RC15-3172 Miami Shores Village
` MR —
Building Department B
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 1
FBc 20 I�
BUILDING Master Permit No.�C�_ 2-
PERMIT APPLICATIONSu Permit N16-5��
BUILDING ELECTRIC ROOFING WIREVISION d EXTENSION DRENEWAL
PLUMBI G ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
t r CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: Q,g�
FFE:
OWNER:Name{(Fee
�Simple
+ Titleholder): Igo( s
Phone#:3 — % —��10
Address: Oqr IV W d� 2
City: l Q- State: j Zip:
Tenant/Lessee Name: Phone#:
Email:
C
CONTRACTOR:Company Nam L " � Phone#:
Address t) 16"
-
City: M/", ' Q3 State: 1 Zip• /
Qualifier Name: Q (' Phone#: 6
�� iJ.1ii
State Certification or Registration#: Certificate of Com
DESIGNER:Architect/Engineer: Phone#:
Address: _Ci t+ Zip:
Value of Work for this Permit:$122E.0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alte ation ❑ New Repair/Replace De olition
Description of Work:
l e M9E YWYAL
Spec colon!f coldr-th&# •f
Subm I Fce$ �' _ CCF$ I. 2-0_ CO/CC$
Scanning Fee$ f `/��(; Radon Fee$ , �� DBPR$ aL Notary$
Technology Fee$ 1 -46 Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ CP
TOTAL FEE NOW DUE$ 1 AG
(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. 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.
SignatS(gnature ,
OWNER o AGENT CONTRACTOR
The foregoing instr ant as acknowledged before me this The foregoing instrument was acknowledged before me this
da f CL� 20 1U ,by ZO day of 2�"tcc/� 20 1(,_,by
C: ....
wltts"issonally known to who is personally known to
me or who has produced �-L as me or who has produced p L- as
identification and who di identification and who did take an oath.
NOTARY PUBLIC: NOTARY PU C:
d
Si Sign:
Pri 1 Print:
Notary Public Stets of Florida JAYMY BEN010
Seal: Seal: 9 N Florida
Stacey Ann Levem Ringrose � dry SIM•State 01
My Commission FF 048348 ,�� Q MY Comm.ExpAres Mer 31.2017
Expires 09/10/2017 -y�.F °• Comm188ion#EE 870357
'"°����• Bonded.TAr
lf APPROVED BY _JC4 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
_ _ STAFF OF FLORMA
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ISSUED: 08/17/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408170002619
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.. DSEC-L >ON sec T OR _
5 g INC 196 PLUMBING PAYME RECEI
Y �500 49/23/ 5
y ' PPU 12 15-004276
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Policy Number: Date Entered:
,A�® DATE IMMIDD1YYYY)
CERTIFICATE OF LIABILITY INSURANCE F
12/,5/2015
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'IDOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT- if the certiflcale hokler Is an ADDITIONAL INSURED,the policy(les)must be endorsed. if SUBROGATION IS WAIVED,subject tD
Me term 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 ACT
$AL1�N INSURANCE N ALLISON
730 SW 4TH ST. #3 PHONE . (866)587-7147 Fax No; (888)542-3507
CARE CORAL, FL 33991 E•MAL ,ALLISON@SALVENINSURE.CCM
INSU 8 AFFORDING COVERAGE NAIL#
1flSURERA:PRBPZRRED CCNTRACTORS INS. CO. (RRG) 12497
INSURED JMIES L. DIMICO CONTRACTING INC INSURER B:
JAMS DEMICO INSURER C:
10055 SISCA7= BLVD. INSURER D:
NM SHORES, FL 33138 MSE;
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 POi ICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADOL SWR TYPE OF INSURANCE AM Jm POLICY NUMBER 1Pr�EFF MMM O EXP
--umrrs
A COMMFRCIAI GENERALLUIBILITY EACH OCCURRENCE $ 1,000-
TO
CLAIMS-MADE 19OCCURPCICS026-PM70585 8/25/2015 /25/2018 PREMISES aEccur $ 50,0
-06 MED EXP(Any oneperson) $ 5,000
PERSONAL 8 ADV INJURY $ 00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY 7 JET LOC PRODUCTS-COMPIOP AGG $ 1,000.00,
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LNIT $
Me accid
ANYAUTO BODILY INJURY(Per person) $
ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ -�
AUTOS AUTOS
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Peraccide
UMBRELLA LMB OCCUR EACH OCCURRENCE $
EXCESS UAB' CLAIM84MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION 8TA ER-
AND EMPLOYERIr LIABILITY Y!N TUT
ANY PRDPRIETORIPARTNERIE%ECUTNE [7 NIA E.L.EACH, $
OFFlCERIMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If y�describe under
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY UNIT $
DESCRIPTION OF OPERATIONS!LOCATIONS i VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is required)
C=SE NMMM GCGO13750
CFC019056-PLUMING
CERTIFICATE HOLDER CANCELLATION
LZANI SHORES V71LRGS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
10050 NE 22M AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI SHCRIIIS, FL 33138
305 756 8972 AUTHORIZED REPRESENTATIVE �r
®1988-2014 ACORD CORPORATION. All rights nerve
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
05-08-2014
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: 05/03/2014 EXPIRATION DATE: 05/02/2016
PERSON: DENTICO JAMES L
FEIN: 592246282
BUSINESS NAME AND ADDRESS:
JAMES L DENTICO CONTRACTING INC
10055 BISCAYNE BOULEVARD
MIAMI SHORES FL 33138
SCOPES OF BUSINESS OR TRADE:
1- HEATING, VENTILATION, AIR-GOND 2- LICENSED ELECTRICAL CONTRACTOR
3- LICENSED PLUMBING CONTRACTOR 4- LICENSED GENERAL CONTRACTOR
IMPORTANT: Pursuant to Chapter 440 . 0504, 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 440.0503), 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 certificate at any time for failure of the person
named on the certificate to most the requirements of this section.
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1809
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES IMPORTANT
DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05114), F.S., an officer of a cor oration who
CONSTRUCTION INDUSTRY O p
CERTIFICATE of ELECTION TO BE EXEMPT FROM FLORIDA elects exemption from this chapter by filing a certificate of election
WORKERS COMPENSATION LAW L under this section may not recover benefits or compensation under this
EFFECTIVE: 05/03/2014 EXPIRATION DATE: 05/02/2018 0 D chapter.
PERSON: JAMES L DENTICO H 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
FEIN: 582248282 R the notice of election to be exempt
BUSINESS NAME AND ADDRESS:
JAMES L DENTICO CONTRACTING INC E Pursuant to Chapter 440.05(13), F.S., Notices*of election to be exempt
10055 BISCAYNE BOULEVARD and certificates of election to be exempt shall be subject to revocation
MIAMI SHORES, FL 33138 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
SCOPE OF BUSINESS OR TRADE: department shall revoke a certificate at any time for failure of the
erson
1- HEATING, VENTILATION, AIR-COND 2- LICENSED ELECTRICAL CONTRACTOR secton named on the certificate to meet the requirements of this
3- LICENSED PLUMBING CONTRACTOR 4- LICENSED GENERAL CONTRACTOR 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