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DS-16-1483Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 1201 NE 102 Street Miami Shores, FL 33138- Owner Information Pe Permit NO. DS -5-16-1483 ■ Peimit Type: Driveways/Sidewalks/Slabs rn t I Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 6/1412016 Expiration: 12/11/2016 Parcel Number Applicant Address 1132050250160 Block: Lot: MacDAM & DENISE GLINN Phone CeII MacDAM & DENISE GLINN 1201 NE 102 Street MIAMI SHORES FL 33138-2600 Contractor(s) HOME OWNER Phone Cell Phone Valuation: Total Sq Feet: $ 1,500.00 150 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Work: REPLACEMENT OF FRONT WALKWAY Bond Return : Scanning: 3 Additional Info: Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.00 $2.00 $0.40 $5.00 $100.00 $9.00 $1.60 $121.20 Pay Date Pay Type Invoice # DS -5-16-59968 05/27/2016 Credit Card 06/14/2016 Credit Card Amt Paid Amt Due $ 50.00 $ 71.20 $ 71.20 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Planning Review Building 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 ce fy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constru . and zoning. Fut or;, I authorize the above-named contractor to do the work stated. June 14, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date June 14, 2016 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number:INSP-259898 Permit Number: DS -5-16-1483 Scheduled Inspection Date: September 29, 2016 Permit Type: Driveways/Sidewalks/Slabs Inspection Type: Final Owner: GLINN, MacDAM & DENISE Work Classification: Addition/Alteration Job Address: 1201 NE 102 Street Miami Shores, FL 33138 - Inspector: Mesa, Michel Project: <NONE> Contractor: SUPERIOR LANDSCAPING & LAWN SERVICE INC Phone Number Parcel Number 1132050250160 Phone: (800)759-4156 Building Department Comments REPLACEMENT OF FRONT WALKWAY Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. September 28, 2016 For Inspections please call: (305)762-4949 Page 5 of 26 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 5 FBC 20 to BUILDING Master Permit NoD5 & \L-183 UL O 12016 PERMIT APPLICATION Sub Permit No. ❑BUILDING 0 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL El PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS FKHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: (-2.0 1 i L 102 STYZ- t City: Miami Shores County: Miami Dade Zip: 3 313 8 Folio/Parcel#: Is the Building Historically Designated: Yes /� NO Occupancy Type: Load: Construction Type: Flood Zone: BF E: 0�u ON (\i-' OWNER: Name (Fee Simple Titleholder): tic, C - Phone#:30'' (-1t1 Address: \ &) C 1 U SN - City: V_`: S State: Zip: 3 1 3g Tenant/Lessee Name: iv/ /a Email: CONTRACTOR: Company Name: 5l/l1A 4012- (MM se/mot Ns G Address: ZOO Ni../ Z3r:NUE- Phone#: 34s- t 3 Y Phone#: boo- 75er City: NI 1 AU, l State: V'L Zip: 33 142. Qualifier Name: 61iz(Ai..J DtOj 1.IJS Phone#: T J,�'T- COs' 33.17 State Certification or Registration #: C-6 _ KO—logo Certificate of Competency #: DESIGNER: Architect/Engineer: (" ( A Phone#: Address: City: State: Zip: Value of Work for this Permit: $ ( C0 0 . 06 Square/Linear Footage of Work: 02 (' o 4.-4 - Type of Work: ❑--Addition ❑ Alteration New ❑ Repair/Replace n Demolition Description of Work: Specify color of color thru tile: Submittal Fee $ Permit Fee $ —1C a CCF $ CO/CC $ Scanning Fee $ 3 , G7 Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ � ' 00 (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 cks —e s State f L Zip (u 4 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 app . ved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing i strument was acknowledged before me this day of --luLY ,20 fo ,by KOAi>A(v) SIU GJ IN A, who is personally known to me or who has produced T--k---DLIV as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: -,-;lc.1S)M Seal: n. y FF 156750 Frrires 09/03.2018 Signature CONTRACTOR The foregoing instrument was acknowledged before me this as day of Jut -, ,20 G ,by B? -14:\t' ('AArrittJ �lCtc +who is personally known to me or who has produced _ DIZW- Lk -UN SKI, as identification and who did take an oath. NOTARY PUBLI _ Sign: Print: ( 0)1-0 Sea It Pi, NOtaryis State of Florida )' �i .rb Smola , .Ivarez a r -q My Commission FF 156750 '�o_r1,° Expires 09/03/2018 o *******************************************************�f *+ * *' *�************************************ APPROVED BY (Revised02/24/2014) Plans Examiner Zoning Structural Review Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 DICKENS, BRIAN MATTHEW SUPERIOR LANDSCAPING & LAWN SERVICE INC 10 ARAGON AVENUE, UNIT 901 CORAL GABLES FL 33134 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 learn 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. Thank you for doing business in Florida, and congratulations on your new license! RICK SCOTT GOVERNOR CGC1507080 DETACH HERE STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL;REGULATION CGC1507080 �'{' ISSUED.,; 09/08/2015 CERTIFIED GENERAL;CONTRACTOR DICKENS, BRIAN•MAT,,TIHEW ° SUPERIOR LANDSCAPING& LAWN.SERVIC • k1 IS CERTIFIED under the provisions of Ch.489 FS. Expiration date. AUG 31, 2016 L1509030002260 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG'31, 2016 Ilk DICKENS; BRIAN MATTHEW ;' r .,SUPERIOR LANDSCAPING &LAWN'SERVICE INC c, 2200.NW23RDAVENUE" MIAMI v "'Flir33142.p. ISSUED: 09/08/2015 • DISPLAY AS REQUIRED BY LAW , S Q # L1509080002260 • s • calus n• ess Tax' Receip � Miami -Dade ?County, 4 State of Florida':. 1p T1.415 1SrNOT A 611.6'`= 6.0 i ib EPAY4, k BUSINESS '''.2''''1VAME/LOVAT1t31Y RECEIPT NO. r SUPERIOR LANDSCAPING & L W SERO W-, RENEWAL, EXPIRES P ''V DICKEN5 QUALIFIER s i48b3Z3- �_PTMBER 3113,.2096; Must be dispfayitiuini to at place of business 220x):°NW 23 A s� s i Pursuant to County Code •' MIA..,,,,,,,,..144..,,,:::!i4:.:I a ,a, ,,, .v % Chapter tA Art.'9 & 10 y f ti4t-(-- ' r— { f Ovv.eit i l SEC. TYPE OF Ez" iS ESS' s a= ySUAERIOR LANDSCAPING -&LAWN SERV GENERAL BUIL ING CONTRACTOR PAVavlt:lvT gECEiVEO ORLANDO OTERO PRES_ r1 Y TAX COLLECTOR CGC15�7<<©86 } Worker(s) /10 P� t I 7.- 4-... $4 00 06/08/2016 s ' Py i ri 'A--~. EGHECK; 16-164,441 '-. r, s t I( i L This Local Business Tax Receipt anly confirms payment at the (oval Business Tax.The Beseipt is not tit cetsse parinit, ora cen ficouan`of the holder's qualificatsoes to do busineas. Heider rent beitipiy with any gov#rnmentai 1 y,�c or Aongovetnmental tegsilatory laws and reguiirenients which apply to the b,toarneas... The RECEIPT NO. above meet be d splayed an all commatcMol va`icl?s glawsi-ila'Cede Sec 8a<i76. i .s,t . ler GtaYe irtformalian, visYt �,u i : � 4 d • �t: > ta �',.-: z , :.../c,.. • ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)6/29/2016 1 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 Gulfshore Insurance -Naples 4100 Goodlette Road North Naples, FL 34103 -3303 239 261-3646 CONTACT Michelle A. Kalicharan NAME: PHONE , Ext), 239 435-7143 FAX No), 239 213-2852 E-MAIL DRESS: mkalicharan@gulfshoreinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # Amerisure Insurance Company INSURER A : p Y LIABILITY COMMERCIAL GENERAL LIABILITY INSURED Superior Landscaping & Lawn Service,Inc 2200 NW 23rd Ave Miami, FL 33142 INSURER B : Amerisure Mutual Insurance Co GL20901220201 INSURER C Amerisure Partners Insurance Co 12/01/2016 INSURER D INSURER E : $1,000,000 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GL20901220201 12/01/2015 12/01/2016 EACHOCCURRENCE$1,000,000 PREMISES (Ea occurrence) $1,000,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 $2,000,000 GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $2,000,00.0 _ GEN'L AGGREGATE 7 POLICY X LIMIT APPLIES PROT JEC PER: LOC $ C AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS XNON-OWNED _ SCHEDULED AUTOS AUTOS CA20901200205 12/01/2015 12/01/2016 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A x UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CU20901230201 12/01/2015 12/01/2016 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 $ DED X RETENTION $0 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N Y N / A WC20903440202 12/01/2015 12/01/2016 X 7/ORYTIIMITS FROTH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Miami -Dade County Local Business Tax Receipt 7202537 General Building Contractor CGC1507080 Brian Dickens Qualifier CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Avenue Miami, FL 33138 ACORD 25 (2010/05) 1 of 1 #S1025671/M954743 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 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BNC (g` �e �� Miami Shores Village g �� Building Department BUILDING PER APPLICATION ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 JUN 082016 BY• S -1"l FBC 20tLt Master Permit No. VS ((C) " (V l5 Sub Permit No. El PLUMBING ❑MECHANICAL PUBLIC WORKS JOB ADDRESS: i ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: 3. (3 k Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): A.C 4 Gi 6. \.kk- Phone#: 2 0 L < d .(sl, Address:\ ' O \ k) Y t 0.-&o S�- City: i.. w •--` 1 c v 0' t2 S State: Zip: Tenant/Lessee Name: cf .— Phone#: Email: CONTRACTOR: Company Name: Phone:` -- Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ k5 -0Q Type of Work: ❑ Addition ❑ Alteration (AraDescription of Work: 1 � �e Square/Linear Footagf Work: IS v ❑ New O pair/Replace ❑ Demolition Specify color of color thru Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) tile: • Permit Fee $ 03 • CO CCF$ Radon Fee $ DBPR $.' Training/Education Fee $ CO/CC $ Notary $ 6—` CO Double Fee $ Bond$ 16"(253 TOTAL FEE NOW DUE $ i t - 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 app'ived and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this y�,O ADAM dayn,off �k' , 20 (`F-' I ' AC- 14N3, who is per• nally kr by The foregoing instrument was acknowledged before me this day of , 20 , by who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Print: Seal: • __411a. •._ : MiSSrp„... .,/ Sign: '63016,?0 ".• Print: 44' gym: c•*Zr. Seal: 5 #FF 954760 •: Q • 0/4--.4..Z 04 e�y 1611111110 Apt*0************■********************s********************* *** Vii Plans Examiner ` 0,-- oning *************************** APPROVED BY (Revised02/24/2014) Structural Review Clerk t -.3: ;-4 A Bonding Company s Name (if applicable) r 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 app ved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this y�,O day off ,20 I`F-' I ' IAG ADA" ,1 a.1 N-3, who is per me or who has produced identification and who did take an oath. by as The foregoing instrument was acknowledged before me this day of , 20 , by , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: *.e Sign:`(2--2_,t)•_`µ155/p . Print: �G4.at�h6,2o�1A ; = Print: 4 �'m: Seal: -* ...•• N *_ Seal: O #FF 954760•: Q s***********************s****� 49Acs l .******************************************************** *** 'k , /111uiliillt\ APPROVED BY (Revised02/24/2014) , Plans Examiner git oning Structural Review Clerk NAME: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT (/ `L �- ..� _ DATE: V 1 6 /' ADDRESS: t 1o\ fU `( tIV(o,.. C1•o•e I-� '5 3 (31i Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one -family or two-family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and with -holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. Initia 2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits tracts. Initial 4. I understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built or substantially improved it for sale or leas h the exemption. Initial 5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction. Initial !/ 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law and by count unicipal ordinance. Initial ".1 7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner -builder, may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an owner -builder and am aware of the limits of my insurance coverage for injuries to workers on my property. Initis 11' 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow these may subject to serious financial risk. Initial/� 9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and requirement that govern owner -builders as well as employers. I also understand that the Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. Initial 1V/1( 10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http://www.myfloridalicense.com/dbpr/pro/cilb/index.html Initial / 11. I am aware of, and consent to; an owner -builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: kat) 1 via 16- S-1. et.,*, Initib( �� 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any ofth�rm tion that have provided on this disclosure. Initial Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this F day of 5—Le By'('(1 ("D PIerl Ce L.t Produced there License or , 20 1YD who was ersonally known to m or who has ,0, 0 g`5I LVF %i�ii as id iii'' %�'' i \ ' 6 : 20:9A... • Z: ▪ A• g 95A :2 $ NOTARY '%a�9,9 ";:.; a��� OWNER • • ••• •• •• • • • • • • • • •• •• • • • • • •• • • • • • • •1 • • • 370 Waymont Court • Lake Mary, FL 32746 • Voice 407.688.7631 • Fax 407.688.7691 •• amip•ur' ying@gmaijcom • • Lot 8, Block 186, BAY BREEZE SECTION - MIAMI SHORES, according to the plat thereof as recorded in Plat Book 42, Page(s) 25 of the Public Records of Miami -Dade County, FL. • • Community number: 120652 Panel: 0306 Suffix: L F.I.R.M. Date: 9/11/2009 Flood Zone: X Date of field work: 9/28/2012 Completion Date: 10/1/2012 Certified to: Macadam Glinn; Denise Glinn; Law Offices of Evan M. Rosen, P.A.; Old Republic National Title Insurance Company; JP Morgan Chase, its' successors and/or assigns. FIR 1/2" FIR 1/2" • • • • • • • • • ••• of r' i 1 r Il_ • • • -L. l 1,":-N! 2a]Ra'ST .. .-1r' / • •r•: o• • "' IL. / �.I ••• i k� wr'� t►�itrnit• •f �,: Jd .:.,,_ ::= N la � l / ( I " f 1 I ��►4 L__1:... _- I )jI o _._� l \. „r......_____,,L.....1 .�1. �--'`1 , ...r`_:...:ME Ia1ND ST_ r -^-^'s ,--.— _ 7 t= T T "----:; n A _ 1//�—' A nL 1, ,r 7 ' t........— ......1-1.— ) IL \- J _ LOCA TION SKETCH , Not to Scale EAST 0.0' 1- LOT 7 BLOCK 186 D. SCALE: 1 "=30' 130.00' (P& M) FIR 1/2" 0.0; 0.5' h 27.6' ONE STORY RESIDENCE CALC POINT 1 0 LOT 8 BLOCK 186 FIR 1/2" WEST (ASSUMED) B.R. 130' (P&M) WEST 36.28' CONC WEST 93.72' (C) I3o.00' Cp) NE 102ND STREET 75' R/W (IMPROVED) 20.5' ASPHALT PAVEMENT LOT 6 /BLOCK 18E FIP 1" 4WEST ; ,•105°62' (P&M) FD DRILL HOLE EDGE OF ASPHALT Property Address: 1201 Northeast 102nd Street Miami Shores, FL 33138 Survey number: SL 126756 LEGEND -0— Wood Fence —0— Wire Fence C.L.F. Chain Link Fence F.N. Found Nail CONC Concrete M Field Measured I= Asphalt ENCR Encroachment g_ Centerline Concrete FL Property Line C.M. Concrete Monument F.I.R. Found Iron Rod F.I.P. Found Iron Pipe R/W Right of Way N&D Nail & Disk D.E. Drainage Easement U.E. Utility Easement FD. Found P Plat D.U.E. Drainage & Utility Easement P.P. Power Pole TX Transformer CATV Cable Riser CB Chord Bearing W.F. Wood Fence F. Field W.M. Water Meter TEL. Telephone Facilities ® Covered Area B.R. Bearing Reference CH Chord RAD Radial NC Air Conditioning B.M. Bench Mark C. Calculated L Central Angle/Delta D.B. Deed Book D. Description or Deed D.H. Drill Hole D/W Driveway ESMT Easement EL Elevation F.F. Finished Floor F.C.M. Found Concrete Monument F.P.K. Found Parker-Kalon Nail L Length L.B. Licensed Business —1,— Line Break Not to Scale M.H. Manhole OHL Overhead Lines N.T.S. Not to Scale O.R. O.R.B. P.C.P. P.R.M. PG. PVMT. E.O.P. P.B. P.O.B. P.O.C. P.O.L. P.C. P.R.C. P.T. R. R.O.E. S.I.R. s/w T.O.B. TYP. W.C. 10.05 E.O.W. P.C.C. PI T.B.M. Official Records Official Records Book Permanent Control Point Permanent Reference Monument Page Pavement Edge of Pavement Plat Book Point of Beginning Point of Commencement Point on Line Point of Curvature Point of Reverse Curvature Point of Tangency Radius (Radial) Roof Overhang Easement Set Iron Rod & Cap Sidewalk Top of Bank Typical Witness Corner Existing Elevation Edge of Water Point of Compound Curve Point of Intersection Temporary Bench Mark GENERAL NOTES 1. Legal description provided by others. 2. The lands shown hereon were not abstracted for easements or other recorded encumbrances not shown on the plat. 3. Underground portions of footings, foundations or other improvements were not located. 4. Wall ties are to the face of the wall. 5. Only visible encroachments located. 6. No identification found on property corners unless noted. 7. Dimensions shown are plat and measured unless otherwise noted. 8. This s a BOUNDARY SURVEY unless otherwi, te�6 d. seal 9. Not valid unless sealed with t signing 15. Re surveyors embossed seal. 10. Where plat or deed beari measured, this shall ser bearings, unless noted 11. All lines are not radial unl 12 13 FLOOD ZONE DETERMINATIONS ARE PROVIDED AS A COURTESY ONLY, AND ARE DERIVED FROM THE BEST SOURCES AVAILABLE TO THE SURVEYOR. THIS INFORMATION SHOULD NOT BE RELIED UPON FOR FLOOD INSURANCE PURPOSES, AND MAY DIFFER FROM INFORMATION PROVIDED BY OTHERS. Septic tank and/or drainfield locations are approximate and MUST be verified by appropriate utility location companies. • is for reference only unless signed and by a Florida "registered Land Surveyor. rtificatiorl does not indicate an update. is it '.4.ance with the ds promulgated rofessional Land da Administrative rida Statutes. 16. T is identical to;.iin as the basis of therwise. ss otherwise noted. I hereby certify that this survey is a true and correct Ralph Swerdloff urn he Flor rveyor ode, S S pard oft entation.fA .urveyp under my direction. egistered Land Surveyor No. 3411 L.B. 7132 .•. • ... . • • •. •• • • • 00 •• • , • • • • • • •• • • • • • ••• • • • • • • • • ••• • • • • ••• • • ••• • •.• • w •• • •• • • •• • • •• •• • • • •• • • • • ••• •w• • ••• , •• ••M •• 0 • • •• • • • • 0 • • • • •• ••• • • • • • •• tUb1ce 6 i2/ / &ROAD .)< FIRE SCHOOL IMPACT FEE NQT REQUIRE Exp ��� e-eno,%1 Z� JUN 0 6 2016 MIAMI -D APPROVED E COUNTY t4.,vY REVIEW FINAL APPROVAL. DEPARTMENT OF ENVIRONMENTAL RESOURCES MANAGEMENT ARE REVIEWER (PRINT); IC;NATURE Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. Owner's Name (Fee Simple Title Holder): (\11 a C. , kt. 'YP 6/11r)11 Phone #: V C.? cl a a g Owner's Address: laM i(JC jU k- S+ City: r‘ S�- �� e S State : r � Zip Code: 3 ?f 3 Job Address (Of where work is being done): 20 i\t7C, 0 2 5-1-VEET City: Miami Shores State: Florida Zip Code: 3\33 • Contractor's Company Name: Re Doe tbN612(j c p on PE Address: 1(3 ve I(JYde Alicri(/ ' • City: C9-1 tbLeS State: FL - Qualifier's Name : J1 S I Ca r�`0IJZ/11 Lic. Number: C2 12S3 "12-3 hone #: 1196)-2-L03 -3326 Zip Code: 3313 4. Architect/ Engineer of Record Name: Address: City: State: Zip Code: Phone #: Describe Work: 5 (be uva o K '2,07/ki R / ( N5719W i1 cb►J hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal involvement. Signature 0 ner or Agent The foregoing instrument was aknowledged before me this f day of ,>U1L_ ,2d(e,by VN(k ( Signature Who is personally known to me or who has produced llldgyjj}ficationgiVION. 1^filit •..Mi ....... 4(_ 6 Q i rnS _• r = Q2�1'��;•4; Notary Public: Sign: Seal: Contractor or Architect The foregoing instrument was aknowledged before me this IS day of d— , 2d'by 5L3Slc-04 4-(f�NDFZ who is personally known to me or who has produced �✓' �/ P a-Avic L Notary Public: Sign: Seal: • l; .14441cation. Q ' • N• .. = •o; %•46tety Nat 11111 r gEF 954160 -I -315 --2sh iami Shores \Iillae 9 Building Department CONTRACTORS' REGISTRATION 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT C. ✓ COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, EL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: NAM c,v4 T LvaiO d-lOwUziomeArr ((1ICi BUSINESS ADDRESS: 2-43 1,411e12 A1/I, CITYCO(I*t Gitka STATE BUSINESS PHONE: (154 ) 6os • % 11 FAX NUMBER ( ) CELL PHONE (TX ) 2(03 3323 QUALIFIER'S NAME: 31&V4 QUALIFIER'S LIC NUMBER: CV' 1�5 ,3q z3 ZIP 33131 f • STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 GONZALEZ, JESSICA L ABODE CONSTRUCTION & DEVELOPMENT INC 243 VELARDE AVE CORAL GABLES FL 33134 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 learn 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. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE RICK SCOTT, GOVERNOR (850) 487-1395 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CBC1253923 • ISSUED:, .08/17/2014 CERTIFIED BUILDING:CONTRACTOR GONZALEZ, JESSICA L ABODE CONSTRUCTION &DEVELOPMENT I IS CERTIFIED. under theprovisiohs of Ch.489 FS. Expiration date AUG 31, 2016 11408170002227 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CBC1253923 The BUILDING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 GONZALEZ,-JESSICA L. ABODE CONSTRUCTIONr& DEVELOPMENT INC 243 VELARDE AVE.. - .:* CORAL.GABLES FLL33134— f ISSUED: 08/17/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1408170002227 001878 Local Business Tax Receipt Miami -Dade County., State of Florida -THIS IS NOTA BILL - DO`NOT PAY 7170318 BUSINESS NAME/LOCATION ABODE CONSTRUCTION & DEVELOPMENT INC 7151 SW 72 ST MIAMI FL 33143 RECEIPT NO. RENEWAL 7449111 EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS OWNER PAYMENT RECEIVED ABODE CONSTR & DEVELOPMENT INC 196 SUB -GENERAL BLDG CONTRACTOR 8Y TAX COLLECTOR C/0 JESSICA GONZALEZ—HERNANDEZ, PR F.1253923 $$7.50 10/14/2015 Worker(s) 1 CREDITCARD-16-001845 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visit www.miamidade.govitaxsallector ABODE -1 OP ID: KS ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/14/2016 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(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 Ling Risk Management, LLC 2100 Ponce de Leon Blvd, # 601 Coral Gables, FL 33134 Fred Sanchez CONTACT Alex Garcia PHONE FAX (AIC. No. Ext): 3O5-648-2445 (A/C, No): 305-648-2469 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Western World Insurance COMMERCIAL GENERAL LIABILITY INSURED Abode Construction & Dev., Inc Jessica Hernandez 243 Velarde Ave Miami, FL 33134 INSURER B : NPP8195808 INSURER C 01/12/2017 INSURER D : $ 1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY NPP8195808 01/12/2016 01/12/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GE X 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PET PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 Ded $ 1,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS ^ SCHEDULED AUTOSaccident) NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILYINJURY(Per$ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITYY / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) License Number CBC1253923 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 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. AUTHORIZED REPRESENTATIVE Fred Sanchez ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD M' t, 1'4 4 1 /1 > a [ 100% 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 EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 5/16/2016 EXPIRATION DATE: 5/16/2018 PERSON: GONZALEZ-HERNANDEZ FEIN: 020749055 BUSINESS NAME AND ADDRESS: ABODE CONSTRUCTION & DEVELOPMENT, INC JESSICA 243 VELARDE AVENUE CORAL GABLES FL 33134 SCOPES OF BUSINESS OR TRADE: LICENSED BUILDING CONTRACTOR L Pursuant to Chapter 440.05(14), 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 440.05(13), 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Date: June 14, 2016 State of Florida County of Miami -Dade Before me this day personally appeared "ATiSSILA who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at : k2 -o NE (02 ST MAW S iS, Ft, 3313$ Sworn to (or affirmed) and subscribed before me this 1`T day of 'NO E- , 2016, by vSStcA 6V #d 62. Personally known OR Produced Identification Type of Identification Produced il \ i a ,,A. M O eD7 F�Iq. 3e EXPIRE . une 1 %.t2OS ?ate 407) 398-0153 FloridallotaryService.com Notice to Owner — Workers' Com p Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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 and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this By r GC. )i -A0,,,(44_ C, Lew\ Notary: SEAL: day of : L&.4' (__ , 20 (b . who is personally known to me or has produced �--as identification. • Mission: To protect, prarote & improve the health of all people in Florida through integrated state, county & oorrrrunity efforts. Fri) ��oriaa HEALTH Vision: To be the Healthiest State in the Nation Rick Scott Governor Celeste Philip, MD, MPH Interim State Surgeon General June 07, 2016 Macadam Glinn 1201 NE 102 Street Miami, FL 33138 RE: Modification to a Single Family Residence - No Bedroom Addition Application Document Number: Centrax Permit Number: 1201 NE 102 Street Miami, FL 33138 Lot: 8 Block: 186 Subdivision: Dear Applicant, API24293O 13 -SC -1687201 This will acknowledge receipt of a floor plan and site plan on 06/06/2016 for the use of the existing onsite sewage treatment and disposal system located on the above referenced property. This no -objection letter is issued for the addition of a new walkway only. This office has reviewed and verified the floor plan and site plan you submitted, for the proposed remodeling addition or modification to your single-family home. Based on the information you provided, the Health Department concludes that the proposed remodeling addition or modification is not adding a bedroom and that it does not appear to cover any part of the existing system or encroach on the required setback or unobstructed area. No existing system inspection or evaluation and assessment, or modification, replacement, or upgrade authorization is required. Because an inspection or evaluation of the existing septic system was not conducted, the Department cannot attest to the existing system's current condition, size, or adequacy to serve the proposed use. You may request a voluntary inspection and assessment of your system from a licensed septic tank contractor or plumber, or a person certified under section 381.0101, Florida Statutes. If you have any questions, please call our office at (305) 623-3500. Richard Rojas Professional Engineer I Department of Health in Dade County Florida Dsp.rt,...t of H..nr in Dade County • • , Florida PHONE: (305) 623-3500 www.nmwr..Nr4ov TWITTER:HealthyFLA FACEBOOK: FLDepartmentofHealth YOUTUBE: fldoh Arlenis Silvera From: Echeverry, Stephania (RER) <eche@miamidade.gov> Sent: Friday, June 17, 2016 11:32 AM To: Arlenis Silvera Cc: Vuelta, Daniel (RER) Subject: Abode Construction & Development Inc Lic #CBC1253923 Attachments: 20160617112854683.pdf Good Morning Arlene: As per our conversation, attached you will find the memo for Abode Construction & Development Inc Lic #CBC1253923. If you have any other question do not hesitate to contact our office. Regards, Stephania Echeverry RER Support Compliance Representative Contractor Enforcement Section Miami -Dade County Department of Regulatory and Economic Resources 11805 SW 26th Street Miami, FL 33175 Office Phone: 786-315-2561 m {} Delivering Excellence Every Day Miami -Dade County is a public entity subject to Chapter 119 of the Florida Statutes concerning public records. E-mail messages are covered under such laws and thus subject to disclosure. Please consider the environment before printing this e-mail 1 I MIAMI t]ADE COUNTY MIA Mi -DADS COUNTY. FLORIDA METRO-l)ADE FLAGLER BUILDING TO: FROM: DATE: SUBJECT: BUILDING CODE COMPLIANCE OFFICE ME RO-DADF FLAGLER BUILDING 140 WEST ISI AG! .FR :STREET SUI'T'E I607 MIAMI, FLORIDA 33130-1561 (3051 375-2901 FAX (305)375-2908 4;4IN'FRACfOR LICENSING SEC1 ION (305)375-2527 FAX(305)375-2554 CONTRACTOR ENFORCEMENT SECTION (305) 375-2966 FAX (305) 375.2904 PRODUCT CONTROL DIVISION (305) 375-2X)2 FAX 4305) 372-6330 MEMO All Building Officials in Miami Dade County Iierminio F. Gonzalez, P. { ., M.S. Director February 19, 2008 Disciplinary Action JESSICA L. GONZALEZ, QUALIFYING AGENT ABODE CONSTRUCTION & DEVELOPMENT STATE LICENSE # CBC 1253923 7330 SW 631;1' AVENUE SOUTH MIAMI, FL 33143 As a result of a formal hearing before the Board of Rules and Appeals on February 7`", 2008, the above Contractor's permit privileges have been ADMINISTRATIVELY SUSPENDED in Miami -Dade County. This memorandum is to request that your Department REFRAIN FROM ISSUING ANY NEW PERMITS UNDi?,R'I'HIS LICENSE. This suspension does not apply to actions taken to close ota existing, permits. If you have any questions concerning this matter, please do not hesitate to contact Jose le'cano of my staff at 305-375-5888, X: \Code C. Impiianc6C01)CONINAMI INIt.'IIIA3lNFOM1 JNI\AIA.N1UN10080207 ah•de Cons:roctiun Dcvelv11 eul dor Internet mail address: postmasler@buildingeudeonlinc.curn 1Ionwpage: help:/lwww.huildingeodcontine.com • •• •• • • . • ••• • • • ••- • • • • • • • • - • • • • • • • • • • • • • • • - • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ••• • ••• • 1- • •/ •/ • • • •• ••• •• • • • • • • • • • • ••• EXIST. EV114 res l 1000 SF. LIN©B AREA y W W W W .Y CTG • WAY LOCATION OF SOL PROFLE 667 9' DRAINFIELD (15'-0' W X 45-0' LFT I' D!A. WA _ SUPPLY LINE WATER LN3 WI AlERPR00F . I' ` ' -OFF V VE IN ALVE BOX NEW CONNECTION r w TER METER A r'( OCATION AT S MES! REINF. MAY SI NIS BY: PLAN b Y L IB' IT SECTION D J GAL 750 900 1050 1200 W 3' - 6' 3'-9' 3' - 8' 4'-0' L 7-2' 8-0' 7-3' 10'-0' H 4' - 10' 4' - (0' 4' - 10' 4' - 10' 1 MN) 3' 3' 3' 3' 0M4N1 4'-0' 4'-0' 4'-0' 4'-0' REPF. 6X 610/10 CONC. 3000 P51. 28 DAY d PRIENT INVERT SHALL BE 1 MIN/ 3' MAX. ABOVE EFFLUENT INVERT ELEVATION SEPTIC TANK DETAIL NTS GROUND SlRFAOE SITE PLAN PLUMBING SCALE 1/8•- I'-0. 0 4 8 6 SCALE I/8•• I'-0• + + + + + + + + + + + MINERAL AGGREG t. (IB' MW DEPhO + + +++++++++++++++++++ + + + + + + + + + + BOTTON SURFACE OF 11-8 DRAIFIED. WET SEASON WATER TABLE� (3ONGVD) USATISFACTCRY SOL BEV. 946 NGVD FIMS50 GRADE ELEV. 896' NGVD TCP OF D/F ELEV. 7A6' NGVD BOTTON OF D/F SOIL/WATER TABLE SITE EVALUATION CRITERIA NTS. PLUMBING CENERAL NOTES I. 71-E CONTRACTOR 5-9411 91241( 4 ALL LABOR. MATERIALS APD EOI11AWJT NECESSARY FOR 11E INSTALLATION OF A COI.PIETE PLUMBING 5T5TBU IN ACCORDANCE WITH T1 -ESE DRAWINGS. 11-E APPLICABLE EDITION OF 11-E FLORIDA BLILDWG CODE 2010. ALL 011 -HR APPLICABLE STATE CO1NTY AND LOCAL COOES AND ORDINANCES. 2 TLE CONTRACTOR SHALL PAY ALL I EPECTION FE'S. All COSTS OF PERMITS AND ALL ODER COSTS NCDFNTA1 TO 71-E COMPLETION AND TESTING OF 114I5 WORK UPON FINAL ACCEPTANCE A CE2FICATE FROM 71-E LOCAL INSPECTION AUTLDRITT SHALL BE FTRNSED TO 71-E 0WNB2. 3. ALL MATERIALS AND EOLIP1ENTS SWLL BE NEW. OF US. MANIFACTIRE2 AND OF 5000 QUALITY OF RESPECTIVE KPD AND GRADE. AM MIXT BE FIRM5L® SO AS TO PREVENT AND DELAY 6171-E PROGRESS OF 11E WORK ALL WORK 11-ROIIGD39 SHALL BE PERFORMS IN A WORKMAN- LIKE MANN5R BY SUFFICIENT MIME? OF SKILLED WORKMIB1 4 11-E CONTRACTOR SHALL VISIT 71-E SITE AND REVEW All FERTNENT UTILITY DRAWINGS TO FAMILIARIZE HMLSELF WITH 11-E LOCATION OF ALL EXISTNG AND/OR PROPOSE) UTLITY 511.8 OUTS, PIPING. EQUIPMENT. ETC. AND MAKE DLE ALLOWANCE FOR ANY CONDITION AFFECTING HIS WORK 5. ALL LNDERGR0(8D SANITARY E STORM DRAINGE PIPING AND FITTINGS 5-5411 BE PVC-0WV (STM 0-2662/D-30341. 6 ALL ABOVE GROUND SANITARY E STORM GRANGE BRANCH E 5EN1 PIPES AND FITTING SHALL BE PVC-DWV (STM D -2662/D-30341. 7. PROVIDE CLEANOUT (WITH CI -ROVE RATED WALL OR FLOOR ACCESS MANE AND COVEY' AS REQUIRED) AT 11-E BASE OF ALL WASTE AND/OR VENT STACKS. PROVIDE PITCH PANS E LEADS FLASHING FOR ALL SANITARY SYSTEM VENTS 8 ALL HORIZONTAL WASTE PIPING SHALL BE SLOPPED AT I/8 PER FOOT. L NLESS 071-E2WIE NOTED. 9. CONTRACTOR SHALL VERIFY SLOPE AND DEPTLS AND LOCATIONS OF CONNECTION POINTS TO EXISTING PRESSIRE OR DRAINAGE LINES BEFORE STARTING WORK ON SITE SEWAGE SYSTEM CALCINATION AS PER 64E-6.008 (2010 EDITION DATA. 3 BEDROOMS W/23850 5F OF CONDITION SPACE 2251 - 3300 SF OF BLDG AREA 400 GPD. ESTIATED SEWAGE ROW SYNC TANV AS PER TABLE NO 11 f.S9'TIC TANG AID RAP TAN: CAPACITY 301-400 GPD. 1050 GAL CAP. SEPTIC TANK IS REQUIRED. ORALE$) AS 9981.8 F IND III B® SYSTEMS 06 MAX. SEWAGE IOANDNG RATE FSTMATED SEWAGE FLOWW (GPD7 14Q . 667 5F OF 0RAPFIED AND RATE AB5012510N W GPD/SF/DAY 06 1000.0 SF RESERVE 1.6013712UCTED AREA ARE REOD. NO OEJECT'ON Florida Health Miami -Da. -. Counhi O.S.T.D.S. & Well Pr ram Application No.; 4?izY 24130-F Date: _.._6/20/G Signature /Z�, 7-Y 1 PI_UMBY•G SYMBOL LEGEND SYMBOL DESCRITION SAITART SEWER LINE CLEAADUT TO GRADE -59CTG (,\ /1 rno= SEWAGE FLOW. LOT 517E (5911 500 435602 ACRE % 2GPO 11690 SFT X 2,500 GPD • 435602 ACRE • 670.91 GPD TI -ERE ARE NO PERTNE3NT FEATURES ON ADJACENT PROPERTIES AND ACROSS TIE 5TRff5 114AT MAY AFFECT TIE ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM INSTALLATION LEGAL DESORPTION LOT 8, BLOCK 186 OF BAY BREEZE MIAMI SHORES PLATE BOOK 42 AT PAGE 25. MIAMI DADE COUNTY R Ernesto Santana, PE. LEER 1-58 CONSULTING ENGINEERS PE.. 60788 -MECHANICAL (6438 BUJ. BSLn, 111501, Florida 33133 FSonn,ll86A64-4040 Fara (3051388-5805 laste De-ai-tba Date Pr*t ame Interior renovation - Glinn Residence 1201 NE 2nd Street Miami Shores, Florida 33138 Pro} t Number DrOmy TDe SITE PLAN DETAILS LEYEND SCHEDULES Sheet numb. SP -1.0 1 OF 1