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PL-17-634 6rmrQ PL-3-1 7-634 e�!OR S L�4 Miami Shores Village Pe esident(sl.. r 10050 N.E.2nd Avenue NE ..., WO* �asaca� AdditiWAlt t 0" Miami Shores,FL 33138-0000 Peter#Status:APPROVE Phone: (305)795-2204 OR F . IssucF3ata 3t14C2 Expiration: 81062017 Project Address Parcel Number Applicant 270 N E 100 Street 1132060134450 HEIKO 8 ELENICE DOBRIKOW Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell HEIKO&ELENICE DOBRIKOW 270 NE 100 Street MIAMI SHORES FL 33138-2419 Contractor(s) Phone Cell Phone Valuation: $ 600.00 A&L PLUMBING SPECIALISTS LLC (954)274-8915 Total Sq Feet: 0 Type of Work:RESET KITCHEN SINK/FAUCET REPLACE D Available Inspections: Type of Piping: Inspection Type: Additional Info:RESET KITCHEN SINK/FAUCET REPLACE D Top Out Bond Return: Final Classification:Residential Scanning:3 Review PlEE� umbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# PL-3-17-63245 DBPR Fee $2.25 DCA Fee $2.25 03/14/2017 Credit Card $ 115.10 $50.00 Education Surcharge $0.20 03/09/2017 Check#:8037 $50.00 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $165.10 In consideration of the issuance to me of this permit, I a e top orm the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, s, atements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility, for do y either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING, I WS,DOORS,ROOFING and SWIMMING POOL work. OWNERS I e i in ormation is accurate and that all work will be done in compliance with all applicable laws regulating construction an z I e ove- med contractor to do the work stated. March 14, 2017 thorized Signature:Owner / Appli nt / ntractor Agent Date Building Department Copy March 14,2017 1 Miami Shores Village ; N-1112; vil Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 F/�BC 20 I� BUILDING Master Permit No. (`C - z'17-q00 PERMIT APPLICATION Sub Permit No. v->1 I :) - CG- ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING F-1MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP J CONTRACTOR DRAWINGS 9 JOB ADDRESS: ` io /V& a 00 � �) City Miami Shores County Miami Dade Zip: Folio/Parcel#• ` Is the Building Historically Designated:Yes ? Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): H1-' K0 9 W-4r0—z 1010Y W— Phone#: 30S �� 3 14C Address: 9ff— AS City: State: Zip: Tenant/Lessee Name: Phone#: Email: �y CONTRACTOR:Company Name: All- jfj5CA(-L0jS Phone#: 30 5 2I832sy Address: 3I.24 eovyn City: WAP',Z State: FL— Zip: !33 CK Qualifier Name: I - � A VA4 FA Phone#: 305 211A2-90' State Certification or Registration#: / Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$ �-� Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New KRepair/Replace ❑ Demolition Description of Work: �i� -� �I�N �� �• ��` W< P 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$ (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 issuanc ilding permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice ncement and construction lien law brochure will be delivered to the person whose property is subject to attachment. A!s ,a ifi copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs se ys fter the building permit is issued. In the absence of such posted notice, the inspection will not be approved are' will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this �6 day of I, i1� 120 11 by day of 2011 by A .l"['"� Cwho i ersonall to c2 who i erso a ow me or who has produced as me or who has produced as identification and who did ta4 an ath. identification and who d t an oath. NOTARY PUBLIC: NOTARY PUBLIC: C A INEZ ��"�"•, of L' J_ Ronda da A T C NEZ Apr x,20/6 ap+' of f#MW Sign Signc. ton dF EE 189111110 Print: Throh ' Print `'•• Boom 11itmi Seal: Seal: *�w+����ra��ac�+ra��xa�sa��ara*a�sa��*»+�+►+�*�*r*�����+���aae��x*�**r���*�*e*���*a��r�+r�*aroax+�a�a�a�eette��*Www*w�x�rr�r�xr�ra��**�*axor�x��wr APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/08/2017 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 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). PRODUCERAC NAME: PHONE FAX Automatic Data Processing Insurance Agency,Inc. A/c No Ext): AIC,No 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Technology Insurance Company,Inc. 42376 INSURED INSURER B: A&L PLUMBING SPECIALISTS LLC INSURER C: 1712 W FORE DR Tampa,FL 33612 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 631075 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY MM/DD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE El OCCUR PREMISES Ea occurrence $ MED FRCP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E T [7 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE DMTT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ;IN R-TSE R TATUTE ER IH AND EMPLOYERS'LIABILITY 1'000'000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA N TWC3587650 11/27/2016 11/27/2017 E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ (Mandatory in NH) If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERA11ONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Job Reference:EVIDENCE OF INSURANCE Contractor License:CFC#1418028 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Villlage Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE Miami,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD