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PT-14-1826 Miami Shores Village ` Building Department AUG 21 2814, 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY': vv Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 204 PAINT Master Permit No. ��" I�?Z PERMIT APPLICATION Sub Permit No. JOB ADDRESS: Syrea- City: Miami Shores County: Miami Dade Zio:,33/50-1`7,51 Folio/Parcel#: Is the' Building Historically Designated:Yes NO OWNER:Name4 q 4X (Fee Simple Titleholder): �• C,.�� li/a Phone#: Address: V ��" / V A)1 ° X p City: ( I State:_ ¢o Zip:83160-17-53 Tenant/Lessee Name: Phone#: mail: U) -neAkU P beA�> ' W1 4 CONTRACTOR:Company Name: 7 oee Phone#: Address: ���� +���A��� �1 City: State: Zip: Qualifier Name: ��L�f s— Phone#: 5 State Certification or Registration#: Certificate of Competency#: Value of Work for this Permit:$ � "� Square/Linear Footage of Work. 0017 >J� Description of Work: �!''�!'�� Ro1l 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,PLUMBING,SIGNS,WELLS,POOLS,FURNACES,BOILERS, HEATERS,TANKS,AIR CONDITIONERS,ETC..... 11W41F _ia�C:-SUR FAILURE TO RECORD AN Ei ENCEMENT 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$2500,the applicant must promise in good faith that a copy of the potice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven(7)days after the building permit is issued. In the absence of such posted notice,the inspection will not be approved and an inspection fee will be charged. Permit Fee$ CCF Fee$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ TOTAL FEE NOW DUE$ �I PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be painted DIRECTIONS: Please circle corresponding number to appropriate color sample. Walls: 1 2 3 4 Attach color sample with name and number Fascia: 1 2 3 4 Drip edge: 1 2 3 4 1. Soffit: 1 2 3 4 Flower Bins: 1 2 3 4 Shutters: 1 2 3 4 Awnings: 1 2 3 4 2. Chimney: 1 2 3 4 Doors&Jambs: 1 2 3 4 Garage Doors: 1 2 3 4 Railings: 1 2 3 4 3. Fences: 1 2 3 4 All Brick: 1 2 3 4 Stucco Bands: 1 2 3 4 Other Stucco Feature: 1 2 3 4 4• Accessory Bldg: 1 2 3 4 OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate a at -witl-tre-sione in compliance with all applicable laws regulating construction and zoning. Signature � Signa OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of,)qfJ 0US r ,20 by �day of� &-/- .20�by it o 1 e e /a) / who is personally known to W 1) ��I �° who is personally known to me or who has produced as me or who has produce s identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign Sign: Print otter°�o Notary Public State of Florida Seal: ? Joanna M Feliciano Seal: 0001% Notary Public State of Florida y, My Commission FF 082753 ? Joanna M Feliciano °?oP pyo` Explra3 01112/2018 ;V41, 0` My Commission FF 082753 pExpires01J12/2018 APPROVED BY: 11. Code Official Historic Preservation Board SNn�c.R ms`s Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 CONTRACTORS' REGISTRATION Fax: (305) 756.8972 ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* " IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL J CONTRACTOR'S TAX RECEIPT. C. COPY OF LIABILITY INSURACE* D. &--'COPY OF WORKERS COMPENSATION INSURANCE* *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ..................ow so. ................................................................... BUSINESS NAME: CL- �'�Lr'v�= !A,"e Davi-z.�t� BUSINESS ADDRESS:_ Lob p0 v'6-A-Ofs CITY_ i wo®D STATE ZIP CODE 3302 Ct BUSINESS PHONE: ) ��� 7 FAX NUMBER CELL PHONE(2f f) 96e- SS�� QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: ACC-Mb i CERTIFICATE OF LIABILITY INSURANCE DATE IYYYY) 088/19/1/19/14 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(les)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: Southeast Insurance Agency PAIICONNo Ext: (954)680 2255 FAX No• (954)680-3208 5001 S University Drive Suite K ADDRE : southeastinsuran@bellsouth.net Davie,FL 33328 INSURERS AFFORDING COVERAGE NAIC# Phone (954)680-2255 Fax (954)680-3208 INSURER A: SCOTTSDALE INSURANCE COMPANY INSURED INSURER B: CLEANLINE INC INSURER C: 6600 Douglas Street INSURER D: Hollywood,FL 33024 (954)989-0007 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR ADDLSUBR POLICY EFF POLICY EXP TYPE OF INSURANCE R WVD POLICY NUMBER MMIDD MM/DDIYYYY LIMITS j GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 ❑ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000.00 PREMISES a occurrence $ A F-1 [:] 05128/2014 05/28/2015 CLAIMS-MADE V OCCUR JJSWO-N MED EXP(Any one person $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER* PRODUCTS-COMPIOP AGG $ 1,000,000.00 11 POLICY POLICY PRO- ❑ LOC $ AUTOMOBILE LIABILITY CO aBIINdED ent)SINGLE LIMIT $ ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ ❑ AUTOS ❑ AUTOS ( ) NON-OWNED TOPER DAMAGE ❑ HIRED AUTOS ❑ AUTOS er accident $ ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑W RSTAT L M ❑ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER 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 $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) BUSINESS CERTIFICATE OF COMPENTENCY LICENSE#95BS00154 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 NE 2 AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE i MASSIMO PULCINI ©1988-2 10 RD C05RRORKTION. All rights reserved. ACORD 25(2010/05)OF The ACOR ame go are registered marks of ACORD Contra oe-s Tax Re eel t l fialrM fade Cbunty,State cif Floelda f1 51S t4OTA BILL-DO NGT PAY CC :9 58SW154 Ousm"O NAMMOCA"M ` ReCelpr NO. EXPIRES Ci.FMUM INC. NEW BUSINESS 1InIG CUs IN DARE CO SEPTEMBER 3© 2014 AIfllU11"F 33000 7453844 tVlust displayed at pracs of lureln pumom to County code' SeC10-24 OVIEMER TYPE OF B1181N8S8 PAYMENTMICEIVED CLEANUNE INC SPECIALTY BUILDING CONTRACtOR BY TAX cBuEMOR 18.75 08/19/2014 0225-14 005230 RoWeted to City►of MImM Shm Formpte ,visk _ I' 000m - LOcai Business tax Receipt roe--DadeCou=PHv,,State of Florida IS IS NOT A 8 oo NOT PAY 6038202 TI EXPIRES suSINESS nlanNE�LOCa-170N RECEIPT NO. An►uN� n na+n►at SEPT EMBED 10, 4014 DOING BUS IN DADE CO 629$069' Must be�+spleyedat pteFe of business; MIAMI FL 330 PursustOm County Cote Chapter 8A Art E&io OWNER, Stb�IYPE OF iUJSINESS ZIGNE INC 1� CIAITY BUItl1ING CON'tRNMR .PAYMENT RECEIVED 9565' 154 BY rax COLLECTOR Wp*er(s) t $93.75 01/27/2614 CREDITCARD-14-014118 This Low Bas<ness Tft Rpayamust of the Local Business Tax.The Receipt is not a license pwa ti;or a ce*NHcaBea of#e hales gna ons tan dabus418ss. Voidermnst comply with repht*taws and -whkb apply to the basinem Tile RECEIPT ILIO.abovmos e t be.dtsplayed on all eomme.miai v&Lkle;:-N110mm- tel ode Sec tea-21e. .: - Focrnoream,,visitrmxrvmtemitfetde.�bli�frmmllec�r . t'V 4 CTQB Cormftu tion Trades Gtua�tying Board BUSINESS CERTIFICATE OF COMPETENCY 95BS®OI r4 'CLEANUNE INC 'AAW VWLLIAM B i is oerbTad under the provisions of Chapter 90 of M Dade !fi9I ?1lt i.iC41 h t�.GC?isITgACTINC� ilNTil.091364644 QUALIFYING TRADE(S) 1 0036 PAINTNG.&WATERPRFG 4 chafts RE i ry off6a BSM cf5 -- d enmw.re�NRadegw/Eevsla ' ®5,H®R Miami Shore s V ills e 9 Building Department IRI� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exe • mptton Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 r 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. Therefore,you maybe personally liable for the worker com enation in'uries of an person allowed to work under this ermit. 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. / / Print Name: gn .�® Si lure: � ® Signa N �? Xz State of Florida) „a g State of Florida) m„m County of Miami-Dade) �Q Sworn to d subscribed before me this County of Miami-Dade N o.- da of 2 ch W Sworn to and subscribed before me this T m. Y , `� m day of ,20 o g B N� BCLW y m (SEAL (SEAL) T e o Identification produced T e of Iden tification roduced 000 01-24-2013 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: 01/24/2013 EXPIRATION DATE: 01/24/2015 PERSON: SHAW WILLIAM B FEIN: 650367519 BUSINESS NAME AND ADDRESS. CLEANLINE INC 6600 DOUGLAS ST HOLLYWOOD FL 33024 SCOPES OF BUSINESS OR TRADE: 1- PAINTING NOC & SHOP OPERATIONS IMPORTANT. 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. Personal to Chapter 440.05021, 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 as 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 an the certificate to meet the requirements of this section. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY 0 elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION-TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS!COMPENSATION LAW ' D chapter. EFFECTIVE: 01/24/2013 EXPIRATION DATE: 01/24/2015 Pursuant to Chapter 440.05(12), F.S, Certificates of election to be PERSON: WILLIAM B SHAW H exempt.. apply only within the scope of the business or trade listed on FEIN: 660367819 R the-notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt CLEANLINE INC and certificates of election to be exempt shall be subject to revocation 6600 DOUGLAS ST if, at any time after the filing of the notice or the issuance of the HOLLYWOOD, FL 33024 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 SCOPE OF BUSINESS OR TRADE person named on the certificate to meet the requirements of this 1- PAINTING NOC & SHOP OPERATIONS Section. QUESTIONS? (850) 413-1609 CUT HERE Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 I CLEANMNE INC. f.r9p osa.I ........... .................'. ....*"**'**"* "**"......'***"...................................."**"*"*...*"*....*'*** *"**.................... FROM: Cleanline, Inc. Page. No. 6600 Douglas St Hollywood, FI 33024 954-989-0007 PROPOSAL SUBMITTED TO: Name: Phone: ��' �� ��',� Date: Street: 'A' City: &�ij 5L2er_- 2 State: FI Zip: I propose to furnish all materials and perform all labor necessary to complete the following: Somay Roof Coating System : Apply Chlorine Solution/ Pressure Clean Roof (3 3LAO 0 sf) Prime .Roof. Product#777 "PST' Primer, Sealer,, Seal all joints, cracks. Product#992 "Patch and Seal" s Apply 2 coats Product#842 Somay° Roof Mastic" AII'of the work is to be completed in a substantial aped vo anlike manner fohe sum of 'df j� a �/�Q �"j ��c 4 S Dollars( `Payment to be mage as follows: one third (1/ ) deposit, (1/3) pressure clean/prime/seal completed. Balance'bf'the contract to be paid upon completion. Any alterations or deviation from the above specifications involving extra cost of material or labor will be executed upon written order for same, and will become an extra charge over the a' sum mentioned in this contract. AU agreemefts st be made in writing. Authorized Sigure ACCEPTANCE You are hereby authorized to furnish all materials and labor required to complete the work mentioned in the above proposal for which customer agrees to pay the amount mentioned in said proposal and according to the terms thereof. Signature Date www.socrates.com Page 1 of 1 ss4W1-840-Rev.05M4 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-250030 Permit Number: PT-8-14-1826 Scheduled Inspection Date: December 30,2015 Permit Type: Paint Inspector: Rodriguez,Jorge Inspection Type: Final Owner: WHITFIELD,CORNELIUS Work Classification: Addition/Alteration Job Address:78 NW 96 Street Miami Shores, FL 33150- Phone Number Parcel Number 1131010330520 Project: <NONE> Contractor: HOME OWNER Building Department Comments PAINT Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments PassedC FATED AS REINSPECTION FOR INSP-218281 No paint sample El� supplied J Failed Correction Needed ❑ Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid December 29,2015 For Inspections please call: (305)762-4949 Page 22 of 34