RC-15-2809 Inspection Worksheet 1/
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-255993 PermitNumber: RC-11-15-2809
Scheduled Inspection Date:April 01,2016 Permit Type: Residential Construction
Inspector: Rodriguez,Jorge Inspection Type: Final Building
Owner: DEVELOPEMENT LLC,OORT Work Classification: Alteration
01"0"000
Job Address:326 NE 92 Street
Miami Shores,FL 33138-
Phone Number (305)842-8745
Parcel Number 1132060136470
Project: <NONE>
Contractor: ROMERO MALLON FLOORING CONTRACTOR SERVICES It Phone: (786)301-3558
Building Department Comments
INSTALL FLOORING TILE 24 X 24 AND KITCHEN Infractio Passed Comments
CABINETS INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
March 31,2016 For Inspections please call: (305)762.4949 Page 21 of 32
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Miami Shores Village
10050 N.E.2nd Avenue NE 8
Miami Shores,FL 33138-00003 r `
Phone: (305)795-2204
Expiration:0610 2016
Project Address Parcel Number Applicant
326 NE 92 Street 1132060136470
INTER-TEN LLC
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
INTER-TEN LLC 6187 NW 167 Street (305)842-8745
HIALEAH FL 33015-
6187 NW 167 Street
HIALEAH FL 33015-
Contractor(s) Phone Cell Phone Valuation: $ 12,900.00
ROMERO MALLON FLOORING CONTI (786)301-3558 Total Sq Feet: 600
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review
Final PE Certification
Date Denied: Window Door Attachment
Type of Construction:INSTALL FLOORING TILE 24 X 24 A Occupancy: Framing
Stories: Exterior. Insulation
Front Setback: Rear Setback: Drywall Screw
Left Setback: Right Setback: Fill Cells Columns
Bedrooms: Bathrooms: Window and Door Buck
Pians Submitted:Yes Certificate Status: Review Planning
Certificate Date: Additional Info: Review Building
Bond Retum: Classification:Residential Review Building
Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Electrical
CCF $7.80 Review Electrical
DBPR Fee $5.81 Invoice# RC-11-15.57660 Review Electrical
DCA Fee $5.81 12/07/2015 Credit Card $383.42 $50.00 Review Structural
Education Surcharge $2.60 11/04/2015 Credit Card $50.00 $0.00 Review Mechanical
Notary Fee $5.00
Permit Fee $387.00
Scanning Fee $9.00
Technology Fee $10.40
Total: $433.42
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 rtify that alL the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoni uthe authorize the above-named contractor to do the work stated.
December 07,2015
Autho ature:Owner / Applicant / Contractor / Agent Date
Wilding Department Copy
.ember 07,2015 1
t Miami Shores Village � � %
U Building Department NOV 04215
.�\ g
Y ��\ 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 f3y;
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 6+4
FBC ZO N
BUILDING Master Permit No. V1.. tS— !U0q
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS r-1 CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: V69 Z SX
City Miami Shores County: Miami Dade -Zig: -fir
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): -: ,,74er 'I n -1—L C, Phone#: 30:5- Y?
Address: -7 /V W / 7 �u V4
City: �� ' I G e Q State: ( Zip: 3
Tenant/Lessee Name: Phone#:
Email: /,, ' //►., �i
CONTRACTOR:Company Name:
Address 2:]6)a)
City: State: f-ICer Zip: a Z
Qualifier Name: rnoow� - Phone#:
State Certification or Registration#: 09 65 00?) r Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: Ci State: Zip:
Value of Work for this Permit:$ I2-r Squ re/ near Footage of Work: (0 191j
Type of Work: ❑ Addition ❑ Alterati�o ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: NSM +'� '�S rtZ, PCZ 4 14 A c�,PeN Cc 6Cn e4S
Specify color of color thru tile:
Submittal Fee$ ® Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
ozs
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ �' •' �2—
(Revised02/24/2014)
v
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 not be approved and a reinspection fee will be charged.
Signature Signature
OWNER oAGENT NTRACTOR
19,
Theforegoingi trument was acknowledged
before me this The foregoing instrument was acknowledged before me this
,3D day of Qt-�A C Ej�2— ,20 k 5 ,by day of 20 �. J�Z ,by
w�� \c�.►.r,�tl ,� ,who is personally known to 'Vyz? -erg ,who is personally known to
me or who has produced as me or who has produced as
identification d w did take a ath. identification and who did take an oath.
NOTARY P UC: NOTARY PUBLIC:
Sign: Sign
Print: Print:
Notary Public o
Seal: "•°: Lf Seal: ' Joanna M FeNdano
* * W COMMISSIMI A FF 231';, My Commission FF 082753
EXPIRES:Jw99,2W�, »a e,�xssoutano+9
s#s#####***#*#*s#s####****** **#*### ###*#******#***##s#*##*###*#**********#s##s*s##s##*s***********#*##****
APPROVED BY 3 ` Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
CTQB
Construction Trades Qualifying Board
BUSINESS CERTIFICATE OF COMPETENCY
08BS00351
.' '`.ROMEROMALLON FLOORING CONTRACTOR SERVICES I
D.B.A.:
OM RO ALVARO E
is certified under the provisions of Chapter 10 of Miami-Dade County
VAL10.FOS,CONT,RACTING UNTIL 09/30/2016,
W4902
Local Business Tax Receipt
-Miami-Dade County, State .- of Florida
THIS IS NOTA BILL -<00 NOT PAY
6557350 \1LBTJ
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
ROMEROMALLON FLOORING CONTRACTOR SERvIanyMAL SEPTEMBER 30, 201:6
4727 NW 4 ST 6827951 Must be displayed at place of business
MIAMI FL 33126 Pursuant to County Code
Chapter 8A-Art.9&10
OWNER SEC.TYPE OF BUSINESS
ROMEROMALLON FLOORING 196 SPECIALTY BUILDING CONTRACTOR PAYMENT RECEIVED
CONTRACTOR OBBS00351 BY TAX COLLECTOR
Worker(s) 1 $49.50 10/01/2015
ECHECK-16-000426
This Local Busitnms Tax Receipt only catfinne payment of the Local Business Tax.The Receipt is not a license,
permit or o cerNeadm of the hoidw's goal icatiou%N do buWness.Holder austcomfy with any govemmental
or nongovernmental regulatory laws and requirements which apply to the busbWeL
The RECEIPT NO.above must be displayed an all cononercial vehicles—Miami-bade C te; 8a-y276
For mors inhumation,visit
t
M uni ci pal Contractor's Tax Recei pt
M!am i-Dade County, State of Florida
THIS IS NOT A BILL-DO NOT PAY
CC NO: 08BS00351
BUSINESS NAM EILOCATION RECEIPT NO. EX PIRES
FUMEROMALLON FLOORNG
OONTPACTORSGUCPSINC 7475529 SEPTEMBER 30, 2016
4727 NW4 ST
MIAMI,FL 33126 Pursuant to County Coda
Sec 10-24
OWNER TYPE OF BUSINESS PAYMENT RECEIVED
FUMEROMALLON FLOORING S`£CIALlYBUILDING CONTRACTOR BY TAX COLLECTOR
CONTRACTOR 37.50 11/04/2015
0237-16-000607
Restticted to City of Miami Shores
goigh
mFw more infomlation,visit>rvww.naarridxe gov/taxcdlectar
t
CERTIFICATE OF LIABILITY INSURANCE �;; ,°
THIS CERTIFICATE IS ISSUED AS A(HATTER 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(Sh AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: BUfe Certificate tower Is an ADDITIONAL INSURED,the poncrtles)must be endorsed. K 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 tower In Ilea of such endorsement(s).
PRODUCER CONTACT
McWs Insurance&Setvims E )228-7333 Ne (305)228-7400
10000 SW 40 St
Miami,FL 33165 INIAIRIM AFFORDING COVERAGE NAM#
Phone 228-7333 Fax 228-7400 INSURER
INSURED IN a. GRANADA INSURANCE COMPANY
ROMERO MALLON FLORING CONSTRACTOR SEVICES,INC INSURER C:
4727 NW 4TH STREET INSURERD:
MIAMI,FL 33126 (786)301-3556 tNsuRER E
INF:
COVERAGE$ CERTIFICATE NUMBER. REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF 14SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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.
TIT
TYPE OF INSURANCE ADOL SUBR POLICYNUMBER
EFF M EXP LIMITS
GENERAL LIAR MCH OC ENCE 1000„0 .00
Q
COMMERCIAL GENERAL LwuuT+r TO $ 100,000.00
❑ ❑ CI.Aat&MADE ❑ OCCUR 0185FL�44095-1 MED EXP as $ 5,000.00
B ❑ N 037182075 037182016 PERSONAL&ADV INJURY $ 1,000,000.00
❑ GENemAGGREGATE $ 2000,DW.00
GEWL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPADP AGG $ 2,000,000.00
❑ POLICY ❑ ❑ LOC $
AUTOMOBILE LIABILITY 60MBIND SINGLE LIMIT
❑ ANY AUTO BODILY INJURY(Per Pusan) S
❑ AUTOSNED ❑ %WLED
BODILYINJURY(Pe►ex6 INA $
❑ HIRED Auros ❑ NONOIN"ED �AAAGE $
❑ UM1#iB1A LIAR ❑OCCUR EACH OCCURRENCE $
IXcess UAB ❑CL msmADE AGGREGATE $
DED El RETENTION $
YRS COMPENSATIONWC ATU OTH-
AND EMPLOYERS LIABILITY Y I N El ER
ANY PROPMETORNIARTNERIEXECUTIVEN/A E.L.EAC14 ACCIDENT $
OFFICERJM E(CLUDED7
(M In r F-1EL DISEASE-EA EMPLOYE $
gamwdw OF OPERATIONS below EL wEAsE-mJCY LIMIT I S
E . I
DESCRpnoNOFUDERATONSILOrA=MIVBUCLES V tt M ACORD let,Adder Rmmtm SaindLde,Bmae spsae M m
LICENSE;#OBBS00361
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OBD POLICES BE CANCELLED BEFORE
Mom(Shores VMW THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
10050 NE 2 Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Mord Shares V#kw FL 33138 AUTHORIZED Rt ITATM
J
0IM-2010 ACORD CORPORATION. All rights reseried.
ACORD 25(2010"QF The ACORD Tame and logo Bre registered marks of ACORD
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DMSION 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: 10/1/2014 EXPIRATION DATE: W012016
PERSON: ROMERO ALVARO E
FEIN: 364626344
BUSINESS NAME AND ADDRESS:
ROMEROMALLON FLOORING CONTRACTOR SERVICES INC
4727 NW 4 ST
MIAMI FL 33126
SCOPES OF BUSINESS OR TRADE:
CERAMIC TILE,INDOOR
STONE,MA
Pwauant to Chapter 440.05(14).F.S.,an ofterof a corporation who elects exerroon f m No chaff by&V a caAticata of elerdon uWar tis seefEan
may riot recover betetta or conte►mater tds chapter.Pma snt to Chapter 440.05(12).F.S..Cefdgcdn of awe to be exw WL..apply only
weds the scope of the busbum or haft bW an bre rro5ce of elm to be enwnVL Pursuant to Chapter 440.05(13).F.S..Nolkes,of elector to be
exempt and owfificafte of election to be enempt shell be subject to revocation if,at any fires attar the Mw of to teoti,P or to lastumce of the ,
the person raunW on to note or cwtficata no lorrgar meets to requkwrmft of fids sedan for isarwmos of a cwllikate.The depsrhmd shag revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1608
rrrr a� Miami shores V11age
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 Exem tion
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 parttime or fiill_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:
own
State of Flo
County of Miami-Dade
The foregoing was acknowledge before me this day o f (Vby�A4$ ,20 .
By v who isy
peisonall known to me or has produced
as identification.
Notary:
SEAL:
�'+�i�,R�t�'~ Bofl0ed11�tYB1�etN�y3
www.romeromallon.blogspotcom
www.romeromallon@gmaii.com
ROMEROMALLON F TELEFONO 786 3013558
TELEFAX 305 8426808
CONTRACTOR SERVICES, INC
DATE: 11/03/2015
STATE OF: FLORIDA
COUNTY OF:MIAMI DADE
BEFORE ME THMS DAY PERSONALLY APPEARED ALVARO ROMERO WHO,BEING DULY SWORN,
DEPOSES AND SAYS:
THAT HE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED AT:326 NE 92nd ST,
MIAMI SHORES FLORIDA 33138
SWORN TO(OR AFFIRMED)AND SUBSCRIBED BEFORE ME THIS DAY OF
20_/�BYy��a
PERSONALLY KNOW
OR PRODUCED IDENTIFICATION
TYPE OF IDENTIFICATION PRODUCED ���
PRINT,TYPE OR STAMP NANUF NOTARY
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Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
CONTRACTORS' REGISTRATION Fax: (305) 756.8972
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*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL
CONTRACTOR'S TAX RECEIPT.
D. COPY OF LIABILITY INSURACE*
E. COPY OF WORKERS COMPENSATION INSURANCE*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit)
'YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW:
Certiftcate 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.
■rrrrrrrrrrrrrrrrr■ ■rrrrrrrrrrrrr■ rrrrrrr■ ■rrrrrrrrr ■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
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BUSINESS ADDRESS: :!I./—CITY .^ STATE_ZIP /Z
BUSINESS PHONE: � � 0/3�S FAX NUMBER(—T ,
CELL PHONE(!3 Z p��^ QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER:_ DS6-5
Stone International
r 5280 NW 165th St
Hialeah, FL 33014
'f 305-627-8889109-22-15
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