PL-17-1583 P . PL.-6-17-1583
Miami Shores Village Pel`7ype: .1lumbing-
�� 10050 N.E.2nd Avenue NE it
r. Work classj>sawn:Gas
Miami Shores,FL 33138-0000
Phone: (305)795-2204 Permit Status. i����I��E�
�coR.�A
Fxpiralflon: 02/07/201
ate.8111017
Project Address Parcel Number Applicant
853 NE 96 Street 1132060142820
LUIS 8,IRENE HERNANDEZ
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
LUIS 8,IRENE HERNANDEZ 853 NE 93 Street (305)754-4811
MIAMI SHORES FL 33138-2521
Contractor(s) Phone Cell Phone Valuation: $ 2,461.00
FERRELLGAS (772)287-4330 Total Sq Feet: 0
Type of Work:500 GALLON UNDERGROUND LP GAS TANK Available Inspections:
Type of Piping:500 GALLON UNDERGROUND LP GAS TANK Inspection Type:
Additional Info:
Final
Bond Return: Press Test
Classification:Residential Scanning:3 Review Plumbing
Fees Due Am ]50.00
Pay Date Pay Type Amt Paid Amt Due
CCF Invoice# PL-6-17-64320
DBPR Fee
DCA Fee 08/11/2017 Credit Card $ 168.30 $0.00
Education Surcharge
Permit Fee $
Scanning Fee Technology Fee Total: $16
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AF IDAVIT: that alltl ��o► g information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoni ut authorize the above-named contractor to do the work stated.
August 11, 2017
Authorized Signature:Owner scant / Contractor / Agent Date
Building Department Copy
August 11, 2017 1
Miami Shores Village
Building Department ✓��°�
g p 1®,>
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
�1 F�BC 2014
BUILDING Master Permit No. {( L1-1 — 157 3
PERMIT APPLICATION Sub Permit No.
F-1 BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL
❑■ PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 853 NE 96th St
Citv: Miami Shores Countv: Miami Dade Zip:
Folio/Parcel#:11-3206-014-2820 Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): Luis Hernandez Phone#:786-229-6200
Address:853 NE 96th St
City- Miami Shores state: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:company Name: Ferrellgas, LP Phone#: 772-287-4330
Address: 3232 SE Dixie Hwy
city: Stuart State: FL Zip: 34997
Qualifier Name: Jonathan Hurd Phone#: 772-287-4330
State Certification or Registration#: 01237 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$2461.00 Square/Linear Footage of Work:
Type of Work: ❑ Addition ElAlteration A New ❑ Repair/Replace E--] Demolition
Description of Work: 500 gallon underground LP gas tank and line to existing generator
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ d/ZS CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ r—OO Y
TOTAL FEE NOW DUE$ I( , 3 0
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after a building permit is is777
ch posted notice, the
inspection will not be approved a a reinspection fee wil a charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The fore ng instrument was acknowledged before me this
- 1 da u of .2o11 by 6th day of June .20 1 7 by
�5 00 who is so n to Jonathan Hurd ,who i personally known)o
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: `\\\\N*t) Illtl//// NOTARY PUBLIC:
a Cp F
Sign: _, dr��,•„�cs> Sign:
0.c:� -
Print �n� � ,zz ;�r print Melissa S VOigtSberge
Seal:
�� kM Y Seal: fiiEl.13SJ1S.VOIApd L9�.2021
GER
0j,,'�:. }. MY GOMMIS310N1751
Baled Tldu NoEXPIREtyMtite�s
*�+�r�x��e�ar**�*�*��xxs*��xx�s: �a*$*�r�r�:xy�ax-��***��a*s�aa���a�� �r�raa��•
APPROVED BY ����i Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Florida Department of Agriculture and Cncsumef Services
Bureau of Liquefied Petroleum Gas Inspection
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
Master Qualifier Mailing Address Licensed Location Address
JONATHAN G HURD
FERRELLGAS#5539 FERRELLGAS#5539
400 N OLD DIXIE HWY 3232 SE DIXIIz-HWY
JUPITER,FL 33458-4986 STUART,FL 3.3458
Certificate Number License Number
20217 01237
This Master Qualifier Certificate iS issued.pursu"ani o Chapter 527, F!�r;da &atuit s. This certiticate
is valid only for the person and licensed holder listed. Any changes to the Master Qualifier status
(such as transfer or termination of employment)must be reported to the Bureau of LP Gas Inspector.
at(850)921-1600 immediately.
The Master Qualifier Certificate is valid only through the date noted on the Certificate_ A notice of
renewal will be sent to you in advance of your expiration date. A Master Qualifier Certificate may be
renewed if certification of a minimum of 16 (sixteen)hours continuing education is provided along with
the renewal form. If training cannot be documented,an examination must be taken.
If there are any errors on the certificate, please submit all changes in writing to:
Florida Department of Agriculture and Consumer Services
Bureau of Liquefied Petroleum Gas inspection
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
Cut'Here
------------------------------------------------------
State of Florida
nccia 9 v
Department of Agriculture and Consumer Services
Division of Consumer Services Certificate No: 20217
Bureau of Liquefied Petroieum Gas Inspection Exam Date: March 30,2005
a� (850)921-1600 Issue Date: December 17,2014
Expiration Date: December 16,2017
Tallahassee, Florida Exam: 0601
MASTER QUALIFIER CERTIFICATE
This Certificate is issued under authority of Section 527.02,Florida Statutes,to:
JONATHAN G HURD
Valid For
License Number. 01237
FERRELLGAS#5539ew a
3232:SE DIXIE HWY ADAM H.PUTNAW,
STUART,FL 33456 COMMISSIONER Of AGRICULTURE
„V
Florida Department of Agriculture and Consumer Services
P.O. Box 6700
Tallahassee,Florida 32399-6700
License Number: 01237
Business Mailing Address Licensed Location Address
FERRELLGAS#5539 FERRELLGAS*5539
44fl N OLD DIXIE HWY 3232 SE DIXIE HW
JUPITER.FL 33458-4986 STUART,FL 34NT
a fiae
gjed pb-o6-thn gas Iii ansa at the bottom vi till-1vi,r is vzAd ONIL Y ilii She:oirip kirly iocaIt!d in it ie aaitll b
on the license_ Each business location of a company must be licensed. All LP Gas licenses must be renewed
annually. Any license allowed to expire shall become Inoperative because of failure to renew. The fee for
restoration of a license is equal to the original license fee and must be paid before the licensee may resume _
operations. -
IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be
transferred to any person,firm or corporation for the remainder of the current license year upon written request to
the department by the original manse holder. License transfers must be approved by the department Ali licensing
requirements must be met by the transferee and a transfer fee of$50 will apply. To apply for a transfer,contact the
Bureau of LP Gas Inspections at(850)921-1600.
Pursuant to Chapter 527,Florida Statutes,LP Gas licensees must present proof of licensure to any consumer,
owner,or and user upon request when engaged in the business of servicing,testing,repairing,maintaining or
mstalting LP Gas systems and/or equipment
For future correspondence,please make any needed corrections or changes to your business mailing address
and/or your licensed location address and return the UPPER PORTION vrith corrections to:
Florida Department of Agriculture and Consumer Services
P.O. Box 6700
Tallahassee, Florida 32399-6700
�:ut FiPre
State of Florida y
Department of Agriculture and Cunsumer Seearacea
Division of Consumer Services License Number. 41237
17
Bureau of Liquefied Petroleum Gas Inspection
Expiration of Date: August 31, 1,2
850 921-1600 Date of Issue: $425.00Septem1,2016
4 ) License fee: �4zs.00
POST LICENSE Tallahassee,Florida Type and class: 0601
CONSPICUOUSLY Liquefied
fled Pet ®gym License
6"�E�A '®CATEGORY I l.�' GAS DEALER �►o�r �i
GOOD FOR ONE LOCATION ONLY
ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE
INVALID
This license is Issued under authority of Section 527.02,Florida Statutes,to:
FERRELLOAS#5539
3232 SE DIXIE HWY ADAM H.PUTNAM
STUART, FL 34997 COMMISSIONER OF AGRICULTURE
CITY ®F STUART --RECEIPTNO. ACCOUNT o _CATEGORY:NO.
D 767 12440 120430
��- LOCAL BUSINESS TAX RECEIPT
2016-2017 TAX YEAR BEGINS OCTOBER 1 AND ENDS SEPTEMBER 30.
PAYMENT OCTOBER 1 CONSTITUTES VIOLATION
BUSINESI GAS DISTRIBUTOR OF CITY CODE OF ORDINANCES
TYPE. 11
THERMOGAS This local luuinas tax receipt dos not permit the holder to operate M violation of any Chv
OWNER law,ordinance,or regulation Any Changes in location or ownarship must be approved
AND 3232 SE DIXIE HIGHWAY by ttm City Ucenw Semon.subject m zmung restrictions.This receipt does=t cordlitute
LOCATION an endarsvment,approval,or disapproval of the holder's sWI or competence or of the
compliance cr non-comptiance of the holder mtn other laws,regulations,or standards.
STicTv' AP01080628
LICENSE-
Local Business Taxing Questions 772-288-5319
oescaiPr GAS DISTRIBUTIQNtiNSowl
'ClFEE:. PENALTY%:: <<TRANSFER ..,:: rWsCFTLANEOUs >::i� PAID .
B°�a 100.00 .00 0.00 0.00 100.00
�+ , DATE
FERRELLGAS 09/29/2016
BUSINESS NA#*RE THERMOGAS
AND 3232 SE DIXIE HW
MAILING STUART FL 34997 CHERYL WHITE
ADDRESS
CITY CLERK
KEEP THIS RECEIPT -NO TRANSFER WITHOUT ORIGINAL RECEIPT
a
LL la
N
m
THIS IS NOT AN INVOICE
N
THIS IS U ST C 1
DATE(V=DfYYYY)
ACCOR" CERTIFICATE OF LIABILITY INSURANCE 8/1/2017 1
5/18/2017
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). AUTHOREMO
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cart119cate holder Is an ADDITIONAL INSURED,the poAcy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain Italie may require an endorsement. A statement on
this certifies does not Confer rights to the certiPicatte holder In{leu of such endorsement
PRODUCER Lockton Companies WARA6 T ---j-
444 W.47th Street,Suite 900 =KE adXX No
Kansas City MO 64112-1906 E-MAIL
(816)960-9000 ADDRESS:
__—wsurER s)aFwRDu�a eovEEtzac -
__ _ DasuRERA:Qd Republic Insurance Company_._ 24147_
INSURED FERRF LLGAS,LP INSURER a -- --
80265 ONE LIBERTY PLAZA INSURERC:
LIBERTY,MO 64068 INSURE 0:
INSURER E:
INSURER F:
COVERAGES MAIN 1 CERTIFICATE NUMBER: 14702214 REVISION NUMBER: XXXXXXX
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 CLAMS.
INjR TYPE OF INSURANCE ADO. POLICY NUMBER IM EFF POLICY E8� UNITS
A I X CM"MtCIALGENERAL UAHILRY N N MWZY-302658 16 8/1/2016 18/1/2017 :DANCE S 3 000 000
I CLAIMS-MADE t X l OCCUR I� res(Fi _ $ 1,000,000.-..--
x
000,000 _X 500.000(SIR) i NEED t7CP(Any artaImrsdn) $ XXXXXXx
PERSONAL&ADV INJURY $ 3.000000
iGENERAL AGGREGA—TE—T'$ 10,000,000
GEN1 AGGREGATE LIMIT APPLIES PER GENERAL;�
POLICY�JEC, l�LOC ' PRODUCTS-coraPrOP acG $ 3000000
I OTHER:
A AUTOMOBILE LIABILITY N N' MWTB-30265916 8/1/2016 &1112017LIMT $ 3.000,000
NX
ANY AUTOBODILY INJURY(Terperms) $}{X{}QQ{�{OWNED SCHEDULED BODILY INJURY(Per accident) $ XXXXXXX
Ai�ONLY � NON-OWNED I �a $ XX_X
AUTOS ONLY AUTOS ONLY i I $ XXXXXXX
i
UMBRELLA IJAB OAR i NOT APPLICABLE EACH OCCURRENCE 5 XXX?CXXX
EXCESS LUIS AGGREGATE $ XXXXXXX
XXXXXXX DED RETENTION $
v NI)EMPLOYERS'
LIABILITY
I ATwN i N MWC 302657 02 f 8/1/2016 TTil/2017 X ATuiE
A AND'ERS OW LIA TION
ANY PROPRtETOR/PARTNER/EXECUTiVE Y t N N!A E4 EACH ACCIDENT $ 1,000,000 _�
OFFICER/MEMW EXCLUDED? FN j
(N-uw-v in NN) 1 EL DISEASE-EA EMPLO $ 1 000 000
Iiyesdescribe under E.L DISEASE-POLICY UNIT $ 1.000.000
DESCRIPTION OF OPERATIONS bet=
A CARGO N N MVITEI-30265916 8/1/2016 8/1,2017 $100,E
DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES(ACORD 901.A*MGMa1 RemaAcs SdW&ft May be Ntadwd B mom space is m4ub>
THE LIMIT EVIDENCED FOR GENERAL LIABILITY INCLUDES A$500,000 SIR-
CERTIFICATE HOLDER CANCELLATION
14702214
MIAMI SHORES VILLGE BUILDING DEPARTMENT SHOULD ANY THE ABOVE DESCRIBED POLICIES LL CANCELLED BEFORE
10050 NE 2ND AVENUE THE ExPIRt►TION DATE THI�teDF, NOTICE WILL BEE DELIVERED IN
ACCORDANCE W TH THE POLICY PROVISIONS.
MIAMI SHORES,FL 33138
AUTNOmm REPREsawwn7l
O Ign 5015 ACORD CORDO /RATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD