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RF-12-1769fleew l e 41 / 6e No 4/4 , v r ' 104' d'si eckseeiceie cad /14249446- 'or-4*Y- of 0 f /' Miami Shores Village Building Department '10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20(' Permit Type: BUILDING ROOFING ari. .';F". SEP 24-2,01a Permit No. ) 2 Master Permit No J- 2 11, OWNER: Name (Fee Simple Titleholder): 6kl Uf" J ( Phone#: 30S-: 8 — / / f O Address: 11 So) fit- 2.4 P-e City: il i k/1.4e . -ie. i State: E(._. zip: 3 5 16 1 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 66406 UN; 4f€ IS City: Miami Shores Socc ( Ale County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Company Name: YLA Address: // '3010 NG. 211' City: L1 kott&E 190 & tt State: Qualifier Name: L Qcesz\Z1-1 - Codobe_c 1%0 State Certification or Registration #: ct. Z..1 Contact Phone #:L 5'-1/4'y (01574-04"1 E DESIGNER: Architect/Engineer: NO Flood Zone: o'S-f- 6 75--17-0 Zip: .3.3®� Phone4t5(>toin 1 0q ertificate of Competency #: Phone #: Value of Work for this Permit: $ Ig •`' Square/Linear Footage of Work: Type of Work: DAddition Description of Work: � UAlteration New r • epair/Replace h /teemk attovil ®d'1 ODemolition Sub ittM Fee` $ Fe nit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 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 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 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' a rspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of co r_ , 2012, by Cio' la via who is personally knower me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commissio 4.10 r * * * * * * * * * * * ** Signature LPl�dl•(2) ;4Oi2C6 l /. Contractor The foregoing instrument was acknowledged before me this day of SA:=0 ° , 20 \'t , by .__CAV C3 'T.exiC'b( O who is personally knowj u me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: C VQtc:SSO TO Obe,c My Commission Expires: ,x *,x,x*x:u:*x:**** ** * *** :******* pax:,x,x,x,x,x********** ** APPROVED BY Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Clerk BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL' 33301 -1895 — 954 -831 -4000 VALID OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012 DBA: Business Name: KUYOC ROOFING CORP Owner Name: LORENZO TODOBERTO /AQUAL Business Location: 3020 NE 28 AVE LIGHTHOUSE POINT Business Phone: 954-675-1709 Rooms Seats Employees 1 Receipt #:185- 229505 Business Type:ROOFING /SHEET METAL Business Opened:09 /17/2009 State /County /Cert/Reg:ccC13 2 92 74 Exemption Code:NONEXEMPT Machines Professionals For Vending Business Only Vending Type: CONT • r`i TOR Tax Amount Transfer Fee - NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: KUYOC ROOFING CORP 3020 NE 28 AVE LIGHTHOUSE POINT, FL 33064 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 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. 2011 - 2012 Receipt *10B -10- 00005893 Paid 07/15/2011 27.00 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 TODOBERTO, LORENZO KUYOC ROOFING CORP 3020 NE 28TH AVENUE LIGHTHOUSE POINT FL 33064 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better] For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. IS CERTIFIED under the provisions of ch.4$9 FS Thank you for doing business in Florida, and congratulations on your new license! ! Expiration date. AUG 31, 2014 L12080600961 (850) 487 -1395 STATE OF FLORIDA AC# 6 2119 2 9' DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CCC1329274 08/06/12 128030363 CERTIFIED ROOFING CONTRACTOR TODOBERTO, " LORENZO KUYOC ROOFING CORP DETACH HERE THIS DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING • LINEMARK "' PATENTED PAPER AC#6249297 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ# L12080600961 DATE BATCH NUMBER LICENSE NBR 08/06/2012 128030363 CCC1329274,. The ROOFING CONTRACTOR Named below IS CERTIFIED Under the provisions of ChaptEr .a Expiration date: AUG 31, 2014 TODOBERTO, LORENZO KUYOC ROOFING CORP 3020 NE 28TH AVENUE LIGHTHOUSE POINT RICK SCOTT GOVERNOR FL 33064 ninny AX/ AL, nrni nnc•n ov 1 ALAI LAWSON SECRETARY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/11/12 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 Express Service Insurance Agency 900 E. Atlantic Blvd. #10 Pompano Beach, FL 33060 Phone (954) 943 -7900 Fax (954) 943 -1810 CONTACT NAME N . : (954) 943 -7900 FAX No): (954) 943-1810 ADDRESS: paulor express4u.net INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Western Heritage Insurance INSURED KUYOC ROOFING CORP 3020 NE 28th Ave Light House Pt, FL 33064 (954) 675 -1709 INSURER B : 11/29/2011 INSURER C: EACH' OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E : Q COMMERCIAL GENERAL LIABILITY INSURER F : MED EXP (Anyone person 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE. INSR`SWVD POLICY NUMBER (MMOILDDYNYYY) (MM POLICY LIMITS A GENERAL LIABILITY SCP087 .4580 11/29/2011 11/29/2012 EACH' OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 101:0°°'°° Q COMMERCIAL GENERAL LIABILITY I♦ • CLAIMS -MADE n OCCUR MED EXP (Anyone person $ 5,000.00 In PERSONAL & ADV INJURY $ 1,000,000.00 • GENERAL AGGREGATE $ 2,000,000.00 GERM AGGREGATE UMIT APPLIES PER: n POLICY • JEa • LOC PRODUCTS - COMP/OP AGE $ 2,000,000.00 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ • ANY AUTO BODILY INJURY (Per person) $ • AAUTOLL OWS • AUNED SCHETOS DULED BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE (Per accident) $ • • $ • UMBRELLA LIAB • OCCUR • EXCESS LIAB II CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ • DED . RETENI)ON $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N IA • ORY LIMITS • ER EL. EACH ACCIDENT $ El. DISEASE - EA EMPLOYE $ EL. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE and Ave. Miami Shores, FL 33138 Fax: (305) 756 8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE... `_•! .. ACORD 25 (2010 /05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MNUDD/YYYY) 09/11/2012 09:44 AM 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 cerflcate holder is an ADDITIONAL INSURED, the pollcy(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 Hghts to the certificate holder in lieu of such endorsement(s). PRODUCER Highpoint Risk Services LLC 5501 LBJ Freeway, Suite 1200 Dallas, TX 75240 CONTACTNAMAE: PHONE WO. NO. E:rk (800)728.0623 IPAm(AC,10k(972)404 -0380 &NAIL=REIM INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: Companion Property and Casualty insurance Company 12157 INSURED: Aspen Staff Leasing, Inc. 1 /c /f: KUYOC ROOFING CORP 3020 NE 28TH AVE LIGHTHOUSE POINT, FL 33064 Phone: (954) 675 -1709 Fax: 0 - INSURER B: INSURER C: INSURER D: $ INSURER E: INSURER F: MED EXP (Any one person) COVERAGES CERTIFICATE NUMBER: AC12- 12 4 0 1 4 8 0- 1132 518 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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 HiAVF RFFN RFDUCFD BY PAID CI AIMS INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF DATE (MM/DD/YYI POLICY EXP DATE (MM/DDIYY) LIMITS AUTHORIZED REPRESENTATIVE GENERAL — LIABIUTY COMMERCIAL GENERAL LIABIUTY ICLAIMS MADE 0 OCCUR 0 0 EACH OCCURRENCE $ PREMISE(Ea occuD MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEM. AGGREGATE LIMIT APPUES PER I oucv El EC I UE I LOc PRODUCTS - COMP /OP AGG $ AUTOMOBILE — _ — — — LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS ❑ ❑ COMBINED SINGLE UMR (Ea accident) $ BODILY INJURY (Per person) $ BODILY INURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ — UMBRELLA LIAR EXCESS LIAB CLAIMS -MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ e DEDUCTIBLE RETENTION $ $ $ A WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPERIETOR/EXECUTIVE OFRCER.MEMBEREXCLUDED? (Mandatory In NH) It yes, describe under SPECIAL PROVISION below AND N/A DPE26272740260 04/01/2012 04/01/2013 g 7U X I TWC ORY LAMBS I I OER 7H E.L. EACH ACCIDENT $ 1000000 © L. E. DISEASE -EA EMPLOYEE $ 1000000 E.L. DISEASE - POUCYUMIT $ 1000000 00 DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES(Attaohed ACORD101, Additional Remarks Schedule, It more space is required 1 Thi ce ;tificate r ins in effect, roV'd d the client's acc unt $ n good standing with As Staff Leasin , In eeove ;a e is not ppro Tcteed £o y impbloyee !or wniic the client is not reporting aces to en aa ££ LI,eaass g, I c.., p ],eg Oue o e emmnp Dye o Aspen Sta g Leasin Inc. l�eased to 1labi OFTNG COoRP, effective e /UL /281 2 Insurpa-is a Nor Rd workers Co.pet�ga ;eon,& Ind Dyers iability as a co- employer under thole po icy tor emp ogees eased from Aspen Std easing, CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE * ** SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 10050 NE 2ND AVE THE POLICY PROVISIONS. PH. 305- 795 -2204 FAX. 305- 756 -8972 MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE _,,,,„®,.y4r —'— = ACORD 25 (2010/05) O 1988 -2010 ACORD CORPORATION. All right resery