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MC-16-1238Miami 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 ❑BUILDING ❑ ELECTRIC ❑ ROOFING MAY RO 9 2016 _-tk-t FBC 2001 _ Master Permit No. , �-79 Sub Permit No. 1 o_(G ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING t7 MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9ft 1'r A1.1 A -K ' j_r u 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: ,. ' ao Limo u 'TiX16�G., OWNER: Name (Fee Simple T ..it leholder): eS ,, n4 .. �61'i� JAj AA '#� QC ?4 Phone#: (0 IT ,Y 4 Address: cgQi r Nx 4-1kU-2`4- r City: k i k_. , 9ADq;'z State: %Z_ Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: K,a) 1 41; j 1L _N Address: 4 �Ir 2Yr st' Ul *- City: State: T'2- Zip: 330/0 Qualifier Name: ���_e %z I Iwo S Phone#: State Certification or Registration #: _ e A� ©5(�0� Certificate of Competency #: DESIGNER: Architect/Engineer: Address: City: State: Zip: Value of Work for this Permit: $ `ISIa Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace r❑ Demolition Description of Work: A VL' SyS PtM VWL At,,V aj OT- �W 34&:t(Lw V , Specify.color" of color, th,n ;tile. ` % r �. Submittal Fee $ S4 "� - Permit Fr,eee�$ 1 CCF $ 3-00 CO/CC $ ..•�d't.+t�'i'4••�'i �'.,t y5 ."•yy,^.,1 1:y-tl t, RfY O M ;>�'�.��lf .j.. f� .. ..ti• #'7 Scanning Fee $ y Radon Fee $ U� DDBP/R�$ a ' `A Notary $ Technology Fee $ L4 ' W Training/Education Fee $ 1 �--E ) Double Fee $ Q Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 1 6 d (Revised02/24/2014) I 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. "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-rratice of-cammEncemenrmust be poted afthe job fife - 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 an a reinspection fee will be charged. Signature Signature OWNER VAGENT TRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this V4 day of / � 120 14 by 2)ft day of 20 {(e by 5iA& d%qA Wk)GaWmho is personally known to who 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 PUBLIC• Sign: Sign: Print: Print: Seal: Seal: tate o1 Florida pV hi4, No ry Public State of Florida ionato g t,atdcia Faggionato KBYONAjn/� 46�,; Plans ion F F 956608 My Commission FF 956808 /2020 Expires 03115/2020 *APPROVEv Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) DATE(MMIDO/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/9/2016 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 pohcy(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)._ PRODUCERCONTACT ME: NAME: Ethel Gruntler Casualty Systems, Inc. PH�Q.Extl: (305)551-0590 FNAXC N (305)551-0857 3331 SW 107 Ave ADDDDRIESS.admin@casualtysystems.com INSURE_RI§I AFFORDING COVERAGE NAIC s Miami FL 33165 INSURER A Arch Specialty Insurnace Co. INSURED INSURER 0: C i T Air Service Inc. INSURER C: 40 West 22 St Bay # 4 INSURER D: INSURER E Hialeah FL 33010 INSURER F: COVERAGES CERTIFICATE NUMBER CL164604534 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. INSRTYPE OF INSURANCE B POLICY NUMBER POLICY EFF MMIDDI ELICY XP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 DAMAGE TO A CLAIMADE 0 OCCURRENTEc S-M 100,000 PREMISES Ea accunence s AGL0035379-00 3/25/2016 3/25/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY F-1 PRO- ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: S AUTOMOBILE LIABILITY Ea seg en_t $ ANY AUTO BODILY INJURY(Per person) $ _^ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS NON- OS OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS {Per accident) $ UMBRELLA LM8 OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS 5 WORKERS COMPENSATION _. PER. _ O AND EMPLOYERS'LIA6ILITY Y/N STATUTE I IER_ ANY PROPRIETORIPARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE•EA EMPLOYE $ 0 describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached K more space Is required) CAC056705 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Juan Hernandez/JUAN 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 0r,44nn 0 DATE (MMIDO ACCMV _ CERTIFICATE OF LIABILITY INSURANCE 5 g 2o,s" 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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). CONt PRODUCER SUNZ Insurance Solutions, LLC. ID: (Ally) NAME:TAT Melissa Ash c/o Ally HR, Inc. PIAM.A91-94). 904-739-2722 FAX 904-262-2760 9016 Philips Highway E-MAIL Jacksonville, FL 32256 p REss: mash@rpptrixonesource com_ INSURERSS)AFFORDING COVERAGE NAtC 0 INSURER A: SUNZ Insurance Company ---t-1347-62_- INSURED INSURER s- Aspen Re_London-Best Ratinq"A+" _ Ally HR, Inc. 9016 Philips Hwy INSURER C! Chaucer Syndicate=Uoyds-Best Rating"A+" i _ Jacksonville FL 32256 INSURER o_Faradav Syndicate-Uovds-Best Rating"A+" MISURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 29835647 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.POLIC LTR TYPE OF INSURANCE L,S BR POLICY NUMBER MMMfDDY EFF i IMPM DD EXP - ---- — LIMITS COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE s --- CLAIMS MADE OCCUR I ( PREMISES(ga occurnMge) s __ MED EXP(Any one person) E ' I PERSONAL 6 ADV INJURY $ GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Icy E PROa LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY OM INED SINGL L MIT s _ i ,_LEe acdeeng _ ANY AUTO i i BODILY INJURY(Per person) $ OWNED SCHEDULED i , BODILY INJURY(Per accident) $ AUTO$ONLY AUTOS — HIRED NON-OWNED PROPERTY�DAMAGE s AUTOS ONLY AUTOS ONLY i Per aecidentL- — UMBRELLA LIAR OCCUR I EACH OCCURRENCE is EXCESS LIMB CLAIMS MADE AGGR _AEG TE S f DED RETENTION s ! 1 i is A woRKERscoMP NSATiON WCPE00000323 02 j 1/1/2016 11/1/2017 PER OTH M EMPLOYERS'LIABILITY YIN STATUTE ANYPROPRIETORIPARTNEP,IEXECUTIVE Q NIA + E.L.EACH_ACCIDENT �T 5--_1,000,000 OFFICER/MEMBER EXCLUDED? 1 (Mandatory to NH) I I E.L DISEASE-EA EMPLOY�EEI 1,000,000 tt es,descnbe under OF OPERATIONS below i ELL.DISEASE-POLICY LIMIT I S 1,000,000 CRIPTION Workers Compensation i I This is for informational purposes Excess Coverage and nothing shall create any right BC Iunder such reinsurance. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be a tachod if more space is required) Coverage provided for all leased employees but not subcontractors of:CT Air Service Inc 40 W 22nd Street Bay 4 Effective date: 1/1/2015 CERTIFICATE HOLDER CANCELLATION 7181 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE &PIRATION. DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 HE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS, Miami Shores FL 33138 / AUTHORIZED REPRESENTATIVE Glen J Distefano 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD �� � �� �2�� M � ��