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RC-16-795 ~ Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-256283 Permit Number: RC-3-16-795 Scheduled Inspection Date:April 06,2016 Permit Type: Residential Construction Inspector. Rodriguez,Jorge Inspection Type: Final Owner. CLAY, MICHAEL &GENEVIEVE Work Classification: Alteration Job Address:141 NE 109 Street Miami Shores,FL 33161- Phone Number 305-756-9832 Parcel Number 1121360040520 Project: <NONE> Contractor: EMERALD CONSTRUCTION CORPORATION Phone: (305)3104543 Building Department Comments REPAIR/REPLACE OF BATHROOM AND CLOSET. Infractlo Passed Comments INSPECTOR COMMENTS False TO CANCEL PERMIT#RC10-573 Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-256034. CREATED AS REINSPECTION FOR INSP-255843. No access PLEASE CALL: Failed ED DEGENHARET 305-588-7847 Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid April 05,2016 For Inspections please call: (305)762-4949 Page 38 of 45 Miami Shores Village 10050 N.E.2nd Avenue NE . Miami Shores,FL 33138-0000 k Phone: (305)795-2204vlp Expiration: 09/2612016 Project Address Parcel Number Applicant 141 NE 109 Street 1121360040520 MICHAEL 8 GENEVIEVE CLAY Miami Shores, FL 33161- Block: Lot: Owner Information Address Phone Cell MICHAEL &GENEVIEVE CLAY 141 NE 109 Street 305-756-9832 MIAMI SHORES FL 33161 Contractor(s) Phone Cell Phone Valuation: $ 2,000.00 EMERALD CONSTRUCTION CORPOR (305)310-4543 (954)309-0680 --�------�-- ----�---- Total Sq Feet: 150 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Window Door Attachment Date Denied: Framing Type of Construction:REPAIR/REPLACE OF BATHROOM Occupancy: Insulation Stories: Exterior. Drywall Screw Front Setback: Rear Setback: Final PE Certification Left Setback: Right Setback: Window and Door Buck Bedrooms: Bathrooms: Fill Cells Columns Plans Submitted: Certificate Status: Review Building Certificate Date: Additional Info: Review Planning IBond Return: Classification:Residential Review Electrical Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural CCF $1:20 Invoice# RC-3-16-59150 Review Mechanical DBPR Fee $2.25 03/24/2016 Credit Card $50.00 $116.70 DCA Fee $2.25 Education Surcharge $0.40 03/29/2016 Credit Card $116.70 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $1.60 Toth: $166.70 4� Irg—�onsideration 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 epting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are r4.ouired for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. 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 instruction and zoning. Fu't�h(er�more,I authorize the above-named contractor to do the work stated. del March 28,2016 Authorized Signature:Owner / Applicant / Contractor / Agent ate Building Department Copy =' March 29,2016 1 ` Miami Shores Village aBY: �� sr -, BuildingDepartment 24 ots p10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC ® 201 _ BUILDING Master Permit No.yw(o`-) PERMIT APPLICATION Sub Permit No. OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 141 NE 109 Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Michael Clay Phone#:786-295-0356 Address: 141 NE 109 Street city. Miami Shores State: FL Zip: 33161 Tenant/Lessee Name: Phone#: Email: / CONTRACTOR:Company Name: �MQXLIk� CoASkfvC k_as CoR�pPhone#: 954t `a� —_•S 63 Address: l �. �" \VL�t✓-A Qf)CAA . S"\fie. 10(n . City:"V�(kPAC).• State: ''_L- Zip: Qualifier Name: ,���`eS• c9 Phone#: 4 rJ�{ 2�-� `ZSCS 3 . State Certification or Registration#: c'i���gVe), rr-•� 1�2 k 25(4 -75Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ m Square/Unear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New F01 Repair/Replace ❑ Demolition Description of Work: Repair/replace of bathroom and closet. Reference original Permit: RC-4-10-573 Specify color of color thru tile: Q �\ Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ °�( •/� Radon Fee$ C DBIP,R$ a-' Notary$ Technology Fee$ Training/Education Fee$ b • "'l 6 Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 116 .-'n L 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 seve (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a re' pecti n fe ill be charged. Signatur Signature OWNER or AGENT CONTRACTOR The foregoing instrument was ackn wledged bef a me this The foregoing instrument was acknowledged before me this �a. day f 20 f� ,by �� day qf V/� • _ ,20 1 1p ,by who is personally known to (0 UL4.%, who is personally known to me or who has produ ed as me or who has produced as identification and who did take an oath. identification and did take an ath. NOTARY PUBLIC: NOTARY PUB Sign: Sign: p Print: Print: L SANDRA L PACK Seal: ` 7 ,% Seal: ,. ¢t�.,, Gilda Pe" * •= MY COMMISSION#FFf 20848 = Commissbn # M420......... d 4 , EXPIRES May S.2018 %= Expires:December 9,2019 3"53 Floridallotaryservlce c om �''�.��' ��`� Both 1i1N Aaron Notuy �x* wer* e�sx�x�+x+ .xsa�at.�xx�*sa.a * �w * �xee+�xwx�*asaeeex� �x *eet�ra�xea ee* ea*eaa kP APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 WE 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 HUMBLES, MARK R EMERALD CONSTRUCTION CORPORATION 1211 STIRLING ROAD#106 DANIA FL 33004 Congratulations! With this license you become one of the nearly one million or, licensed by the Department of Business and t Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, f DEPAR F BUSINESS AND and they keep Florida's economy strong. PROF uLATION r Every day we work to improve the way we do business in order to CGC1518475,", j �11 07/07/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more information CERTIFIED G about our divisions and the regulations that impact you,subscribe HUMBLES, , °' to department newsletters and learn more about the Department's } EMERALD C TION p initiatives. mission at the Department is:License Efficiently,Regulate Fairly. ,F constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CtR71F-MP ttno.er the provisions*Of.Ch.488 FS. f and congratulations on your new license! :'auc3lrzore LU07M00004M DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1518478 The GENERAL CONTRACTOR Nated del©vv 1S CERTIFIED U= fhe;provisians of Chapter 489 FS. 4b. Expiration date: AUG 31, 2016 14llI8tE3�_MARK R ,_ - EMERALD CONSTRU � � N � �� �� �, i '1211 �'11ii ?AQ DANCA s. ISSUED: 07/07/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407070000426 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#:18 0-232 4 92 EMERALD CONSTRUCTION CORPORATION GENERAL CONTRACTOR (CERT Business Name: Business Type:GENERAL CONTRACTOR) Owner Name:MARK R HUMBLES Business Opened:O 4/13/2 010 Business Location:1211 STIRLING RD #106 State/County/Cert/Reg:CGC 1518 4 7 5 DANIA BEACH Exemption Code: Business Phone:954-241-2583 Rooms seats Employees Machines Professionals 3 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 2.70 0.00 0.00 29.70 i I t� THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS ' THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements.This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: MARK R HUMBLES Receipt #IOB-15-00000158 1211 STIRLING RD #106 Paid 10/05/2015 29.70 DANIA BCH, FL 33004 I I I I 2015 - 2016 AC'o® CERTIFICATE OF LIABILITY INSURANCE DATE{MMtDDIYYYY) 8/5/2015 THIS OERTIFICATE 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 endorserrmnt(s). PRODUCER CONTACT NAME: Frank H. Furman, Inc. PHONE (954)943-5050 C No: (954)943-5417 1314 East Atlantic Blvd. ADORL P. O. BOX 1927 INSURERS AFFORDING COVERAGE NAIC# Pompano Beach FL 33061 INSURERA Evanston Insurance Company 35378 INSURED INSURER Offiridgefteld Emlovers Ins CO 10701 Emerald Construction Corp. INSURER C Ohio Securltir Insurance Company 24082 1211 Stirling Road #105/#106 INSURER D: INSURER E: Dania FL 33004 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 Liability w/forms 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 IADDLSUaR NSURANCE POLICY NUMBER MMtuDCY EFF MMIIDD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE � PRMAG EMISES OCCUR OA R occurrence + 100 000 $ X 3CO6496 6/12/2015 6/12/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ]i I LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: r $ AUTOMOBILE LIABILITY CO aB,'.n SINGLE LIMIT $ 1,000,000 C X ANY AUTO BAS(16)56223080 8/11/2015 8/11/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accideq $ AUTOS AUTOS DAMAGE $ X HIRED AUTOS X AUTOS ,scads Personal Injury Protection $ 10,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTIONS NKLV20LZ101878 6/12/2015 6/12/2016 $ WORKERS COMPENSATION X I 8TTATUTE I I OETRH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMB (Mandatory in H)EXCLUDED? 83053567 4/15/2015 4/15/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 {Mandatory in NH) H es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) License # CGC #1518475 Project: _ Certificate holder is named additional insured as respects Commercial General Liability if required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Dirk DeJong/HB ©1988 2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 rmi4ni)