REV-16-2141 Miami Shores Village ,;-
Building Department JUL 29 2016
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY._
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC201f rD+h
BUILDING Master Permit No. 46, r QUO -Z-
PERMIT APPLICATION Sub Permit No. Rv 16 —�1�
❑BUILDING 4 ELECTRIC ❑ ROOFING [,f REVISION ❑ EXTENSION [:]RENEWAL
❑PLUMBING [--] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:] CANCELLATION ❑ SHOP
OL) }� I 0 \/ CONTRACTOR DRAWINGS
(�
JOB ADDRESS: y O L) 1 V �n � X p
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:
C ut
OWNER: Name(Fee Simple Titleholder): LS [ +V SA " '` � S one#: J✓�J CT��J b
Address: lU / �'K elo
City: State: Zip:
Tenant/Le ee Name: Phone#:
Email: l,S (AiCfl
CONTRACTOR:Company Name: Phone#:
Address:
City: / State:'/ (t,c Zip:
Qualifier Name: li Phone#:
State Certification or Registration 1000 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 1()L) Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration/► ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 1- U���^ S F=-1L�( I �^ �1�I(/uIA
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$
TOTAL FEE NOW DUE$ CP
(Revised02/24/2014)
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 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. t
"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.
Signature Signature r'
O NE �/ /
R o AGENT CONTRACTOR
The foreoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
�2f L
day of J 20 < 6 by G Y day of 2(��J by
`enY1 r� who is personally known to �T— who is personally known to
me or who has produced rty1Y LICAAS-Q, as me or who has produced as
identification and who did to oa identification and who did take an oath.
NOTARY PU NOTARY UBI �B Cry RAYMORE
N , M OMM(SSION #FF020273
Sign: �--o Sign:
me 19,2017
n , taryService nn
Print: VLR�13Print:
Seal• YAN
Seal:
ADY PRI[�I'0
MY COMMISSION{i PF
_I
c d,€ EXPIRES:March.P5, R
Af, Bonded Thru h'otav Put',Und nvriters
APPROVED BY ,2 9`�-4'4Y l� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
CERTIFICATE OF LIABILITY INSUkANCE °^-M(MiZDD/YY
PRODUCER Silva and Jael Insurance Agency 08/12/16
THIS
CE
13 ISSUED AS A MATTER OF INFORMATION
5939 Johnson St ONLY AND CONF S NO RIGHTS UPON THE CERTIFICATE
Hollywood,FL 33021 HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
Phone (954)965940 LTER 1 IiE COVE GE AFFORDED BY THE pOLICII=S BELOW.
Fax (954)965$541 INSURERS AFFORDING COVERAGE
NgIC 7
INSURED •(METpLANET)ELECTRICAL CONTRACTOR INC, INSURERA: Ascendant Insurance Company
6231 Grant Court IN B: Infinity Auto Insurance Company
HOLLYWOOD, FL 33024 INSURER C:
INSURER 4: —
COVERAGES INSURER E
INSURER F:
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANb1NG
ANY REQUIREMENT,TT<wRM OR CONDITION OF AN}r CONTIigCT Olt OTyEft DOCUMENT Wiry RESPECT TO WHICH THIS C1=RTIFiCATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN fS SUBJECT TO ALL THE
GATE LIMITS SHOWN MAY HAVE BEEN REDUCED BTERMS,EXCLUSIONS AND CONDITIONS OR SUCH
POLICIES.AGGRI= Y PAID CLAIMS,
Jj IGR ADD'.
1 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DAT$ MM/OQA'Y DATE MWOQ LIMITS
GENERAL LIABILITY
Q COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,00 AO
GL-44228-2 04/07/16 04/07/17 PREMISES Ea ooeuranoe $100, .00
1:1L CLAIMS MADE E/] OCCUR MED EXP(Any one person)
`� 00
❑ I PERSONAL 8 ADV INJURY $1.000,00C.00
GGENERAL AGGREGATE $20000,00 00
EN'LAGY AGGREGATE I PRODUCTS-CCMP/OPAGG $1,000,00
00
® POLICY El PROJECT C) LOC
AUTOMOBILE LIABILITY
❑ ANY AUTO 509-80000-8283-001 I 02/28/16 02128/17 Ea olden SINGLE LIMIT
_n ALL OWNED AUTOS
SCHEDULED AUTOS I BODILY INJURY
❑ HIREDAUTOS (Perpon) 10,000 00
's
❑ NON OWNEDAUTOS BODILY INJURY ZO,OOD O
❑ (Per accident
PROPERTY DAMAGE 10,000 0
GARAGE LIABILITY (Per aoGA
❑ ANYAUTO
AUTO ONLY-EA ACCIDENT
❑ OTHER THAN EAACC
ExcEss/UMBRELi,A LIABILITY AUTO ONLY: AGG
-
❑' ❑ OCCUR ❑ CLAIMS MADE EACH
OCCURRENCE
AGGREATE
I❑ DEDUCTIBLE
❑ RETENTION S
WORKSRS COMPENSATION AND
I EMPLOYERS'LIABILITY ❑ WC STATU- ❑ PTH
ANY PROPRIETOR/PARTNER/EXECUTIVE TORY LIMITS ER
OFFICER/MEMBER EXCLUDED? EL EACH ACCIDENT
If Yes,describe under E.L.DISEASE-EA EMPLOYEE
FSPECIAL PROVISIONS below
OTHER E.L.DISEASE-POLICY LIMIT
D CRIPTI)N Of OPERATIONS/LOCATIONS L VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
l E ECTRICAL CONTRACTOR.
C TIFICAYE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ON DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL
VILLAGE OF MIAMI SHORES E 30 n DAYS WRITTEN NOTICE O THE CERTIFICATE HOLDER NAMED TO
10050 NE 2 AVE THE LEFT,BLIT FAILURE TO DO 30 SHALL IMPOSE NO OBLIGATION OR LIABILITY
MIAMI SHORES,FL,33037 OF ANY KIND UPON THE INSURER,ITS AGENTS OR RI:PRESEdT'ATIVES.
FAX#305-756-8972• AUTHORIZED REPIIESENTATIvE
LEYNNI MARRERO
oRD z5(zoof/oe)QF
®ACORD CORPORATION 1988