf� l csc $Y TA34 E s) 1 C1 m 5 00 0S/� Rt3f71ti -1 85 � t liC6ff dace' orrttrms " cai Bus)U.ness Tsit.The Pt is netieanse era car# afthe Is gtraltttc � 4tf t any#*wMatemat or u _ tat��aqutrertIitswMctotheMin 4l',ii RECEt above �y d taYf 'fun all c ial veh cede Sec 9e. 11-20-2012 JEFF ATWATER STATE OF FLORIDA C141EF FINANCIAL OFF=ICER DEPARTMENT OF FINANCIAL. SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE Of ELECTION TO Of 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: 11120/2012 EXPIRATION DATE: 11/20/2014 PERSON: GARCIA DANIEL FEIN; 273673291 BUSINESS NAME AND ADDRESS: DVG'13UILDERS INC 284 PAYNE' OR MIAMI SPRINGSFL 33166 SCOPES OF BUSINESS OR TRADE: 1 LICENSED GENERAL CONTRACTOR 1061`044tdNT Pursuant to tbaptei 440 , 11504t, F,S., an officer of a corporation who #leets exemption tram this chapter by filing a certificate of electron tinder this setuoo may not tetaver benefits or compensation under this tttaptet, Pursuant to Chapter 440.05{12), fry„ Certificates of electron to be exempt., apply onty within the scapi of the business or trade listed on the notice of election to be exempt, Pursuant to Chapter 440,0+500?, f,S., atatstes of election to be exempt aad certificates of election to be eaiampt shall be subject to revocation it,at any time atter the filing of the notice or ft 'issuance of the certificate, the person named on the notice or certificate no longer meats the tetiuitemeots of this section tot issuance of a ce(fificate. The department shall revoke a certificate at 30Y time tot faifote of the poison named on the certificate to meet the requirements of this section, QUESTIONS? J950) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE 'EXEMPT REVISED 01-11