REV-17-117 Miami Shores Village
Building Department I
J g p JAN 11 2-017
10050 N.E.2nd Avenue,Miami Shores, Florida 33138 4
Tel:(305)795-2204 Fax:(305)756-8972 j BY-
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. -4 n- 11
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
j CONTRACTOR DRAWINGS
JOB ADDRESS: /zzc,� /V F �- ���
City: Miami Shores // z County: Miami Dade Zip: - ' k
Folio/Parcel#: �� _3=� �' � )C%� / Is the Building Historically Designated:Yes NO
Occupancy Type:.5 �� Load: Construction Type: L' J Flood Zone: BFE �,.(''L- FFE:
OWNER:Name(Fee Simple Titleholder): G'//�/ z /I ,f c�f '1 � YPhone#: 3'�-,"J; 3-V3
Address: /,� � J.S ��f���E' 7-
City: `�1/��,�/� ,1 r�iG/ C"1 State: f=f— Zip: 3 3 / 3
Tenant/Lessee Name: Phone#:
Email: d /fc�C�GI y �ili7c�/�i �f'1�r
CONTRACTOR:Company Name:�r�+.�7A���'1 y ��r"�- Phone#:
Address: 3�ryl A63 z
City: C7h9k (` /�State: v- s�o' Zip:
Qualifier Name: -Sr"ia Phone#:
State Certification or Registration#: �` V�L 6-;2 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 IBJ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of work: �t �l !-Je' &X /j 71-)�cl h--) o a idr i� r'
iii .; nrio%,'rr&!e s
Specify color of color thru tile: � 'W 14P 0
Submittal Fee$ Permit Fee$ Z— CCF$ o CO/CC$
Scanning Fee$ ry Radon Fee$ '0- DBPR$ Notary$ .�
Technology Fee$ (�� Training/Education Fee$ + y 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 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 approved and a reinspection fee will be charged.
. AA ✓ l /`
r
Signature Signature �/ ✓�
OtVNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The for4 ing instrument was acknowledged before me this
day of 20 17 by J '7 day of 9 120 by
who is personally known to rr-jc-o �-.2t7ho is personally known to
me or who has produced -J'& as me or who has produced RZ- f� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: F I HIS dcra.. Sign:
�—
JOSE LUIS PRIET
Print: 9� Print:
!"K,
•�Seal: •E*M i d 22.2019 Seal: MyComm.Expires Jul 22,2018
° t ,
tl�h NalonW NeteryM�.
APPROVED BY ` Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
TE(MM/DD(YY)
CERTIFICATE OF LIABILITY INSURANCEDA
_ 01/17/17 _
PRODUCER Excellence Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
3801 SW 107 Avenue ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Miami,FL 33165 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.-..___
- Phone (305)226-3900 Fax (305)226-3997 INSURERS AFFORDING COVERAGE NAIC#
INSURED PSG Plumbing Service, Inc INSURER_A Scottsdale Insurance Company 41297
3892 NW 125 Street INSURER B Infinity Auto Insurance Company- - 11738
INSURER c: Ascendant Commercial Insurance Co. 11398
Opalocka, FL 33054 - ---- -- --- ------------- -- -- --
INSURER D:
INSURER E
COVERAGES INSURER F
THE POLICIES OF INSURANCE LISTED 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.
INSR ADD'L I TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LT INSRD DATE(MM/DD/YY)-� DATE MMIDDIYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE 3,000,000.00
DA
®COMMERCIAL GENERAL LIABILITY MAGE
CPS2525345 08/22/16 i 08/22/17 PREMISES TO(EaNTED
REoNTED ce 300 000.00
❑0 CLAIMS MADE ❑ OCCUR —MED EXP(Anyone person) 5,000.00
A S/� ❑ PERSONAL R ADV INJURY 1,000,000,00
GENERAL AGGREGATE 3,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 3,000,000,00
I Q POLICY ❑PROJECT F-1 LOC_
AUTOMOBILE LIABILITY 509-55946_---- - -------- 1-------- ICOMBINED
-� 1,000,000.00
C BINED SINGLE LIMIT -1
El ANY AUTO 6827 001 07/09/16 07/09/17 (Ea accident)
ALL OWNED AUTOS - - -- --- _
B d I❑ SCHEDULED AUTOS
BODILY INJURY
❑ (Per person)
Q HIRED AUTOS
BODILY INJURY ---- - --
d❑ NON OWNED AUTOS Per accident)
Com $500.00 Ded ! - --.- -- -----..
— P
- --- --- — PROPERTY DAMAGE
d Coll $500.00 Ded (Per accident) I
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
C ❑ ❑ ANY AUTO OTHER THAN EA ACC
---- _-_-� AUTO ONLY: AGG -_
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 2,000,000.00
EBU 067946468 08/22/16 08/22/17 --- ---
' Q OCCUR ❑ CLAIMS MADE -`- ---
AGGREGATE 2_,000,000.00
❑ DEDUCTIBLE
(❑ RETENTION $ -- -
WORKERS COMPENSATION AND TV] WC STATU- [] OTH-
EMPLOYERS'LIABILITY WC-66349-1 11/18/16 11/18/17 TORY LIMITSER _ _ _��
C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1,000,000.001
OFFICER/MEMBER EXCLUDED? N ---- -- J-----, :_
SEASE-EA
Syes,describe underIf E.L.DISEASE_POLICY LIMIT Ei 1,000,000.00
SPECIAL PROVISIONS below �_ _
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
jAll Plumbing Operations and all vehicles covered under Umbrella Liability.All Personel.
CERTIFICATE HOLDER CANCELLATION
� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Miami Shores Village Building Dep 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
10050 NE 2 Ave THE LEFT,BUT FAILURE T O SO SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE RER,ITS AGENTS OR REPRESENTATIVES.
f Miami Shore, Ff 33138 AUTHORIZED REPRES E
Fax 305-756-8972 - 4
ACORD 25(2001/08)QF T O ACORD CORPORATION 1988