DS-11-1777Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
nspection i ember. INSP- 164884 Permit Number: DS -9 -11 -1777
Inspection [ ite: October 27, 2011
Inspector: E'ruhn, t orman
Owner:
Job Addres : 1050' BISCAYNE Boulevard
1idn Shores, FL 331:',3-
Project: <NOr E>
Contractor: r M DESIGN CflH RETE CORP
Permit Type: Driveways /Sidewalks /Slabs
Inspection Type: Final
Work Classification: New
Phone Number
Parcel Number 1122300010500
Building D rtm nt Comments
REMOVE :l F -3LACE EXISTING WALKWAY WITH 4'
OF PLAIN :NC ETE. 300 PSI FILER MESH AND BRUM
FINISH
permit on
Passe :'
Failec
bouncech
Inspector Comments
Corre O l i
Need
Re-In n
NoAdditi, ns can be s until
re- inspei 1.
For Inspections please call: (305)762 -4949
October 28, Page 1 of 1
MIAMI -DADE COUNTY TAX COLLECTOR
140 W. Flagler Street
Miami, Florida 33130
Please keep your receipt for
future reference.
Thank you and have a nice day.
10/5/2011 1300/221/001ML42 0027 -0001
Last Seq. #:0001 WI LBT #:30 482924 -9
Local Business Tax $175.00
CK
CHANGE
$175.00
$0.00
MIAMI -DADE COUNTY TAX COLLECTOR
LOCAL BUSINESS TAX SECTION
140 W. Flagler St. - 1st Floor
Miami, Florida 33130
TEMPORARY RECEIPT
2011-2012
MUNICIPAL CONTRACTOR TAX
Local Business Tax #:30482924 -9
State /CC #:E211800
Issued to:
R & M DESIGN CONCRETE CORP
Type of Business:
SPECIALTY ENGINEERING CONTRACT
SEE BACK OF OFFICIAL RECEIPT FOR
NONPARTICIPATING MUNICIPALITIES
THIS RECEIPT IS ISSUED AS EVIDENCE OF
PAYMENT FOR YOUR LOCAL BUSINESS TAX
OR PERMIT.
YOUR OFFICIAL RECEIPT WILL BE MAILED
TO YOU WITHIN 10 DAYS FROM THE
VALIDATION DATE ON THIS RECEIPT,
Payment Received as Certified Above
Miami -Dade County Tax Collector
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
10500 BISCAYNE Boulevard
Miami Shores, FL 33138-
Owner Information
ICUC HOLDINGS INC
Address
Parcel Number
1122300010500
Block: Lot:
10500 BISCAYNE Boulevard
MIAMI SHORES FL 33138-
3009 N MAIN Street
SANTA ANA CA 92705-
Applicant
Phone
ICUC HOLDINGS INC
CeII
Contractor(s) Phone CeII Phone
R&M DESIGN CONCRETE CORP
Approved: Yes
Comments:
Date Approved: 9/28/2011: Yes
Date Denied:
Type of Work: SIDEWALKS
Bond Retum :
Scanning: 3
Additional Info: CONCRETE
Classification: Commercial
Valuation:
Total Sq Feet:
$ 5,000.00
0
Available Inspections:
Inspection Type:
Final
Foundation
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$3.00
$2.25
$2.25
$1.00
$150.00
$9.00
$4.00
$171.50
Pay Date Pay Type
Invoice # DS -9 -11 -42136
10/05/2011 Check #: 4446
Amt Paid Amt Due
$ 171.50 $ 0.00
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compl
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the prof
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes
required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL wor
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in com
construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated.
ince with all ordinances and regulations
ar authorities of Miami Shores Village. In
I understand that separate permits are
)fiance with all applicable laws regulating
Otto )er 05, 2011
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
October 05, 2011
Jate
1
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
Permit No0 `1 _._.�'1�
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING ROOFING
OWNER: Name (Fee Simple Titleholder): 'C'�KL f l Z?/C
Address: (05'00 Isscsf7tJe .4LY1i
City: #4IAMi SHDgtl' State: ►
Tenant/Lessee Name: AN My
Email: MY1ft rlf N1 cor""-asetseue . Con,
JOB ADDRESS: /0 50 0
SEP 2 3 701'
Master Permit No.
Phone #:
Zip: 33438
8
Phone #: 150S *3704/TP
City: Miami Shores County: Miami Dade Zip: .33I 3e
Folio/Parcel #: �Sh$ A� S7`SC�t /t, M�+TEL..
Is the Building Historically Designated: Yes
Flood Zone:
CONTRACTOR: Company Name: --t ` Q•L Phone #: w r9 3"74, ''Z
Address: 4)a,&7 S Gd../ /3 04' ,�-tf�
City: / 14 ^4 j State: �'G Zip: 03/41X
Qualifier Name: ® qTi /1441 LJ �� cB Phone #:.3t" ct .3 4 Z
State Certification or Registration #:
Contact Phone #:
DESIGNER: Architect/Engineer:
Certificate of Competency #: 6"---"c9,46.01%
0`1 r/d% �'� ', L Email Address: +r''o q" • 471-0,744.107c-.b d7'XL% l • 2p
Phone #:
Value of Work for this Permit: $ feo . Square/Linear Foota of Work:
Type of Work: ❑Addition ❑Alteat
Description of Work: /l�..,2' o ),e, '�
P
UNew epair/Replace ❑Demolition
e c(tC494y &/ i"..4 P,44 Li/ ezi,4 •
u.,
#20.09 .■) /.0 4
�o
******* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** *Fees * * * **
o J
Submittal Fee $ Permit Fee $ / J 2
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 and a reinspection fee will be charged.
Signature Signature
weer or Agent
The forego g ' trument was acknowledged before me this /IC The foregoing ins
day of , 20 if , by 1417-401 / , day of
own to me or who has produced
As identification and who did take an oath.
NOTARY P
Sign:
Print:
My Commi
es:
***********************
* **
APPROVED BY
ent was acknowledged before me this
20 1t , by I vv1XLC-0
who is personally known to me or who has produced Ft/9
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
qq1
My Commission Expires:
cla
1 ^.
**** **** X**** ******* *** * ** *** * * **** * **** *** * * ** **** * ***** *3: * ** * * ***3: * * *' tipry ** *7TC*
��Feri Plans Examiner
Structural Review
(Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
Zoning
Clerk
1
1
Planning and Zoning Criteria
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit NO. DS -9 -11 -1777
Issue Date: Not Issued
Expires:Not Issued
Folio Number:1122300010500
Owner's Name:
Job Address: 10500 BISCAYNE Boulevard
Miami Shores, FL 33138-
Owner's Phone:
Total Square Feet: 0
Total Job Valuation: $ 5,000.00
Contractor(s)
R &M DESIGN CONCRETE CORP
Phone
Primary Contractor
Yes
Planning and Zoning Criteria and Comments
Approved: Yes Date Approved: 9/28/2011: Yes
Comments:
10/05/2011 15:01 3055564354
ACORD.y CERTIFICATE OF LIABILI
3RODUCER
ALL INSURANCE SERVICES, CORP.
3682 W 12th Ave
Hialeah, FIR 33012
(305)82a-4472
INSURED R Ss M DESIGN CONCRETE CORP
10251 SW 130 AYE
=AKE, FT, 33186
COVERAGES
ALL INSURANCE SERV
PAGE 01/01
r INSURANCE 1
DATE(MM/QD/TYYY)
THIS CERTIFICATE IS ISSUED As A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON TIME CERTIFICATE.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE N
NAIC#
INsulz t A: GRANADA ZNST3RANCE •
•
INSURER 13:
INSURER C;
INSURER D:
INSURER W;
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDmON 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 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
1
POLICY EFFECTIVE • Y RATIO LIMITS
O
LTR NSRD TYPP F INSI ARAN :F POLICY NUMBER CsATE fMMtUD/YY1 DA 't D/YYI
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL UUA[3IUTY PREMISES [Ea occurence) $ 3,00 00 0
CLAIMSMADE X OCCUR MEDt7(P(Any one per3on) $ 9,000
11 -3096 09/14/11 09/14/12 PERSONAL &ADVINJURY $ 1.000,000
GENERAL AGGREGATE $ IA 0 0, 0 0 0
GEM_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 1, 000,• 000
POLICY n j LOC
■
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $
ANYAUTO (Es accident)
_ ALL OWNED AUTOS BODILY INJURY
ScMEDULED AUTOS (Per person)
$
HIRED AUTOS BODILY INJURY
NON- OWNEDAUTOS (P racmdent) $
PROPERTY DAMAGE $
(Parma :lent)
GARAGEUABILITY AUTO ONLY -EA ACCIDENT $
H ANYAUTO OTHER THAN EA ACC $
AuTOONLY: AGO $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
7 OCCUR 7 CLAIMSMADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATIONANO WU IA I •TH-
EMPLOYERS LIABILITY �QRYUMfTS E
ANY PROPI�IETORMARTNER/ESECUTIVE
E.L, EACH ACCIDENT $
oFl BEA/MEMDER @XG-uneo7 E,L DISEASE - EA EMPLOYEE $
N darcribeund�aa.r
SPECIAL PROV19tONS Wow E,L, DISEASE - PDUCY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED EY ENDORSMIENT f SPECIAL PROVISIONS
CERTIFICATE HOLDER
NIA= SNORES
10050 NE 2 AVE
NIA= SHORES, TT, 33138
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLfCIES BE CANOELLED BEFORE THE, EXPIRATfON
DATE THEREOF. THE ISSUING IN$Uv'ER WILL ENDEAVOR TO MAIL3O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHAD,
IMPOSE NO GB LATIN OR LIABILITY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTA
AUTHOR
ACORD25(2001 /08)
CORPORATION 1988
CERTIFICATE HOLDER
NIA= SNORES
10050 NE 2 AVE
NIA= SHORES, TT, 33138
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLfCIES BE CANOELLED BEFORE THE, EXPIRATfON
DATE THEREOF. THE ISSUING IN$Uv'ER WILL ENDEAVOR TO MAIL3O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHAD,
IMPOSE NO GB LATIN OR LIABILITY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTA
AUTHOR
ACORD25(2001 /08)
CORPORATION 1988