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RC-15-2000 Permit No. RC-8-15-2000 SDORE,S yam` Miami Shores Village Permit Type:Residential Construction Perill 'it 10050 N.E.2nd AvenueWork Classification:Alteration '• 1 ""''" Miami Shores,FL 33138-0000 Permit Status:APPROVED Phone: (305)795-2204 EYORIDp` issue Date:9/29/201`5 Expiration: 03/27/2016 Project Address Parcel Number Applicant 665 GRAND CONCOURSE 1132060172160 Miami Shores, FL 33138- Block: Lot: PETRONELLA LAWSON Owner Information Address Phone Cell PETRONELLA LAWSON 665 GRAND Concourse (305)458-8621 MIAMI SHORES FL 33138- 665 GRAND Concourse MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 25,000.00 ROTH DIVERSIFIED CONSTRUCTION (305)218-4579 Total Sq Feet: 1000 Approved: In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Fill Cells Columns Date Denied: Final PE Certification Type of Construction:REMODEL KITCHEN AND MASTER Occupancy:Single Family Window Door Attachment Stories: 1 Exterior: Framing Front Setback: Rear Setback: Insulation Left Setback: Right Setback: Drywall Screw Bedrooms:4 Bathrooms:3 Window and Door Buck Plans Submitted:Yes Certificate Status: Review Planning Certificate Date: Additional Info: Review Structural Review Electrical Bond Return: Classification:Residential Review Electrical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Plumbing CCF $15.00 Review Building DSPR Fee $11.25 Invoice# RC-8-15-56654 Review Building DCA Fee $11 25 08/10/2015 Credit Card $200.00 $624.50 Review Mechanical Education Surcharge $5.00 09/29/2015 Check#: 1738 $624.50 $0.00 Review Mechanical Permit Fee $750.00 Scanning Fee $12.00 Technology Fee $20.00 Total: $824.50 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 and zoning. Futhermore, I authorize the above-named contractor to do the work stated. �� a�= September 29, 2015 Authorized Signatur . wner / Applicant / Contractor / Agent Date Building Department Copy September 29,2015 1 Miami Shores Village DECEIVED Building Department AUG 102015 0, I g p 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FB�C 20/,L/sem. BUILDING Master Permit No.�1_ _2 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 665 Grand Concourse City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: Is the Building Historically Designated:Yes NO NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): Marcus& Pea Lawson Phone#: Address: 665 Grand Concourse City: Miami Shores State: Florida Zip; 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Roth Diversified Construction Phone#: (305)218-4579 Address: 2714 Oakbrook Drive City: Weston State: Florida Zip: 33332 Qualifier Name: Philip Y. Roth Phone#: State Certification or Registration#: CGC#1516927 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$, 25,000 Square/Linear Footage of Work: 1,000 sq. ft. Type of Work: ❑ Addition ' ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Remodel Kitchen & Master bathroom Specify color of colort�h�ru tile: /" Submittal Fee$ 47* CPermit Fee$ 03 CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$//'�� Structural Reviews$ Bond$ - TOTAL FEE NOW DUE$ 'T (Revised02/24/2014) � � - - - _ i � �ss � r� � �. �. su� I I f __ _ _ J Bonding Company's Name(if applicable) N/A Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) N/A 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$1500, 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 ' opp oved and reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The f regoing instr ment was ack1nowledged before me this The foregoing instrum it was acknowledged before me this day of �1 20. .by ZQ day o _,20 by C .Q11q LOol85'^who is personally known to ` who is ersonally known o me or who has produced L o 2— as m0lrr o has produced _ J as identification and wh did tace an identification and who did take n nath- EVELYNARTOLAMARYANNE NIXON NOTARY PUBLIC: ;�` Notary Public,State of Florida NOTA PUBLIC: ;':� �:: Commission#EE 167448 Y COMMISSION#FF074703 My comm.expires Feb,7,@A1® �'•' M1 �' E IRES December 9,2017 Sign: "' Si -0153 ioridallota ice.com Print: Print: 6 Seal: Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ,SNORES Li Miami Shores Village Building Department ��ORiDP' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A$30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ✓ COPY OF QUALIFIER'S STATE LIC CARD B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT C. ✓ COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. ✓ COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE(EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: Zaw bwr=z=PspD BUSINESS ADDRESS: 2:4%,A oM56ao,4- rg— CITY_ STATE Ft, ZIP CODE 3333 2 BUSINESS PHONE: S&& 2a�S- 4S4I FAX NUMBER( CELL PHONE(--) QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: CAC- E-MAIL C-E-MAIL ADDRESS(IF APPLICABLE): •\.nc�Yal�'wcr�•�:cd. coon Created on 3119109 BY MLDV I RV 3126109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 4-0, 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ROTH, PHILIP YALE ROTH DIVERSIFIED CONSTRUCTION INC 2714 OAKBROOK DRIVE WESTON FL 33332 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 1 '` STATE OF FLORIDA t t from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF,BUSINESS AND and they keep Florida's economy strong. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to CGC1516927 a*` ; ISSUED:' 06/29/2014 ' serve you better. For information about our services,please log onto �� www.myfloridalicense.com. There you can find more information CERTIFIED GENERAL CONTRACTOR I about our divisions and the regulations that impact you, subscribe ROTH, PHILIP;YALE to department newsletters and learn more about the Department's ROTH DIVERSIFIED CONSTRUCTION INC { initiatives. _ t 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, IS CERTIFIED under the provisions of Ch.489.FS, and congratulations on your new license! ' Expiration date AUG 37,2016 L1408290001554 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1516927 "a !"tet The GENERAL CONTRACTOR ' Named below IS CERTIFIED Under the provisions of Chapter 489 FS. "�- -Expiration date: AUG 31, 2016 ROTH, PHILIP YALE 1� J `ROTH DIVERSIFIED"CONSTRUCTION INC-- —. - - ' 2714 OAKBROOK DRIVE r, WESTON - FL 33332 J" ISSUED: 06/29/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406290001564 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 DBA: Receipt DIVERSIFIED CONSTRUCTION INC Receipt#:GENE AL4CONTRACTOR Business Name: Business Type: Owner Name:PHILIP Y. ROTH Business Opened:06/15/2010 Business Location:2714 OAKBROOK DR State/County/Cert/Reg:CGC1516927 WESTON Exemption Code: Business Phone:305-218-4579 Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.0ol 0.000.00 0.00 0.00 27.00 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 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: ROTH DIVERSIFIED CONSTRUCTION INC Receipt fl1CP-14-00018616 2714 OAKBROOK DR Paid 07/28/2015 27.00 WESTON, FL 33332 2015 - 2016 Client#:1640951 132ROTHDIV ACORD_ CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 8/10/2015 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 CONTAC NAME: BB&T-Oswald Trippe and Company PHONE 954 389-1289FAX AIC No Ext: AIC Noy666-602-8684 2400 N Commerce Pkwy,Ste 204 E-MAIL ADDRESS: Weston,FL 33326 INSURER(S)AFFORDING COVERAGE NAIC N 954 389-1289 INSURERA:Builders Insurance(A Mutual Ca 10704 INSURED INSURER B: Roth Diversified Construction INSURER C: 2714 Oakbrook Drive INSURER D: Fort Lauderdale,FL 33332 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY GLP18017301 1/23/2015 01/23/2011E EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES To RENTED D�rence $100 000 [;VCLAIMS-MADE F—XI OCCUR MED EXP(An one person) $5,000 D Ded:500 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY JE" LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per acddent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCV019941600 7/16/2015 07/16/201 X WC SAlmlOTH- FR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI$100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) General Contractor CERTIFICATE HOLDER CANCELLATION ANY OFBEFORE Miami Shores Village Building THE SHOULD EXPIRA IONH DATE VTHEREOF,E NOTICEI ES WILL CBE CDELIVERED N Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE _W.i"d.L/ '4r1'cL.4"- ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S14630992/M14505940 LIGO fzc t-s-- 26CD I � 1 s - 23 q Z. WN0 CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) r06/02/2016 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 CONTACT Ralph Russo NA E Russo Insurance Group PHONE 954 345-1904 F4X 954 345-1954 1700 North University Drive E-MAIL ralph@russoig.com Suite 215 INSURERS AFFORDING COVERAGE NAIC k Coral Springs FL 33071 IN URERA: COVINGTON SPECIALTY INS CO. INSURED INSURER B: CAVALIERE ELECTRIC&SONS,INC INSURER C: 12358 WILES ROAD, INSURER D: UNIT 5 INSURER E: CORAL SPRINGS FL 33076 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 CONTRACTOR 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICYJJIL MBR LIMITS GENERAL LIABILITY EACH OCCURRENCE $2,000,000 A X COMMERCIAL GENERAL LIABILITY DAMAGE q(RENTED $100,000 CLAIMS-MADE OCCUR X VBA452305 05/11/2016 05/11/2017 MED EXPRFmI'P An one erson $5,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY F7 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS 'rI UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE D I I RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIV E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DE RIPTI N OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ELECTRICAL SERVICE AND REPAIR CBC 1255611 CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY. 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 Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E.2nd Avenue Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE <DA> ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD