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REV-16-2881 Miami Shores Village NT Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 20 BUILDING Master Permit No.W- 8 -rho' 237-T I PERMIT APPLICATION sub Permit NO.-Re,,"-4 1(0 - ?-9&1 ❑BUILDING ❑ ELECTRIC ❑ ROOFING aREVISION ❑ EXTENSION ❑RENEWAL F-1 PLUMBING [:] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP ` � CONTRACTOR DRAWINGS Q oIB JOB ADDRESS: -l J E I Q City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: ?2 1 j0 ©20 00 1 () s the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: /� ` /Flood Zone: BFE: FFEE:1 i OWNER:Name(Fee Simple Titleholder): E3 Vla 101 %a V I S Phone#: 9 0 6" ( !2`- q Y2 Address: ® i City: 0.� State: zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: �� ►nPhone#: Address: C7 G S f54 1 City: F,a W -State: Zip: C Qualifier Name: h t Phone#: ':?:;Io State Certification or Registration#: C 0 6 0 I ! �- Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/linear Footage of Work: .401- Type of Work: ❑ Addition V� Alteration � t ❑ New [:1Repair/Replace ❑ Demolition Description of Work: 92111�Iovq -- b V A1- L P2LO C Ic -PET L_ Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ ot Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ 20 Bond$ TOTAL FEE NOW DUE$ / "1 (Revised02/24/2014) Boridii'ag Ampany'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 approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CO RACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 2-0 / day of l�---TO _,20 by (('� day of P—,6 LO'-"— .20 1 L ,by ►/h t S w ' ersonall n to h utiyt O ►Q ,wh 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 PUBL i n: Sign: S g Print: U 10 Print: nX Seal: no 11 SF3 5 17 0 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 1 I (�0_�1 1� _fit .4COR© CERTIFICATE OF LIABILITY INSURANCE °A 9, 23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT -KATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIOS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT- N the cerBflc ate holder Is an ADDITIONAL INSURED,the pOW(ift)must be endorsed. V SUBROGATION IS WAIVED,subject to the terms and eond1dons of the polity,certabr toBdes may require an endorsement. A statement on dft cufficals does not confer rigs to the CerBticate holder In Hsu of such endo 8). PRODUCER TriOea Insurance Solutions, Inc. Fax 315 BE Kinuar Blvd PHONE 877 987-4436 954 252-4426 Saito 213 CB8T88TRItiBNsolutions.emi Soon Raton IPL 33432 0WR8R[S)AFFO1WWGC0VERAQE Kwo wsuRaRA•anarantee Insurance 11398 INSURED (90 ) 7 - . Convergence Employee Leasing, Inc. DISURERs Convergence Employ" Leasing Ii, Ino. MMIRERC: Convergence EENsloyad Leasing III, Inc. INSUMMO, Jacksonville FL 32217 =F: CERTIFICATE NUMBER:Cert IO 18441 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 ISSUE)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 PAD)CLAIMS TYPOOFDSURANCE POLICY NUlatERAlm LpMB C tABR ALQQ(BtALLriY EACH OCCURRENCECLABS-MADE F-1 OCCUR 09'MRMnw g S PERSONAL&ADV UUIRY S oEN1.AGGREGATE wWrAPm.IEs PER: oEVERaLAcsREOATE s POLICY , LOC PR x=M_COMP%OPAGG S AUTO&WIRLE LIABRJIY LST S ANYAUTOBODRYSCHEDULED 8IRRY(Parpe ) g AUTO AVI10S SomLYRdRRY(PwwCh " S HREDAUTOS PERTY S S UNIBRELLA UAB EACHQCQIRREHCE S EXCESS LIAR CIA ADE AGGREGATE S DED QNSS WORI(ENSCONPENONFIGN A ANDEWt0nWL1A811ffY YIN VCP500075002GIC 09/30/201 09/30/2017 Z WRTNERADURNMYE ANY NIA E.L.EACHACCMEPr S 1,000,000 phn"MYInw!1 E.L.D83EP3E-EARR O S 1,000,000 9 ya9TION OF OPERATMNS below oMEASE-POUCY LAST Is 1,000,000 S $ VESCRIPIMNOFOPERAZONSILOCA=NSIVE11=28(ACQRD W%Adel R®adm S mWh*nftadudffm=ap=b Coverage provided for all leased employees but not of: Johnnie C. Cope Jr Tao. Location coverage effective: 9/30/16. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICFES BE CANCELLED 9 THE EXPIRATION DATE THEREOF, NOTICE WBJ. BE DELIVERED IN Miami Shores village ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NB 2nd Avenue AUTHORR ED REPRESFNTATWE Niami Shores IPL 33138 eoh, ®1988,2013 ACORD CORPORATION. All NQhts resevecL ACORD 26(2093104) The ACORD Mune and logo are registered maifts OT ACORD Page 1 of 1