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DS-14-1951Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-219183 Permit Number: DS -9-14-1951 Scheduled Inspection Date: December 03, 2014 Inspector: Rodriguez, Jorge Owner: HURLEY, JAMES Job Address: 685 GRAND CONCOURSE Miami Shores, FL 33138 - Project: <NONE> Contractor: HENRY AND CO tiunamg ueparltment comments PRE CAST PAD Permit Type: Driveways/Sidewalks/Slabs Inspection Type: Final Work Classification: New Phone Number Parcel Number INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. 1132060172180 Phone: (954)527-1597 December 02, 2014 For Inspections please call: (305)762-4949 Page 6 of 28 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 BUILDING PERMIT APPLICATION QBUILDING ❑ ELECTRIC ❑ ROOFING FIvk q g 2014 FBC 20101 Master Permit No. C�- 1%-f — «50 Sub Permit No. _ 14 — lqs� ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 685 GRAND CONCOURSE City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): JAMES HURLEY Phone#: Address: 685 GRAND CONSOURSE City: MIAMI SHORES State: FL Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: HENRY AND CO Phone#: 954-527-1957 Address: 757 SE 17 ST 176 City: FT LAUDERDALE State: FL Zip: 33318 Qualifier Name: HENRY AND CO Phone#: State Certification or Registration #: EC0001322 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration SdNew ❑ Repair/Replace ❑ Demolition Description of Work: PRE CAST PAD 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 $ Ll TOTAL FEE NOW DUE $ (Rev1sed02/24/2014) 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 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 approved and a reinspection fee will be charged. Signat�'--� Signature OWNER or AGENT ONTRACTOR The foregoing instrument was acknowledged before m this The foregoing instrument was acknowledged before m this day of / 20 / t day f 20 by I��t��! o is personally known to who is ersonally know o 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 ,t �t,t�,L]Q/YN Sig&. -A o, 41 k 14 l nc�� Print: M�1 CST/'� �Print: 1' VAia%lie— upc)Ljt!�26'l. Seal: NOTARY PLBLIC-STATE OF FLOR== l Seal: o•"""'•,, Melanie Watson NOTA, A Corr om:�ussion # EE0585�19[ 4�R�k �M��k BO�D£DTHY.L' !.�;r' 0\ L'iC. 9•.. .: `(1"ImssjOn {Y�iYatson s � r �I�i�•t��• EOS APPROVED BY `� ``Z Plans Examine " r7 ABB• 1 �, � 19 Zoning .Co Zoprq� , Y4 Structural Review Clerk (Revised02/24/2014) ACCM CERTIFICATE OF LIABILITY INSURANCE D09/04/20114 ) 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 Doug Jones Go Artex Risk Solutions, Inc. 8800 E. Chaparral Rd, Suite 230 Scottsdale, AZ 85250 CONTACT NAME: PHONE 480 951-4177 FAX AIC No Ext): ( ) Arc No): (480) 951-4266 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA: American Zurich Insurance Company 40142 INSURED Oasis Acquisition, Inc Alt. Emp: HENRY KARP. INC dba: HENRY AND CO. 2054 Vista Parkway Suite 300 INSURER B INSURER C : West Palm Beach, FL 33411 INSURER D : INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 14FLO75803764 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. I TR TYPE OF INSURANCE ADDLSUBIR IN R WVD POLICY NUMBER MMMLIDDIYYYY MNWDrYYxYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR DA A D PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO- RO LOC JECT $ AUTOMOBILE LIABILITY BINED NGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N OFFICER/MEMBEREXCLUDED? El (Mandatory In NH) NIA WC 29-38-687-12 06/01/2014 06/01/2015 X , VJC STATU- LIM TSOTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Location Coverage Period: 06/01/2014 06/01/2015 Client# 7847-1 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more apace is required) HENRY KARP, INC dba: HENRY AND CO. ELECTRICAL CONTRACTOR LIC NUMBER ECOOF01322 Coverage is provided for 899 NE 42ND STREET only those employees leased to but not OAKLAND PARK, FL 33334 subcontractors of: CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2 AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE �0�4 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation 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 . f: 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. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner a Print Name: Signature 7 State of Florida ) County of Miami -Dade) Sworn to and subscribed before me s_ day ofS, A_ , 20 lLi . I rX ,..`Q By (SEAL) CcT iiss cn it EE058519 `° r, _ _.., �R:P 11, 2015 Type of Identification prodt� Contractor Print Name: t - J Signature• State of Florida ) County of Miami -Dade ) Sworn to apd subscribed before me s_ day of A20. of : '`,�Ianie «'arson Cemir,ission # EE058519