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PW-12-1596Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 177760 Permit Number: PW -8 -12 -1596 Inspection Date: February 04, 2013 Inspector: Bruhn, Norman Owner: VILLAGE, MIAMI SHORES Job Address: 10050 NE 2 Avenue Miami Shores, FL 33138 Project: <NONE> Contractor: H&R PAVING INC Permit Type: Public Works Inspection Type: Final Work Classification: Public Works Phone Number Parcel Number PUBLIC WORKS Phone: (305)261 -3005 Building Department Comments MILLING AND RESURFACING Passed J ...24/4e Inspector Comments cc Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until February 04, 2013 For Inspections please call: (305)762 -4949 Page 1 of 1 •/ iLCEJVE AUG 2 8 202 Miami. Shores Village Public Works Department ZiIji Works Permit Application FBC 50ftit a2 if 0 Permit Type: Public Works WATER Owners Name (Fee Simple Titleholder) ovine? aw. , , 4 ,, / .4S st9te-----------7— 4 33a, Tenant/Lessee Name /Li/4 Phone #: /0/4 Job Address (where the work is befog done) I 5Ce 1,415 . City Miami Shores Village County Maori Dale Zip 331? Is Building Historically Deellirotied: 10050 N.E. 2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 an/ pomita01-15glo $10/<1 v,/,4e 375=-07.02aV Contractors Company Name Contractors Address City YES C 4 efri ; 4hite fiz- NO Phone d: Architect/Engineers Name (if applitable) $ Value of Work For this Permit Type of Work Describe Work: :• • • 1::i Adirdion • "(1.4 06* o'oc Phone d: Lineal Footage Of Work: Submittal Fee Permit Fee $ CCF $ CO= Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ Zoning ions, $ Code Enforcement $ Structural Plan Review $ Total Fee Now [hie $ (Continued on opposite side) Bonding Company's Name (if applicable) �G ✓� 1 ?�' / ���% y � Bonding Company's Address /e/ 5"//.0.4a-e- WA 20 1) /k4/V:6 State 5 Zip City / . Al //.4 Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State N/A Zip Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 this issuance of a Public Works 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 rein . fee will be charged. Signature Owner or Agent oing instrument was acknowledged before me this NOTARY PUB Sign: Print 4 \':' . \ �� G) My Commission Expires: ��,, C� Q,•\ ...0, ���• �•• r,,,r8 TAT E 14 �‘�\\\• Signature The foregoing instrument was alai ?, befo a is 0._.._-by "cai? !i day of #44/ 2041); by , I12/3 or who has produced Who is personally knme nr ti9� as ide t r; i . tmsdt} Wyrdi 4a e an oath. Oaks identifi an oath. Sign: Print: ''..ui i, 0 Bonded Through Natio r`..otary sn. APPLICATION APPROVED BY: 11/17/2005 Public Works Director or his designee. aC 9riCtllif pGK(a40PAJlly ."nAa r_5t ]T? PR P'EI ►,UST Y LIP; L_CENSE':NB d TZ GENE Q1NTIZAC'I'(�R I�'am�ed .glow YS' CERT1FIR: Ux1c%er the`..pr visiotts.. off° ha E spiratioxn date AUG '31. 29 1�EC'��t7LATION BQA, tD SEQ #L120.51800429. FL 33179 S REQL3IREi7 BY' LIEN LAWSON SECRETARY Q 4 IFY.ING ` iADE(s) 7 PAVIWG ERIGINI ERING H &RPAVI -01 STWIGGS AW RD " DATE (MI:7lDD/YYYYj CERTIFICATE OF LIABILITY INSURANCE 6�23/zo12 _ 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(ies) 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 Collinsworth, Alter, Fowler & French, LLC 8000 Governors Square Blvd Suite 301 Miami Lakes, FL 33016 INSURED H & R Paving inc. 1955 NW 110th Ave Miami, FL 33172 COVERAGES CNAT�ACT MM f No�Fad (305) 822 -7800 ADDRESS: L( (305) 362-2443 INSURERS) AFFORDING COVERAGE NAIC $ INSURER A :Travelers indemnity Co. of America '25666 INSURER B :Travelers Property & Casualty Co. of America 25674 INSURER C : Commerce & Industry Ins. Co. 19410 INSURER D : INSURER E : INSURER F : 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 INNSSRL WVD POLICY NUMBER (MMIDDIYYYY) {& tD0 1t) LIMITS LTR TYPE OF INSURANCE GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X I OCCUR XCU included GEM AGGREGATE UMTTAPPLIES PER POLICY X JECT j LOC AUTOMOBILE LIABILITY B X I ANY AUTO ALL OWNED SCHEDULED AUTOS L AUTOS NON-OWNED HIRED AUTOS X X DTC09831P196TIA12 1 611/2012 EACH OCCURRENCE 1,000,000 DAMAGE-TORENTED_____. 5!1/2013 PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ _ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 1 PRODUCTS - COMP /OP AGG $ 2,000,000 $ IX DT8109831P196C0F12 51112012 X 1 UMBREU.ALJAB EXCESS UAB OCCUR CLAD/IS-MADE DEB X RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ! N ANY PROPRIETORIPARTNEWEXECUTIVE OFFiCER/MEMBER EXCLUDED? L ._ (Mandatory In NH) 11 yes, describe under DESCRIPTION OF OPERATIONS below B Leased /Rented Equip N /A, BE012031134 COMBINED SINGLE LIMIT (Ea acclde, 5/1/2013 BODILY INJURY (Per person) 5/1/2012 BODILY INJURY (Per accent) PROPERTY DAMAGE (Per accident) $ 1,000,000 $ $ S $ EACH OCCURRENCE 5/1/2013 AGGREGATE $ $ 5,000,000 5,000,000 QT6600877R99ATiL12 6/2012 TORY LJMITS L L ER E.1- EACH ACCIDENT E.L DISEASE - EA EMPLOY $ E.L DISEASE - POLICY OMIT $ 5/6/2013 $1,000. Ded Applies 250,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACOR1101, Additional Remarks Schedule, H more apace M required) Project # 2012 -08 Project name: Citywide Roadway Resurfacing Project CERTIFICATE HOLDER 3O tto Miami Shores Village 10050 NE 2nd Ave Attn:Scott Davis (P.W. Dep. Director) Miami Shores, FL 33138 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD A ©' CERTIFICATE OF LIABILITY INSURANCE 9/a (MMIDE 2rr) 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 poiicy(ies) 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 Eastern Insurance Group, Inc. 9570 SW 107 Avenue Suite 104 Miami FL 33176 C CT David M. Lopez PHONE EMI: 595 -3323 ' No. (305)585 -7135 Amman: J csr @easterninsuranae.net INSURER(S) AFFORDING COVERAGE NAIC # INSURER :Bridgefield Employers Insuranc LIABIU Y COMMERCIAL GENERAL LIABILITY INSURED H & R Paving, Inc. 1955 NW 110 Avenue Miami FL 33172 INSURER B : INSURER C : INSURERD: $ INSURER E : $ INSURERF: 1 C441MS.MADE E OCCUR CERTIFICATE NUMBER star 11 -12 • 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 WTH 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. L� R TYPE OF INSURANCE ADM INSR WEIR LAND POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MM/DD!YYYY) LIMITS GENERAL — LIABIU Y COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1 C441MS.MADE E OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEM_ AGGREGATE LIMIT JEC n Loa APPLIES PER: -1 POLICY I I PRODUCTS - COMP/OP AGO $ $ AUTOMOBILE — — LIABILITY ANY AUTO UTOOS ED HIRED AUTOS _ AA SCHEDULED NON-OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Per perean) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Pereocklerd) $ $ UMBRELLA L IAB EXCESS LIAR _ BUR CLNMS„MADE EACH OCCURRENCE $ AGGREGATE $ DED 1 1 RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS belo w N!A 830 -50175 12/25/2011 12/25/2012 , I W Y LIMITS 110/H- E.L. EACH ACCIDENT $ 1, 000 , 000 El. DISEASE - EA EMPLOYEE $ 1, 000 , 000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OP OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Asphalt paving, sidewalks, curbs, asphalt plant Project name: "Citywide Roadway Resurfacing" Project # 2012 -06 CERTIFICATE HOLDER CANCELLATION (305) 075 -6972 Miami Shores Village Scott Davis (P.W. Dep. Director) 10050 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR® REPRESENTATIVE David Lopez /AMANDA s. ACORD 25 (2010/05) INS025 Mni nnm n1 ©1988-2010 ACORD CORPORATION. All rights reserved. Tha A[:ARf names anti Innn ar a roniatarmi mark of Ar:ARi1 11111AMI-DADE COUNTY • TAX COLLECTOR 140 W. FLAGLER ST. •istnooR _ itammi"3313p, 067477-1 'IIIIIANIFDADE'COUN'tY;;STATVOFFLORIDA't'..:77.7 0.V1,13 ”.EP3:;;-A■41 , - OSTI4L4*""10:;-1Z",PC.A.Pg THIS IS NOT A BILL - DO NOT PAY RENEWAL • BUSINESS NAME / LOCATION H & R PAVING INC 1955 NW 110 AVE 33172 UNIN DADE COUNTY • OWNER • H & R PAVING INC Sec. Type of Business 196 SPECIALTY ENGINEERING CONTRACT THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT, IT DOES NOT PERSIST THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. TITS is NOT A CERTIFICKRON OF THE HOLDER'S OLIALIRCA- SIGNS. PAYMENT RECEIVED BRAM-DADE COUNTY TAX COLLECTOR: 08/22/2011 60000000349 000075.00 I SEE OTHER SIDE • RECEIPT NO. CC # E844 WORKER/S 10 DO NOT FORWARD H & R PAVING INC RAUL GONZALEZ JR PRES 1955 NW 110 AVE MIAMI FL 33172 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 067477-1 WhADJ141d.difj..MAJJALMN ' ,.tig60.07:„-ct,, iiiihio*...,T47b#-.154-4!‘ RECO opO-FlE;9sR.SppTospd-CisiDLATA:GsE1 ......: "-:-..-....... .- ,.,..'.:'-: .;•, ,4i11.;. ''''-' 126 g..CP ---.7:•-.01X-gP1,Ii01Nk..--- .,,„:„..„.. • „ ;Wfi..---tiwi.07tA.F.k'----.::, ---:___.,:!,,, immitifil, Fl- ''• MM. . [LE . ..i.- --- •DISFLAXP. DectiART...,-,,,,,...,-,-5..-- &TOO= A-- ... ST— *- - ..-.?r:"': ...fx-... - 0-.. .. may 1.4;...A.: - -.....-'....,;_,,,....z.:-.,••• '-.' ...- •=1.-:.-...*....-UfFu-----,$$$.•':.:.--.: ' ' BILL _ DO NOT 44.0:Wr..n.n...,-g,... ....... '...,..:: • .. • ..',.... spANT..J......--K4...5?i'T="''''' - - PAY RENEWAL 3094.33 IVIIIAMkfk...,.... '...t ..:".....".*'. .. ' • ' IS NOT A SILL ,.,. latirr O 23 THIS ' p I NO _ . 295899-0 BUSINESS NAME / LOCATION H & R ASPHALT PLANT 1955 NW 110 AVE 33172 UNIN DADE COUNTY OWNER ONE HUNDRED & TENTH AVE INVEST C Sec. Type of Business 206 MFG/RECYCLING/PROCESSING THIS is ONLY A LOCAL 13US15ESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNIY OR CRIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAM THIS 03 NOT A CERTIRCATION OF THE HOLDER'S QUALIFICA- TIONS. • PAYMENT RECEIVED MIAMI-DADE COUNTY TAX • COLLECTOR 08/22/2011 60000000347 • 000090.00 SEE OTHER SIDE EMPLOYEE/S 12 DO NOT FORWARD H & R ASPHALT PLANT RAUL GONZALEZ 1955 NW 110 AVE MIAMI FL 33172 4. .1 .1 ^-1. I. udianillmlui,139,111, * * * * * * * x * * * * It * It * * * MIAMI -DADE COUNTY TAX COLLECTOR 140 W. Flagler Street Miami, Florida 33130 Please keep your receipt for future reference. Thank you and have a nice day. 8/23/2012 1300 /229 /OO1ILEV 0016 -0001 Last Seq. #:0001 WI LBT #:30 067477 -1. Local Business Tax $175.00 CK CHANGE $175.00 $0.00 MIAMI -DADE COUNTY TAX COLLECTOR LOCAL BUSINESS TAX SECTION 140 W. Flagler St. - 1st Floor Miami, Florida 33130 TEMPORARY RECEIPT 2012 -2013 MUNICIPAL CONTRACTOR TAX Local Business Ta State /CC # :E844 Issued to: H & R PAVING INC :30067477 -1 Type of Business: SPECIALTY ENGINEERING CONTRACT SEE BACK OF OFFICIAL RECEIPT FOR NONPARTICIPATING MUNICIPALITIES THIS RECEIPT IS ISSUED AS EVIDENCE OF PAYMENT FOR YOUR LOCAL BUSINESS TAX OR PERMIT. YOUR OFFICIAL RECEIPT WILL BE MAILED TO YOU WITHIN 10 DAYS FROM THE VALIDATION DATE ON THIS RECEIPT. Payment Received as Certified Above Miami -Dade County Tax Collector CITY -WIDE ROADWAY RESURFACING PROJECT 2012 -6 * Legend 1= Terrible 2 = Bad Bad 3 = Bad STREET STATUS* STREET FROM TO ' 1 2 NE101ST NE2AVE NE6AVE 2 1 NE 101 ST NE 6 AVE TOT LOT 3 1 NE 92 ST NE 1st AVE NE 2 AVE 4 1 NE 3 AVE NE 107 ST NE 105 ST 5 1 NE3CT NE107ST NE105ST 6 1 NE 5 AVE NE 107 ST NE 105 ST 7 1 NE92ST NE8AVE NE9AVE 8 2 NW 1st AVE NE 109 ST NW 103 ST 9 2 NW MIAMI CT NW 103 ST NW 100 ST 10 2 NE 2 CT NE 107 ST NE 105 ST 11 2 NE2PL NE107ST NE105ST 12 2 NE 105 ST NE 6 AVE DEAD END 13 2 NE 101 ST NE-13 AVE NE 1500 14 2 NE 96 ST NE 6 AVE BISCAYNE BLVD * Legend 1= Terrible 2 = Bad Bad 3 = Bad IA HORES VILLAGE T LLECT1 N r--7AMMITI .fri;t tfMftiljir ifgaM71! NW OTINST NE IINTH ST Area 5 Area 1 Lt5.15:L* Area 6 "oet, Area 2 Area 5 Area 4 SUBJECT 0 CCMPLIANCE VI/Trfl ALL FEDERAL 'l:IT.n.TE AND Cr— rj ( HL, LES AND REGULATIONS Prepared By: MamI hares Planning Department December 16, 2009