REV-17-844 Miami Shores Village
Building Department R 28 2017
L3Y. _
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. �G-
PERMIT APPLICATION Sub Permit No.RE L4 q
EdBUILDING ❑ ELECTRIC ❑ ROOFING EYREVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
GHQ l� n,, CONTRACTOR DRAWINGS
/j N
JOB ADDRESS: 1 1 I /"f 'L� ga
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name(Fee Simple Titleholder): _ � �Le��QNjCz kOAU�93 -•wSf_ Phone#: 3nr6f 3 42-4-2-
Address: Nil - 4-kA A(W 'RA—
City: .S State: Zip: 33 13e
Tenant/Lessee Name: Phone#:
Email: rr ,
CONTRACTOR:Company Name: �� 8OZ-6WW9,1 �- Phone#: � (i13 4a-4L
Address: T9I c q , I %AI'Ac *-�b3
City: l V_ �'�r State: Zip: 33i ct I
Qualifier Name: L�u�^-NO A� Phone#: _3J1_
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ "� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: Lw
• •-• a ti, .3`1 "} S' >
r.1..u y l
Specify coi'or'of'colorlthru the
Submittal Fee$ Permit Fee$ S CCF$ CO/CC$
Scanning Fee$ c1- � Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(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.
"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 ro re will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of con ence ent must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the a ence of such posted notice, the
inspection will not be approved and a inspection fee will be charged.
Signature >< Signature
WNER or AGENT CO TRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument w, s�acknowledged before me this
10
day of k44'G�/ 20 by 0 day of 20 f�- by
T-W64Cti Q kP0X%L- ,who is personally known to f4A,'SVW4 p�do,� who is personally known to
r-
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: P c Sjatodcf Florida Sign:
Patdcla agg o N PubNc tale
Print: FF 956M Print: Pat rt Fagglonato
Yn 53W
Seal: ors< Seal: ff-**J�I�JFipi 03/15/2020
APPROVED BY ? ' Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
AOM. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY7
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
RIVERS INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
2879 West 2nd Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hialeah, FL 33010
(305)888-3627 INSURERS AFFORDING COVERAGE NAIC#
INSURED (14B CONSTRUCTION INC INSURER A: COLONY INSURANCE COMPANY
7929 WEST DRIVE #703 INSURER B PROGRESSIVE EXPRESS INSURANCE COMPANY
NORTH BAY VILLAGE, FL 33141 INSURER C
305 613 5572 INSURER D:
INSURER 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.
1 e LPOLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR Nsao F INSURANCE DATE MM/DD/YY DATE MM/DD/YY
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurence $ 100,000
CLAIMSMADE D OCCUR MED EXP(Any one person) $ 5,000
A X $1,000 PD DED GL0051889-02 04/02/17 04/02/18 PERSONAL&ADV INJURY $ 1 ,000,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY JE� LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
X ANYAUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $ 25 000
X SCHEDULED AUTOS (Per person) i
B X HIRED AUTOS 04557579-6 02/12/17 02/12/18
BODILY INJURY $ 50 000
X NON-OWNEDAUTOS (Peraccident) i
X PIP $1,000 DED PROPERTntj DAMAGE $ 25,000
(PerGARAGE LIABILITY AUTOONLY-EAACCIDENT $
ANYAUTO OTHERTHAN EAACC $
AUTOONLY AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CI CLAIMSMADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND TCRY
LtMNC ITS R
EMPLOYERS'LIABILITY
E.L.EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMSER EXCLUDE09 E.L.DISEASE-EA EMPLOYE $
Ifyes,describeunder
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
LICENSE#CGC1514518
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
VILLAGE OF MIAMI SHORES DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
10050 NE 2ND AVE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
MIAMI SHORES, FL 33138 IMPOSE NO OBLIGA'RON OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIV I
AUTHORIZED REP ES f TIVJ '7/
ACORD 25(2001/08) I 0 ACORD CORPORATION 1988