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WS-19-927Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: WS-04-19-927 J Permit Type: Windows/Shutters AFilassification: Window/Door Replacement Permit Status: Approved Issue Date: 05/02/2019 I Expiration: 10/23/2019 Location Address Parcel Number 270 GRAND CONC, Miami Shores, FL 33138 1132060136210 Contacts ERHAN KOSTEPEN Owner FORBES CONSTRUCTION, LLC Contractor 78 NE 47 ST, MIAMI, FL 33137 JOHN FORBES Other: 7863190562 ERHANKOSTEPEN@GMAIL.COM 4565 PONCE DE LEON BLVD 200, CORAL GABLES, FL 33146 Business: 3054460849 luisv@fcdmiami.com Ion Requests: ns ecti Description: NEW ADDITION AND REMODELING TO REPLACE Valuation: $ 12,500.00 PERMIT#WS-16-2201 4949 Total Sq Feet: 2,600.00 Amount Amt Paid Payments Date Paid Fees 100% Permit Renewal Fee $220.00 Total Fees $270.00 I Application Fee - Other $50.00 Credit Card 05/02/2019 $270.00 Total: $270.00 Amount Due: $0.00 Building Department Copy 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 regul.-4ing construction and zoning. Futhermore, I authorize the above named contractor to do the work stated. J 0?. 2,D Signature: Owner / Applicant ! Contractor / Agent Date 02, 2019 Page 2 of 2 ORIs �e f PERMIT INSPECTION REPORT .O • -15-2252) _ lull FtORIDP' FOR MIAMI SHORES VILLAGE Permit Type: Windows/Shutters Application Date: 08/04/2016 Owner: ERHAN KOSTEPEN Work Class: Window/Door Replacement Issue Date: 09/14/2015 Parcel 1132060136210 Status: Expired Expiration Date: 05/11/2016 Address: 270 GRAND CONCOURSE Miami Shores, FL IVR Number: 644158 Subdivision: 113206013 Scheduled Actual Reinspection Date Start Date Inspection Type Inspection No. Inspection Status Primary Inspector Required? Complete 09/03/2015 09/10/2015 Review Building INSP-242809 Passed Ismael Naranjo No Complete Reinspection of INSP-131606 Checklist Item COMMENTS Approved General Comments PLAN REVIEW COMMENTS No 11/03/2015 11/03/2015 Window Door INSP-242807 Re -inspection JORGE RODRIGUEZ No Complete Attachment required Reinspection of INSP-131606 Checklist Item COMMENTS Approved General Comments INSPECTOR COMMENTS No 11/05/2015 11/06/2015 Window Door INSP-247177 Passed JORGE RODRIGUEZ Yes Complete Attachment Reinspection of INSP-242807 Checklist Item COMMENTS Approved General Comments INSPECTOR COMMENTS No 11/13/2015 11/13/2015 Window Door INSP-247694 Passed JORGE RODRIGUEZ No Complete Attachment Reinspection of INSP-131606 Checklist Item COMMENTS Approved General Comments INSPECTOR COMMENTS Yes April 26, 2019 10050 NE 2 Ave Miami Shores FL 33138 Page 1 of 1 Miami Shores Village 11F0, Building Department q,�l 't 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �l%a Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 �-j BUILDI G Master Permit No. P.C, 1 — �33 PER IT APPLICATION Sub Permit No.wSN -I G- 9 7UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [—]CANCELLATION [:]SHOP n CONTRACTOR DRAWINGS JOB ADDRESS: — / v Folio/Parcel#: 1 1 — �) L U Go C> /. � % L /t) Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: 1,, Flood Zone: BFE: FFE:: OWNER: Name (Fee Simple Titleholder)): JkO b-t) I-,�Q peyi Phone#:�/ Address: V City: F Tenant/Lessee Name: Email CONTRACTOR: Company Na Address: )-M 6 City: Qualifier Name: State Certification or Registration #: DESIGNER: Architect/Engineer: 1Q4n Phone#: ` o S -' 76 -0 1/9 State:�%/ Zip: ^^�� TT Phone#: '[/ ertificate of Competency #: _ Address: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: s 1A Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ ..CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 2— �Q GAD (Revised02/24/2014) A Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) _ Mortgage Lender's Address City State Zip 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 low 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. 7fi he absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature q\ OWNER or AGENT The foregoi instrument was acknowledged before me this day of P? (2) t— , 20 , by ��xO �d � who is personally known two , me or who has produced �L-Wq l� LK�� "�s identification and who did take an oath. NOTARY PUBLIC: Sign: Printer Nkp k`J_k__ _i`?:1 Seal: SINDIA ALVAREZ WC OMMISSION q GG 238273 =;�, t ;'s`•.� EXPIRES. September 3, 2022 BWWW Thu Notary Pift t w4ftltati *******------------------ APPROVED BY Signatu The foregoing instrument was acknowledged before me this f day of A4X- 1 20 19 by Jt3:AA R. !:;Y* 4J who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign:"' Print: �1 Ali1 Seal: *************************** Plans Examiner Structural Review , ­ Punlic gtme or rionue .Notary Pu4gy9tate of Flonda Narip�r.,Nunp,; cc 166005 My Commission PG 166008 Expires 03/28/2022 y _ , as *************************** Zoning Clerk V (Revised02/24/2014) FORBE-2 OP ID: AB .44cORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/17/2019 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 Korotkin Insurance Group P O Box 431 Southfield, MI 48037-0431 Matthew Warsh CONTACT Angel Lon thorne PHONE FAX A/c No E>d : 248-352-5140 AIC No): 248-352-0305 E-MAIL angell@getkig.com ss: INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Evanston Insurance Co. 35378 INSURED Forbes Construction LLC INSURERS: Evanston Insurance Co. 35378 1500 Douglas Rd. Ste. 200 Coral Gables, FL 33134 INSURERC: INSURER D : 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 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 DDL BR POLICY NUMBER EFF MM DPOLIDYIYYYY ICY EXP MMLDDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FXIOCCUR Y 3C32666 11/08I2018 11I08/2019 PAMAGE TO RENTEU_ REMISES Ea occurrencel $ 100,000 MED EXP (Any one person) $ excluded PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY � JE� LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ OTHER: AUTOMOBILE LIABILITY COEaMBINED ccident)SINGLE LIMIT a $ 1,000,00 BODILY INJURY (Per person) $ A ANY AUTO Y 3C32666 11/08/2018 11/08/2019 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident) ccident $ X HIRED AUTOS AUUTOSTOSNON-OWNED X $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,00 X AGGREGATE $ 3,000,00 B EXCESS LIAR CLAIMS -MADE Y 11/08/2018 11/08/2019 DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE PER OTH- STATUTE ER E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Certificate Holder is included as Additional insured on the General Liability when required by written contact, written agreement or permit. Description of Operations - General Contractor License # - CGC1522043 CERTIFICATE HOLDER CANCELLATION MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE (/_ 01 Miami Shores, FL 33138 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD A!CORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDD/YYYY) 04/17/2019 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 have ADDITIONAL INSURED provisions or 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 NAME: Automatic Data Processing Insurance Agency, Inc. PHONE FAX A/C No Ext : AX No E-MAIL ADDRESS: 1 Adp Boulevard INSURERS) AFFORDING COVERAGE NAIC# Roseland NJ 07068 INSURER A: Normandy Insurance Company 13012 INSURED Forbes Construction LLC INSURER B : INSURER C : 1500 Douglas Road INSURER D : .Ste 200 INSURER E Coral Gables FL 33134 INSURER F COVERAGES CERTIFICATE NUMBER: 1140182 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 UBR POLICY NUMBER POLICY EFF MWDD/YYYY POLICY EXP MWDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO- ❑ JECT LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLffrMffr_$ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION - A AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? N/A N NHFL0070882018 06/01/2018 06/01/2019 STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Contractor License: CGC1522043 General Contractor License # CGC1522043 wn".V n Miami Shores Village Attn: Building Department 10050 NE 2nd Avenue Miami Shores 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 FL 33138 mi)'t-- ©1988-2015 ACORD CORPORATION. All rights reserved ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD