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DS-15-2004 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-241000 Permit Number: DS-8-15-2004 Scheduled Inspection Date: December 04, 2015 Permit Type: Driveways/Sidewalks/Slabs Inspector: Rodriguez,Jorge Inspection Type: Final Owner: ANA TELLO,JEREMY MICHAEL Work Classification: New UlWfll w 'r7wv Job Address:10 NW 110 Street Miami Shores, FL 33168-4319 Phone Number Parcel Number 1121360030010 Project: <NONE> Contractor: CHAMPION CONCRETE Phone: (305)252-8055 Building Department Comments CONCRETE APPROACH Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed ET� A � Le-3 Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. December 03,2015 For Inspections please call: (305)762-4949 Page 6 of 39 f s , Miami Shores Village W v 10050 N.E.2nd Avenue NW Miami Shores,FL 33138 0000 ` Phone: (305)795-2204 ' &,•; Expiration: 02/21/201 Project Address Parcel Number Applicant 10 NW 110 Street 1121360030010 JEREMY MICHAEL MIKOLAJCZ/ Miami Shores, FL 33168-4319 Block: Lot: Owner Information Address Phone Cell JEREMY MICHAEL MIKOLAJCZAK ANA 10 NW 110 Street -- - MIAMI SHORES FL 33138-4319 10 NW 110 Street MIAMI SHORES FL 33138-4319 Contractor(s) Phone Cell Phone CHAMPION CONCRETE 305 252-8055 Valuation: � 3,000.00 ( ) (786)402-4802 ......._�.._.,..,w_...,.._ w...�.._.._...... __.._._�.�......._ g..._.__� ._...�..-..�....,.�.,_..,�..�..-..._�-,�...__ Total Sq Feet: 500 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:CONCRETE APPROACH Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Owners Bond $500.00 CCF Invoice# DS-8-15-56658 $1.80 08/10/2015 Check*1971 $50.00 $567.80 DBPR Fee $2.00 DCA Fee $2,00 08/25/2015 Credit Card $567.80 $0.00 Education Surcharge $0.60 Bond#:2818 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $617.80 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 AFFIDAVIT: I cprqfy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and za ' F th rm I authorize the above-named contractor to do the work stated. August 25, 2015 Authorized S tur' :Owner / Applicant / Contractor / Agent Date Building De a ment Copy August 25,2015 1 Midl l ll al IUl CJ V 111d t-. 7FE7< _ r� Building Department AUG 10 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tei:(305)795-2204 Fax:(305)756-8972 Y INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2(lq BUILDING Master Permit No. :Sl '5 " PERMIT APPLICATION Sub Permit No. ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP AW 11051—,n CONTRACTOR DRAWINGS JOB ADDRESS: 10 IW l 1V 5.- City: Miami Shores � County:. Miami Dade Zio: Folio/Parcel#: J I774,-?bb—' 42r! — 0 a o Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):—Jft-QY�4 Address: I D 0 7 C City: ,Q S� State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: RC1/k.Bl_� O'I'I/�/?�__ Phone#:A'-5 Address: City: ® State: Zips: Qualifier Name: --� _ r �'l l/4 i� ,Phone#:Y '�'4bZ zf G� State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State• Zip: Value of Work for this Permit:$3�n Square/Linear Footage of Work: _ Type of Work: ❑ Addition ❑ Alteration V New ❑ Repair/Replace ❑ Demolition Description of Work: AC WCAPr7-e— L-"A,10 Specify color of color thru We: Submittal Fee$_ZPermit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ , oz, TOTAL FEE NOW DUE 5 � Bending 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 , such posted notice, the inspection will not be app o ed and a reinspection fee will be charged. 0 Signature Signature R or AGENT CONTRACTOR The foregoing ins rumew s acknowledged before me this The foregoing instrument was acknowledged before me this 10 day o SF 20 If' ,by A) day of AV6y 0 ,20 IS ,by ;TAft is personally known to -C 15"1 It 0 who is per ally known to me or who has producedj?.. ja 1117®as me or who has produced -4 as Identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: t � RUTH[EDESMp NOTARY PUBLIC: r � qu MY COWISSION S FF 172019 Ail' R Lq EXPIRES:Jan 18 2019 . : EXPIq s��6 FF 172019 Botded NoNotary PublTk Uar�terg " BOWed N Pu Sign: Sign: 12019 M 4 Print: Print: Seal: Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk a A SNa s Miami Shores Village '7 ® q.n' Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 �RtUA Tel: (305) 795.2204 Fax: (305) 756.8972 ppCOVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY Whereas, (owner) OkleMV tthA% o 44KAA=4CZWhereinafter referred to as the owner of the following described property(address): I'D Ll® Er— Legal Description Lot Block Subdivision Folio# #'W6 -093-0110 Requests permission to install (describe work): �� ,�/L® Within the public right of way of(address) �-.A PV-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 0000 way. If it becomes necessary for Miami Shores Village or Dade County to make repair.or mairft;"%aid ����• items within public right of way including restoration of street by reason of the Owmer4"Iure tdwv, 0000.. such expense shall be paid by the Owner or shall constitute a lien against the abgve•describeclproperty ••..: 0080 ••0000. • 0000. until paid. ••••.. 0000 ..' •0000 .. sees 0000.. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade Tbribsharmless from any ' 0 and all liability,which may rise by virtue of permitting the installation of these items wrhi r�*e publilltht bf ways000:. 00 • • . ... 0000.. 00 1 r , 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 �-tNGds7— , 2016" (Owner's Signature) 1 SIGNED ED, AND DEI W RED in the presence of: '1P,�cq�'`' BoEnMdXeYPd cOMR M� E� Ioa#FF 1 72019IRESJanuary 18,2019Thm r'*1Y Pubf•Undemrtm sees sees•• sees • • • • • • • • sss•e• • sees•• •s0•se • • sees •Bees• e•0• •see• • so 00 sees• e • • • s00es• •0000• • •see•• • • 0.0••• a •• 0 so 2 Miamishores Village � owes ����� Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 lOR1D� Tel: (305) 795.2204 Fax: (305) 756.8972 SURVEY AFFIDAVIT STATE OF(FLORIDA) COUNTY OF(DADE) The undersigned Affiant,.)1*14 M d,P- P6AAa eby attest that (Property owner) The attached survey,performed by aVA- St7l�opt rj /W C (Name of surveyor's company) For address: 10 AAAJ W9 !2!F- M-444 V160y 61 Performed on (date of survey)is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the-existence of-j"gg)mch structures may affect final inspections as applicable to this or other permits. °01%:9• .00° be A ant say a naught •" • Pro rty er Signature Property6ndr Print j jme• '°••• SW RN T AND SUBSCRIBED before me this a day of 6 s L@ 9."-+ '• •• •'• i•••i• •1O1a• Affia t is ersonally known to me,_produced as dentficetion.• •••• . ••• • RUTHLEDE8MA f MY COMMISSION 0 FF 17EM9 r .•, air EXPIRES:January 18,2019 Notary Banded No NoUr,Rob Underwriters RevLW on 5/2712009/Revised on 6112109 i � 1 BOUNDARYSURVEY /,• / �tCw�"� 'v '-�, �,�'�.���'-$d`�.,a�,�'��._'`-gy�-.�-e�4 �,,�.�.�-- �"� yx, l��J����}�'�"�'- -���.��'S"�� � �F--z�.�'` *� JP i 1 '! . i M 3 � W, Ug­ ka FU sle F . K s cT. A LOT-31. LOT-32 SLOCK-219 BLOCK-219 j: • FT Y..