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PL-15-2566 ti Miami Shores Village � k Building Department M R 2 2016 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 BY' dia- Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 10 BUILDING Master Permit No. 9C- 31V—.3 :)F PERMIT APPLICATION Sub Permit No. F—U E5 V 25(c(�- ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION [-]RENEWAL Q( PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: �•� )3 Folio/Parcel#: W'3 Xc) ©1 Is the Building Historically Designated:Yes ,• NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): /�0)�!a ��ve Phone#: S � 3 6 �(d 13 Address:__///RC1 3c� //LO 1 7 /1f► �.. y� City: /�!l�wK � 7 bJL State: — Zip:Tr 3� Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Az O�/wwa Phone#:._ Address: 8100 City: State: �t-- Zip: i Qualifier Name: 40 Phone#: '�-6 297 State Certification or Registration#: GAG 2 8 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: �( 2y i5N6(1k Address: City: State: Zip: Value of Work for this Permit:$ (Qce, Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace '/❑ Demolition Description of Work: *14000 *WJ PLAY 14 2d o-nn �I F W viv. � � �• �QQ"'7 lel&v KM VP, -real/, — t to Specify color of color thru tiled Submittal Fee$_ v s •Permit Fee$ cJ' vy CCF,$ "CO/.cc$*�" Scanning Fee$ 3'> •0� Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) s Bonding Company's Name(if applicable) Bonding Company's Address sup 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 tl a absence o posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this �_ 2' day of CC 1"` o"� 20 by -7-1 day of A:ke C)-� 20 l by ,—A- �1�� �l (Ue4(c, , ho ispersonally known to �d� �c�� ��who is personally known to me or who has produced as me or who has produced-LX- as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign i c Print: Z- Print: Z� ti`�i9.wa� JOSEFINA GERE2 e of Florida Seal: ;-ro''P �%: Notary PAI Seal: ,=TPZ ;k1i?S Notary Public-State of Florida My Comm Ex Sep 30,2018 My Comm.Expires Sep 30,2018Commission # FF 164325 Commission N FF 164325 �,. '•;°�� Bid through National Notary Assn. Bonded through National Notary Assn. APPROVED BY 3 !� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) �5�►oRFS G�! Miami shores Village "go Building Department ORiDp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. Owner's Name (Fee Simple Title Holder):`r6D14sb Phone#: S'>rl -236 Owner's Address: 493r Nt- WAV-0, City: A-4,-44 S•,N24,-1 State : !ff Zip Code: 33/ 38 Job Address (Of where work is being done): y'93r ouf 13 A'r't-- - City: Miami Shores State:—Florida Zip Code: 3 3-� Contractor's Company Name: l l'i>t..�C�Y S Phone#: Z- 7763U 1 C Address: 5�1(90 City: &,Uatni, R-�p—Q(11,A State: C Zip Code: Qualifier's Name : _ i r'1 i Lic. Number: r'',FG /S�Z C� �� Architect/ Engineer of Record Name: Phone#: Address: City: State: Zip Code: Describe Work: I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami h res harmless of all le I inv dement. Signature Signatur Owner or Agent Contractor or Architect The foregoing instrument was aknow� eed.before me The foregoing instrument was,raknowled//ged before me this�day of `�201�by �`�`` 7 this ZZ day of PCl,rdA , 2Aby �mau Who is personally known to me or who ha produced who is personal) known to me or who has produced -S 4( 6 Z Y 0 �2 0 69 0 as indentification. ��vis I t 1 indentification. Nota Public: Notary Public: Sign: r).P : JOSEFINA GEREZ Sign: v P I.-C, Seal: :• My Comm.Expires Sep 30,2018 Seal: COMMISSION#FF 912061 commission#FF 184325 EXPIRES:August 2,2019 Bonded through NMiOnal NatYY Asan. ?rgM °� Bonded Thru Budget Notary Services f ACDRDu CERTIFICATE OF LIABILITY INSURANCE (MMIDWYY) PRODUCER 0 3 I2 3/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CITINSURANCE AGENCY CORP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8390 WEST FLAGLER ST SUITE 213 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MIAMI FL 33144 305-228-1533 INSURERS AFFORDING COVERAGE INSURED DEL RIO & SON PLUMBING CORP. rysut2£Rk ARCH SPECIALTY INSURANCE CO. INSURER B 8990 SW 24TH STREET,APT #213 FINSURER RC. MIAMI, FL 33165 0 E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 7. ' TYPPEOFINSURANCE POLICY NUMBER _ ..PDOATE'YEFFECTYVEP YM PiRItTl�l "" LIMITS _�... 3 GENERAL LIMUTY EACH OCCURRE%�C 1, 000, 000 1COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(At.y on fm) $ 100, 000_ CLAIMS MADz OCCUR MED EXP( ", one Pisa) ,S 5, 000 A' AGL0009659-02 02—IS-16 02-15-17 `PERSONAL&ADVINJURv `—' 311 000, 000 �� GENERAL AGGREGATE $2 000'. 600 EN`L AGGREGATE LLMITPRO.APPLIES PER PRODUCTS COMPIOP AC,G :$2, 000, 000 POLICY';PRO. LOC -- AUTOMOBILE LIABILITY $ I COMBINED SINGLE LIMIT i ANY AU70 (Ea accent) i S u _�ALL OVtfiVEDAUTOS SCHEDULED AUTOS a BODILY INJURY (Per pennon) S HIRED AUTOS I ,$ NON-OWNED AUTOS BODILY INJURY IPer 9=1047,) PROPERTY DAMAGE (Per aczden€)T GARAGE LIABILITY UTO ONLY ACCIDENT $ ANYAUTD »-n OTHER THAN EA ACC F$ AUTO ONLY EXCESS LIABILITY ! ACsG EACH OCCURRENCE 5 q }OCCURCLAIMS MARE i I AGGREGATE DEDUCTIBLE ) 1 _ E S .... _ RETEN"ON S - WORKERS COMPENSA71ON AND wC SAT EMPLOYERS'UABIUTY _ TOR l Mi FR E.L.EACH ACCIDENT $ i I i E L DISEASE-EA EMPLOYEE $ OTHER $ EI t_D€5EASE-POLICY LiMI7 s l ) I DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESJEXCLUSK)NS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS PLUMBING CONTRACTOR LP GAS CFC1427828 CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MIAMI SHORE VILLAGE DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 10050 NE 2ND AVE IMPOSE NO OBUGATION OR UAMUTY OF ANY KIND UPON THE INSURER ITS AGENTS OR MIAMI SHORE, FL 33138 REP REs RUTH =FAX: 786-362-5426 ACORD 2fi S(7/87) — 0 ACORD CORPORATION 1988