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RC-13-2168 (3) Miami Shores Village Building Department JAN 21 2015 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY: INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 1 0 BUILDING Master Permit No. 2C-1 3" 21 G� PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION rInRENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS --JOB ADDRESS: �I �/MIVP et ° �'vz- �� 3 / 3 !/ Com: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: ConstructionType: Flood Zone: BFE: FFE: Ca m 01� J end `�C DOWNER:Name(Fee Simple Titleholder): Phone#: X3SQ Address: City: '� State: Zip: Tenant/LesseeName: Phone#: Email: CONTRACTOR:Company Name: —TS �jons+rck:&�' 'f�&,s i CSS Phone#:'1 _S —6 9 Address: 9q 90 auD (04 -T- 0 City: 0 i Acv-y-�I State: Zip: _3>5 k- Qualifier Name: Phone#:-79(0 State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ r Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteratiioo�n� ❑ New ❑ Repair/Replace ❑ Demolition c.. y Description of Work: r ce LG��/Iy � � �/✓�iCL�7 Specify color of color thru tile: Submittal Fee$ Permit Fee$ 0® CC41 CO/CC$ Scanning Fee$3-03 Radon Fee$ -O(7 DBPR$ Notary$ Technology Fee$ 2, 4 Q Training/Education Fee$ ( ' Boa Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ '() L (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. Als a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which a urs seven day after the building permit is issued. In the absence of such posted notice, the inspection will not be prove a d a reins c ion f will be charged. Signature Signature or ENT CONTRACTOR The foregoing instr mentrwas acknowledged before me this The foregoing instrument was acknowledged before me this 12- day of �JA1)UO 20 ,by Q(Q day of �anJai20 by J2 ��i-f� ---- who_is-personally known to f who�pe �alnown mer 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: MYLAI HERNANDEZ NOTARY PUBLIC: ►t := MY COMMISSION it EE 221249 Wg EXPIRES:December 1,2016 Banded Tt'Notary Pu19E underwriters Sign: Sign: t Print: ! e--2- Print: 0404; Seal: Sea(: 1111 , MYLAI IIERNANdQ uo ' MY COMMISSION#Ef 221249 ,gti"`E'�N''•., MYLAI HERNANDQ G. � EXPIRES:December 1,2018 =� �% MY COMMISSION#EE 221249 Boomed Thru Put11k Urdierarri<ers P`: EXPIRES:December 1,2016 ' of .• Bonded Thru Notary Public Underwriters 1***** P APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,'GOVERNOR KEN LAWS O '-,-SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1511413 The GENERAL CONTRACTOR Named below IS CERTIFIED �6z Under the provisions of Chapter 489 FS. ou"', Expiration date: AUG 31, 2016 SERRAT, JUAN A NJ a KIS CONSTRUCTIONS qEf_1TICESILC 9980 S W 64TH ST `. - MIAMI FL 3a17371440 .� ISSUED: 08/20/2014 DISPLAY AS REQUIRED BY LAW sEQ# L1408200001788 -�hc�n1� ti�D �G_o. . S � 4 ReceiptLocal Business Tax miamo—Dede "Coum,V, Istaw of florillds DID RVQ FA.,, ., LBT &SWCMUZ RENEWAL I '- 9 MW W 64 75 y , �5:,x�,t.Pi K � $fey•.� �`° "� .� .,- � <..>^`E<;� t¢Ae$a^,�,��aeatrS,s:nr :iY z'nta axa•�,;. "uYx3vE2�P �' ,�.cns? i,vs�'c- -'a ffi tza Srx€,. ! - '�"�;.Vie.» &fT. � €ax...Tc �•,�z.3:�tsm�� �. ra:+���aAw �. 'Su�,3% x Vim.���.fc ©� CERTIFICATE OF LIABILITY INSURANCE rDA04J16/22 1b n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS BELOW.THIS CERTIFICA EFOF (INSURANCE DOES NOTLCO TITUTE AECONTRACT BETWEENTHE IISSUINGFINSURER(S),THE POLICIES AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the cordflcate holder Is an ADDITIONAL INSURED,the policypes)must be endorsed. if SUBROGATION IS WANED,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 M lieu of such endomeme s, PRODUCER • D IELLE GUERRA MONTERINY INSURANCE GROUP P DIVE 305-2741158 9961 SW 62 ST MIAMI FL 33173 INSURERM AFFORDING COVERAGE NAIC# INSURED INSURERA:ATLANT1 SPE IALTY LINES- INSURER 6s INSURER C: KIS CONSTRUCTIONS SERVICES LLC D. 99$0 SW 84 ST,MIAMI FL 33173 INSURER E; 1 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 NTRACWITH RESPE CERTIFICATE H THIS DNMAYY BE ISSUED OR MASTANDING ANY Y PERTTAIINN,THE EIM SURANOR CE AFFORDED BY THNDITION OF ANY C0 T OR E POLICIES DESCRIIBREDHEREIDOCUMENT SUBJECT TO ALL THE-CT TO ICTERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFF LIMITS TYPEOFRANCE POLICY NUMBER GENERAL LIABILITY CLP3266488 04/05/2015 04/05!2018 EACH OCCURRENCE. $ 1-000.0 X COMMERCIAL GENERALLIABIuTYr $ CLAIMS-MADE rX OCCUR 1 1 MED EXP one $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 1000, GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGG $ POLICY PR L� $ ® AUTOMOBILE LIABILITY COMBINED LIMIT $ 1,000,000 (E8 dwit) ANY AUTO I BODILY INJURY(per person) S ALL OWNED AUTOS SoDILY INJURY(Per ewvw* S SCHEDULED AUTOS PR DAMAGE $ HIRED AUTOS $ NON-OWNED AUTOS $ UMBRELLA LIAB SUR EACH OCCURRENCE S EXCESS LtAB CLAIMS MADE AGGREGATE S $ DEDUCTIBLE $ RETENTION S A WORKERS COMPENSATION AND EM PLOVERS'LIABILITYY!N EL EACH ACCIDENT $ ANY PROPRIETOWARTNER/EXECUTNE ' OFFICERIMEIBER EXCLUDED? N/A # E.L.DISEASE-EA EMPLO $ In daunder E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPIRATIONS I LOCAMW I VEHICLES Vwuh ACORD 107,Additional Remarks Sohsdul%It more space Is required) CERTIFIED GENERAL CONTRACTOR•CGC#1116413 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES TSE CANCELLED BEFORE THE EVIRATION DATE THEREOF,NOTICE WILL.BE DELIVERED IN ACCORDANCE LMITH THE 10050 NE 2ND AVE POLICY PROVisIONs MIAMI SHORES,FL 33138 AUTHO » ®1988-2009 ACORD CORPORATION. f rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 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: 9/2/2014 EXPIRATION DATE: 9/1/2016 PERSON: SERRAT JUAN A FEIN: 204452236 BUSINESS NAME AND ADDRESS: KIS CONSTRUCTIONS SERVICES LLC 9980 SW 64 ST MIAMI FL 33173 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 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 tp 3a n Miami V Village Building Department R 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW Y CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTEN'T'S. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this o2/S day of "Je.i'L. ,20^5_. �F.M�i�ic di .2&-2,6ITc�Ovr"S�TJo�J GLC By �i terytba OVA)taij. A C MAx/AgZ_ who is' known to me or has produced as identification. • `W_ _V. y p "� SYLVIA 0.BACHMANN Notary: s ; Notary Public-State of Florida My Comm.Expires Jun 2,2016 SEAL. %� o� Commission#EE 196773 Bonded Through National Notary Assn. KIS Construction Services LLC 9980 SW 64 Street Miami, Florida 33173 786-975-5750 April 21, 2015 State of Florida County of Miami Dade Before me personally appeared Juan Antonio Serrat who being duly sworn, deposes and says: That he will be the on person working on the property located at 119 NW 110 Street Miami Shores Flori 3316 -4 20 Sworn to ( r affirm and subscribed before me this 21" Day of April 2015 Personally Known Or produced Identification Type of Identification j`}jY4 ry11 VoueQro`�� �y ISSiON#EE 221249 o- EXPIRES:December 1,2016 uName of eonaeamN Notary�c naenmilers Notary: Miami Shores Village RIECEIVED Building Department JAN 2 1 2015 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 0 BUILDING Master Permit No. ZC13- 2A PERMIT APPLICATION sub Permit No. ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION Vf NEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP r CON'TR'ACTOR y D�RRAvWINGS JOB ADDRESS: ��� ��® S'Y //� �A�/uC �j-t7 1% J 7( C1 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 Titleh Ider): «� Phone#: _J 9 3 !'r Address: :.a i '5 1 f.> City: State: Zip: D,3 ��— Tenant/Lessee Name: 4Sr//� Phone#: CONTRACTOR:Company Name: 6 A%/?ri0 C'le L'r.­e / .��� +00<�'J; ,. Phone#: �`'�%;21 1 Address: ;'2�1,44�53 City: /46-9,,:5-re--'Cl State: �� �_a Zip: �� L ` Qualifier Name: lV'L,~ V-0TY`lPhone#: 74- ?"— ?f State Certification or Registration#: C/L !`3 G> �S/ GG% Certificate of Competency#:`Z ei'G'G�f 1� DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ `�� Square/Linear-Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New. ❑ Repair/Replace ❑ Demolition Description of Work: ` 1624 T �C Specify color of color,thru.tile: Submittal Fee$ _Permit Fee$ 4�0 CCF$ CO/CC$ Scanning Fee$ Radon Fee$ 2— "L5 DBPR$ ' Notary$ Technology Fee$ U Training/Education Fee$ (:5 , Zc) Double Fee$ Structural Reviews$ Bond$ pp 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 V the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to alta Ment. Also,a ified copy of the recorded notice of commencement must be posted at the job site for the first inspection hick o urs seven (7) ys a er the building permit is issued. In the absence of such posted notice, the inspection will not b pro ed nd a rein ect n fee ill be charged. Signature ' Signature NER o AGENT CONTRACTOR The fwe Ing' strument was acknowledged before me this The foregoing instrument was acknowledged before me this da of -JA,-qL v1 20 /,ZjJ by /:1 day of -7G1r7:t1y7e y ,20 . by who is personally known to ®1--44jV0,t G, -�Vf< who is personally known to -iffe�pr 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: ;1'WAR. MYUUHERNANDEZ NOTARY PUBLIC: MY COMMISSION#EE 221249 o EXPIRES:December 1,2016 „ Bonded Th,Nofatp PWC Underm tw Sign: Sign Print: �✓ ®J �— Pri lam/ A/ YAMIL GUZ AN Seal: Se; ."� •';.: MYW HERNANDQ My COM ISSION EE877112 j : eiu '• MY COMMISSION#EE 221249 .' ,qf� EXPIRES February 21,2017 ra u, EXPIRES:December 1,2016 7 3YB41bi own Bonded Thtu Notary N&Undetwr@era iw�ww�r APPROVED BY5f %7�/� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) i- 14 ' -3Y8" A OP/Zf 5 110/ A)W rrV C.,7 . M14"1 1 2 .7 1 (68 u 7- PHOdue W 11 SEP 2 -J,2513 capj7&, r To 5 t �6 YAc-uA0 6 By-------1- ®mom®o------ 12CA 3 Mimi Shores ViHqga APP7rOVED DATE G DEPT 14 2Y8 G ID F P TS ted s'T)H,if FTMCOMPIJANCF-IA/171-1 ALL I DERAL �y pl,; 04 DOOR 30 X "N1006255 — Wd F4r. JELD-WEN C4 K I T C H E N Ashk T C H E N A, Ln NO POINT ALONG COUNTER TO BE MORE THAN MOKEICARBON MONOXIDE DETECTORS- 2 FEET FROM G.FI PROTECTED RECEPTACLE. ADD S BBER PUT D/W RECEPTACLE UNDER SINK. ANY pNuALL FIXED APPLIANCES ON DEDICATED CKTS, INSULATECONDUCTORS TO BE REPLACED. 9 10?/4 —15 25 ' -3% , r y I I _ k rs 5 LV t KITCHEN ozJ Ln 57 G-�0A O " tip 6 C-)(i S7lN-6 u F-X1A) 6QVIOD 6 V 1,70t.6-7 � 2�a,jo ,mss- / EL D�J`%C + i D C-,04'ax Eo oz A Sb OZ �X�' T i✓ 19 G Y l 5" �aMoLL� D67EEW /Z 1` .W [lDv 6(40 l� XR Stone S Kitchen(USA)Company '3031 NW 79th ave Miami FL 33122 TEL:305-716-2822 ENWL:renyu213@gmaKl.com (09.04.,43) Room 1 W TO scan •2 ea to 24--24-12-24- 24 21 11122 24 23 24 20 15 36 1a 7 3 to 28 ..ST30 16 30 38 101 2 11 3 f3 13710. 11 ..R0 14 36 35 3s 26 2 12 3 24 24 25 s to s1¢ r f4 24 SCOPE OF WORK NEW KITCHEN CABINETS. RELOCATE AND REPLACE THE EXISTING KITCHEN OUTLETS, CONNECTING TO THE A-2 EXISTING CIRCUITS ON THE ELECTRICAL PANELNO POINT ALONG COUNTER RE M 111� N THE ELECTRICAL LOAD IS NOT INCREASE. 2 FEET FROM G.FI PROTECTED - CEPTACLE. W PUT D/W RECEPTACLE UNDER INK. a A-15 LOOM ALL FIXED APPLIANCES ON DEDICATE CKTS. EXISTING PANEL W OFC PROVIDE SMOKE DETECTORSa TO BE 120V, W/BATTERY O 0 - and®WAR BACKUP & INTERCONNECTEp. ~ FEB 4 14 THEY SHALL BE INSTALL AT A- p W Y ...,,,..... LEAST 3 OF A/C OUTLETS 5 Y: Z H oFcl 7Q JI 1 ........ w DISPOSAL IL Adill A ` ...... oFcl A-7 7jN4�R TS RUN O XISTiNG GF A-9 A-1,3 �Fc� a) N i ro cc MICROWAVE RANGE N � x 74" UP Undercounter aca u fn .. E ADD SMOKEICARBON MONOXIDE DMCTOF S. KITCHEN REMODELING Qw Q o ', ANY AND ALL CLOTH AND RUBBER j wz INSULATED CONDUCTORS TO BE REPM . 119 NW 110 ST � � o � t �' ° o 0 I MIAMI SHORES. FL 33168 a w m co