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REV-16-1318 Miami Shores Village MAY 16 2016, Building Department BY: 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20,I> BUILDING Master Permit No. 12C-'�� PERMIT APPLICATION Sub Permit No. 12!E-A/K- 13� BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL r_jPLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 64 Qui qlot -T-' City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO V Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): �� -� Phone#: � Address: e6 NE kc)c� -Gr City: "(/'0 ( State: -E L Zip: 516 Tenant/Lessee Name: N/�t- Phone#: - Email: 'T27 ill @ )C�'t' �• Cep b'( CONTRACTOR:Company Name: /lilt ti-e-f /rig' eLd '7—C-. Phone#: 52-1- ;a-7377 Address: J/276 / A G 7 � . City: 02414 c/ P'C'-1r State: G Zip: 3333`7 Qualifier Name: zSZ 7� ✓A yr T T� Phone#: lag_5-46-/04' State Certification or Registration#: CMC-6S_ 71_92- Certificate of Competency#: DESIGNER:Architect/Engineer: ®VC% � ASOCLU`I-SIS Phone#: � 0 B 700 Address: I<« V/i_: C4X):::!WP-Se �0 ( City: EU�y u' State: F7L Zip: -331454 Value of Work for this Permit:$ 105 •00 Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New Repair/Replace El Demolition r � Description of Work: 61 0V Specify color of color thru tile: Submittal Fee$ 2 Permit Fee$ 2 ` CCF$ `�U`� CO/CC$ Scanning Fee$ Radon Fee$ y .�J DBP�1R$� 1- Notary$ Technology Fee$ Training/Education Fee$ �' f'`' Double Fee$ Structural Reviews$ Bond$ — l TOTAL FEE NOW DUE$ ZO- de "Qavised02/24/2014) Bonding Company's Name(if applicable) N/ 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 approve and a reinspection fee will be charged. Signatur Ore ` OW or CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of '20 �� by `6 day of /y( _ 20 14 by who is personally known to who is personally�nvwn to me or who has produced-T tS�,14= as me or who has produced ,?-T1 (/I as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: I NOTARY PUBLIC: (4hvp-- o�l Sign: Sign: Print: "` Print: AS Co mission# FF 897808 `e``�r �4° Commission#FF 897908 Seal: '., _ , My Commission Expires Seal: My Commission Expires 1FF� '��' March 12, 2018 March 12, 2018 ##################################### ####### ############################################################## APPROVED BY t � s Examiner Zoning Structural Review Clerk (Revised02/24/2014) 3annahSims To: 3057568972 1 800 685 7530 (2 of 3) 05-25-2016 10 : 20 -0400 ACO� 75/24/2016 E(MMlDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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), AUTHORED 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 certiFlcate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Middle Unit 3 Setnor Byer Insurance & Risk A/C NNo E.1): (954)382-4350 A/C No): (959)982-2810 900 S. Pine Island Road #300 E-MAIL ADDRESS:stefanieb@setnorbyer.com INSURERS AFFORDING COVERAGE NAIC# Plantation FL 33324 INSURERA:Western World Ins Co INSURED INSURERB:Associated Industries Ins. Co. Meyer Ladd Davis Air Conditioning, Inc. INSURERC: 3761 NE 4 Ave INSURERD: INSURER E, Oakland Park FL 33334 INSURER F: COVERAGES CERTIFICATE NUMBER:1/8/16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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, EXCLUSIONSAND CONDITIONSOF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE PPOLICY EFF POLICY EXP OUCYNUMBER (MMID D/YYYYI (MM4)DNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X�OCCUR 1717—PREMISES Ea occurrence $ 100,000 NPE8195794 1/7/2016 1/7/2017 MED EXP(Any one person) $ 5,000 PERSONAL B.ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- ❑ LOC OTHER:F—IJE CT PRODUCTS-COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOSAUTOS NED PROPERTY DAMAGE Err iarcident) $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERSCOMPENSAT10N ANDEMPLOYERVUABILITY YIN X I STATUTE I X I ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED7 ry] N/A E.L.EACH ACCIDENT $ 1,000,000 B (Mandatory In NH) AWC1056576 1/1/2016 1/1/2017 E.L.DISEASE-EA EMPLOYEE $ 1 000 0 00 r yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE -POUCY LIMIT $ 11000,000 DESCRIPTIONOF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached Ir mon space Is required) A/C Contractor License #: CMC057132 i CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Bldg Dept THE EXPIRATION DATE THEREOF, NOTICE V11ILL BE DELIVERED IN 10050 NE grid Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE D Saunders/STEFAN ©1988-2014ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INR/194 nn 1en1�