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PL-14-1907 �1v-A Miami Shores Village - .: �I CF,1 - Building Department SEP 2014 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 i BY. Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20[() ��ll BUILDING Master Permit No.-PL' H 11 V� PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [-]RENEWAL [PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 2� .3 . ~C— City: Miw6i Shores County:Dil)P.,Miami Dade Zip: Folio/Parcel#: 1 - Z(� h-Gi-� - Is the Building Historically Designated:Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: OWNER:Name(Fee Simple Titleholder): Phone#: 'ri�12 -��-�- 1--1 1-5' .� Address:_ _ 2 L+S® t-- ✓` S City: i,1 gel 4-1 6 '�ViC.7VC-0� State: �41 0 4 Zip: �S Tenant/Lessee Name: Phone#: Email: -305-9 o 4 �O CONTRACTOR:Company Name: �_�c! 'f2 �.�� � 1 �, �,c° • Phone#: 134 Address: `'`7l� I' / / dti'qo e City: State: Zip: Qualifier Name: '114,11 r?�i��.c/ / z��, (� Phone#;-V� ' > G d/'C'I/ State Certification or Registration M Certificate of Competency M DESIGNER:Architect/Engineer: _ U Phone#: /-J i L n Address: Ci i State: Value of of Work for this Permit:$ ®e Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: t--xd .je, Specify color `ofr3 the Submittal Fee$ Gy / s, ermda �J 6 CCF$ `� CO/CC$ Paz Scanning Fee$ ` °�LJ Radon Fee$ aD 5 DBPR$ a Notary$ Technology Fee$a` -A 0 Training/Education Fee$ Double Fee$_ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 11a o (Revised02/24/2014) /^ I 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. 4 Signature /�) Signature OWNER or AGENT CO ACTOR The foregoing instrument was acknowledged before me this The foregoing instrume was acknowledged before me this day of V Q U `_5� ,20 11 by day of� / , i� � 2 by w o is personally know to ` who is personally kn?-Wwto me or who has produced tmr G7Ti roduced --� as 4. p identification and who did take an oath. eesat' a d who did take an oath. NOTARY PUBLIC: / NOTARY PUBLIC: Sign: / Sign: Print: Print: Seal: 3 Zero I e My Can,mfssion EE077835 Seal: 1,181W Sj a Expiroa OM1512018 to of Rmwe •Vfeow =#FF OW APPROVED BY �"Z T Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) OR Dk 29270 Pss 2184 - 2186► (3p9s) RECORDED 08/14/2114 09:17:54 DEED DOC TAX 2Y641.8n HARVEY RUVINP CLERK OF COURT NIAMI-DARE COUNTY9 FLORIDA au3►1 d b - Richard P.Breger,P.A. 20801 Biscayne Blvd.Suite 300 Aventura,FL 33180 305-9314400 File Number. L14-223 Return to: Cbmtopber P.Kelley,P.A. 11098 Biscayne Boulevard Suite No.205 Miami,FL 33161 (Sp=Above This Line For Recording Data] Warranty Deed This Wawmin r Deed made this 8th day of August,2014 between Patricia M Rodriguez,a single woman,whose post office address is CIQ Cow A. DcDmr. 1:22h 042 Sttee+, &rsxiuntli 4120A , grantor, and Robert Demiduke and Aimee Demiduke,husband and wife,whose post office address is 246 NX-105th Street,Miami Shores, FL 33138,grantee: (Wbenever used heroin the terms"g=tce and"grantee"include all the parties to this Wwunwa and the heirs,legal representatives,and ensigns of individuals,and the sucxeson and aWgns of corporations,trusts and truam) Witnesseth,that said grantor,for and in consideration of the sum of TEN AND NO/100 DOLLARS($10.00)and other good and valuable considerations to said grantor in hand paid by said grantee,the receipt whereof is hereby aclmowledged, has granted,bargained, and sold to the said grantee, and grantee's heirs and assigns forever,the following described land, situate,lying and being in Miami-Dade County,Florida to-wit: Lot 7 and the East 1R of Lot 8,Block 120,MIAMI SHORES SECTION S AMENDED,according to the Plat thereof,recorded in Plat Book 10,Page 47,of the Public Records of Miami Dade County, Florida. Parcel Identification Number.1121360130490 Subject to taxes for 2014 and ts' conditions, restrictions, easements, reservations and limitations of ltlt kup- Together with all the tenements,hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold,the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple;that the grantor has good right and lawful authority to sell and convey said land;that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever•, and that said land is free of all encumbrances,except taxes accruing subsequent to December 31,2013. Doublern"" III Witness Whereon grantor has hereunto set grantor's had and seal the day and year first above written. Signed, ed and de' in our presence: .4 C Ozx4"0C 6 � J With Name: zz, ii4flc�a M R guez Witness Name. State of Florida County of Miami-Dade The foregoing instrument was acknowledged before me this 8th day of August,2014 by Patricia M Rodrigo who is personally known or[X]has produced a driver's license as identification. (Notary Seal] ����^^��f//��((������ Notary Public Nn•hh4, t,�7ry1.111'f COHEN 1pw "K ' pay e3�Q�{u EE 927815 EXRkR Q dbeI V 2014 Printed Name; De Nalazy R�tc unaeiwrlters My Commission Expires: Wa"Way Deed-Page 2 Doubted Registered Septic Tangy: Contractor ANDREW M ZERO 7701 WEST 18 LANE HIALEAH FL 33014 "Ara1° A SUPER SEPTIC TANK. INC. Business Authorization: SA0960829 SR0890722 Registration Expires on September 30; 2014 000410 Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY LBT 3820314 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES A SUPER SEPTIC TANK INC RENEWAL SEPTEMBER 30, 2014 7701 W 18 LA 39$$772 Must be displayed at place of business HIALEAH FL 33014 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF NUSINESS PAYMENT RECEIVED A SUPER SEPTIC TANK INC 196 SPECIALTY 'LUMBING CONTRACTOR BY TAX COLLECTOR Worker(s) 1 SEP890722 $49.50 10/09/2013 CREDITCARD-14-000568 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receippt is not a license, permit or a certification of the holder squelifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276. For more information,visit www.miamidade govAaxcollector A01/110/140/14YIY) CERTIFICATE OF LIABILITY INSURANCE DATE THIS CrER-nFICATE 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 WANED,subject to the tennis 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 endorsemertt(s). PRODUCER CONTACT Blaize&Tyson Insurances PHONE (954)9W9324 No): (954)989-5998 5955 SW 21 st Sttsedt nnRIE anny@btedzeandtyson.cmn Hollywood,FL 33023 INSURER(S) AFFORDING COVERAGE NAIC# Phone (954)989-9324 Fax (954)989-5998 INSURER A: ACCIDENT INSURANCE COMPANY INSURED INSURER B: A SUPER SEPTIC TANK,INC INSURER C: 7701 W 18 LANE INSURER D: HIALEAH,FL 33014 954 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. LLTTRR TYPE OF INSURANCE ADD UBINSR VM POLICY NUMBER MPS Y EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000.00 0 COMMERCIAL GENERAL LABILITY PRATO EMG ENTED S REoccsarerrc e $ 100,000.00 A ❑ ❑ CLAIMS-MADE 0 OCCUR CCP0006254-00 10/10/2013 10/10/2014 ,00MED EXP(Any one person $ 50.00 ❑ PERSONAL&ADV INJURY $ 300,000.00 ❑ GENERAL AGGREGATE $ 300,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 300,000.00 ❑ POLICY ❑ PFe RO- ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AAUTLL OS OWN ❑ AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE ❑ HIRED AUTOS ❑ AUTOS Peracadent $ ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATIONElWC YTATnU ❑OR- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? NIA (Mandatory In NH) ❑ E.L.DISEASE-EA EMPLOYE $ If yes describe under DESd0TION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace is required) SEPTIC TANK INSTALLATION,SERVICE AND REPAIR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI SHORE VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORE VILLAGE,FL 33138 AUTHORIZED REPRESENTATIVE FAX 305-756-8972 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD Report Viewer Page 1 of 1 1Ei1 100% r. JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION •'CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW" CONSTRUCTION INDUSTRY EXEPTION This ceMes that the individual fisted below has elected to be exempt frau Florida Workers'Compensatlon law. EFFECTIVE DATE: 8/4/2014 EXPIRATION DATE: 6/3/2016 PERSON: ZERO ANDREW M FEIN: 650455404 BUSINESS NAIL AND ADDRESS: A SUPER SEPTIC TANK INC 7701 WEST 18 LANE HIALEAH FL 33014 SCOPES OF BUSINESS OR TRADE: IRRIGATION OR DRAINAGE SYSTEM Pureumdto ChepW440.04141.F.S..moffbmofa atonvdreeledsexemptmtmmthiseceManteofe h anGettm section may nol reeaver beaeEb m order ttls dreidet Pemam tto Chapter440AX121 F.&. M�np of electlaa to be exsmpi.apply vr"the smile oftre buskteasmiratle pmad on the rmtce oiekxdfan�beexe ill.Pureuemto Chapfm440. 13 F.B..Notkrea d etec�n to be aehpt mal certificates of eledWn to be exempt shop be subject tom req at any Wee after the of the noticemore ofthe cuVOM te,the persan named on ttre no0ce or mrtl8ade tre fohhgmmeeh the regrdrerrnmha oflf me9vn fm i msme of a eartfte¢e.The depaMhent shop revake a cwffib e a any fere forfe➢ure of em peaseh rarmed mt the oerf�tem mem the repuka olthle seetorh. DFS-F24WJC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 GUESnON87(&50)41&1609 httos://avvs8.fldfs.com/crreiDortviewer/revortViewer-asvx?data.=kdvpginc9D7Q3gH6TER6e... 6/4/2014 5uRs loss Miami shores Viliage "%* Building Department RtD� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers$ Compensation Insurance Exemption 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 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 may be personally liable for the worker compensation iniuries of any person allowed to work under this permit 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: I' Cx�` C. �' (� Print Name: Signature: �1 Signature: � c. Slate of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and su}�scribed before me this Sworn to an subscrib d e ore me tWs day of T h ,201' day of ,20I,� By By P —:: u Ze�O of ° 835 (SE*eo A-, �-• • , @ of Flrxida T e of Identffic c tstzot3 T IdentificationUFAM