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DS-16-318 y �1 Miami Shores Village Building Department FEB 0 2096 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 ct INSPECTION LINE PHONE NUMBER:(305)762-4949 9011\FBC 20\1k BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No.SSI(0 BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP j ° CONTRACTOR DRAWINGS I;zJOB ADDRESS: D� 1?P, I I City: Miami Shores County: Miami Dade zip: p°A Folio/Parcel#: i)--3 q®b —®I 3 —300 0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Free Simple Titleholder): g 1/0 IV o � Phone#: 3�� 22,o® Address: a /� � t /�1e e City: i d'Mi State: FL- zip:...5 3/3 3 Tenant/Lessee Name: Phone#: Email: v � �r a C®� CONTRACTOR:Company Name: L/a P! '( 8)of �ph ne#JS �' Address: S®® City: 4L°(),e0'd' re- Mir ate: Zip: r Qualifier Name: Phone#: State Certification or Registration#: ' Certificate of Competency#: 17`0 J A DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 13" 3 0 Square/Linear Footage of Work: 60 A0 Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: ova. �� Specify-color of color thru tile: `�r d � I�A "17 1" Submittal Fee$ ° j�) Permit Fee$_�� CCF$ G CO/CC$ Scanning Fee$ r� Radon Fee$ 'UL D(�B�PRR$ 03 Notary$ Technology Fee$ t 1 ' 2 0 Training/Education Fee$ 9Cz Double Fee$ Structural Reviews$ Bond$ �� pp�•� TOTAL FEE NOW DUE$1 I V ° Lp (Revised02/24/2014) o 6 4 3 Bonding Company's Name(if applicable) t 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. SignatuolD Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoin ment was acknowledged before me this day of ,20 b by da re 6 20 / by c s� who is personally known to V � �v 2b) who is ally know to me or who h produce �' "�/ as m or who has produced /fl7k, as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: 1' fl� Sign:. 4rEVEN BM Print: Tom' Print: ei i STATE OF FLORIDA Seal: NOTARY PUBLIC Seal: STATE FF228B46 STATE OF FLOPJDA Expires 514=19 Ccmmfl FF22SM Egkw 5/4/2019 *�****�r**�w*�+x*:*:�xrr****�*sx�****.�:.��xar*�*�*****�x�**�**�x�a**�*x��x**r�rrrrr*s • r****:** x**�x*�• APPROVED BY 6I 14. &777�Zonin Plans Examiner g Structural Review Clerk (Revised02/24/2014) iy { i t' Miami Shores Village I �t�s1"faW�s'#i rS%b8 10050 N.E.2nd Avenue NE 'WA al'y �t ? Miami Shores,FL 33138-0000 - tE3� S%� � F ` Phone: (305)795-2204 , , r.. � fY y" 19 Expiration: 10/0412016 Project Address Parcel Number Applicant 295 NE 91 Street 1132060133470 Miami Shores, FL Block: Lot: YELBA BERRY Owner Information Address Phone Cell YELBA BERRY 295 NE 91 ST MIAMI SHORES FL 33138-3127 Contractor(s) Phone Cell Phone Valuation: $ 13,230.00 US BRICK&BLOCK SYSTEMS 954-792-0076 (954)748-2003 Total Sq Feet: 600 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:REMOVE CONCRETE PATIO AND INSTAL Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 Invoice# DS-2-16-58570 CCF $8.40 DBPR Fee $2.00 04/07/2016 Credit Card $610.40 $50.00 DCA Fee $2.00 02/04/2016 Credit Card $50.00 $0.00 Education Surcharge $2.80 Bond#:3049 Permit Fee $125.00 Scanning Fee $9.00 Technology Fee $11.20 Total:. $660.40 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 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction a zo t'ng. Fut ore,Ithori the above-named contractor to do the work stated. April 07,2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy April 07,2016 1 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 I DBA: Receipt S BRICK & BLOCK SYSTEMS LLC Business ERA2L CONTRACTOR (GENERA Business Name: Business Type:CONTRACTOR) I i Owner Name:JAMES s BoND Business Opened:ll/30/2001 Business Location:1800 NW 22 ST State/County/Cert/Reg:CGC 0 5 0 8 8 5 FT LAUDERDALE Exemption Code: j Business Phone:954-792-0076 Rooms seats Employees Machines Professionals 1 For Vending Business only Number of Machines: Vending Type: Tax Amount Transfer Fee Nsi dee Penalty Prior Yearn Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 J I i i j 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 I 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: U S BRICK & BLOCK SYSTEMS LLC Receipt #1CP-14-00021796 1800 NW 22 ST Paid 08/17/2015 27.00 FORT LAUDERDALE, FL 33311 2015 . 2016 ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNWY) ./ 3/23/2016 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 NAME: Certificate Department W.F. Roemer Insurance Agency, Inc. PHONE 954-731-5566 FAX 954-731-8438 3775 NW 124 Avenue E-MAIL Coral Springs FL 33065 .certificates@roemer-ins.com INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:Monroe Guaranty Insurance Co 32506 INSURED USBRI-2 INSURERB:FCCI Insurance Company 10178 US Brick&Block Systems,LLC INSURER c:American Builders Insurance Co 11240 1800 NW 22nd Street Fort Lauderdale FL 33311 INSURER D:United Specialty Insurance 12537 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:71975424 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. INSR ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER M D D A X COMMERCIAL GENERAL LIABILITY GL 0017748 2 3/26/2016 3/26/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X�OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $100,000 MED EXP(Anyone person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT F—]LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY CA 0029435 2 3/26/2016 3/26/2017 COMBINEaacci ED 1 LEI 1 $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ AUTOWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident B X UMBRELLA LIAR X OCCUR UMB 0020797 2 3/26/2016 3/26/2017 EACH OCCURRENCE $5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10,000 $ C WORKERS COMPENSATION WCV 0180179 01 12/20/2015 12/20/2016 X PER OTH- AND EMPLOYERS'LIABILITY �,/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N❑N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Contractors Pollution USA4110833 3/26/2016 3/26/2017 Each Occurrence 2,000,000 Liability Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Re: Paving Installation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 Northeast 2nd Ave Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE -4 -44 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD