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PL-15-2588Amount $3.60 $4.50 $4.50 $1.20 $300.00 $9.00 $4.80 $327.60 • Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 201; Expiration: 06/08/2016 Parcel Number Applicant 186 NE 106 Street Miami Shores, FL 33138- 1121360050010 Block: Lot: CK PROPERTY SOLUTIONS, LLI Owner Information Address Phone CeII CK PROPERTY SOLUTIONS, LLC 209 NE 95 Street MIAMI SHORES FL 33138- (305)758-3133 209 NE 95 Street MIAMI SHORES FL 33138- Contractor(s) Phone CLIVE G NELSON PLUBING INC (954)934-5151 CeII Phone Type of Work: UPDATE KITCHEN, BATHROOM Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Pay Date Pay Type Invoice # PL -10-15-57397 12/11/2015 Credit Card 10/13/2015 Credit Card Amt Paid Amt Due $ 277.60 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 prorer 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 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. Futhermse, I autho • e the above- med contractor to do the work stated. r2- /-� December 11, 2015 Authorized Signatur ner / Applicant / Contractor / Agent Building Department Copy Date December 11, 2015 1 1 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC Miami 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 ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: / GV 6 72'5: /(2 C FBC Master Permit No. i2C 20 14 Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ CHANGE OF CONTRACTOR ❑ RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: /1 2 / ? 6 r� v 4 0 / C? Occupancy Type: Load: Is the Building Historically Designated: Yes Construction Type: ' 4 S Flood Zone: BFE: NO FFE: OWNER: Name (Fee Simple Titleholder): 4A 0,e'/:c177/3.2 7/ $ QPhone#: 3 cd 7S .7/ 3 Address: 2- `- V i ' 7 City: /'�///'/'/( .f/7'cr>"l E( State: fr-6- Zip: } 3 / Tenant/Lessee Name: Phone#: Email: 0 7C' 17 X"; /le ."- • CONTRACTOR: Company Name0-- CZ/ q4.- `'S"/ 44Z 4 Phone#:%5Y337 67 Address: /0241.---(1141: Z3 C-4:914 `,, ,, City: �•z efrh' State:/, p,�0ro" Qualifier Name: • AA-Kr.� 9 State Certification or Registration #: Cry 03. 04C Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Phone#: Value of Work for this Permit: $ 0 00 ('L) Type of Work: ❑ Addition ❑ Alteration Zip: Square/Linear Footage of Work: ❑ New ❑ Repair/Replace Description of Work: /41#rg ) % ch` %/,1T/14/LGfi 7 ❑ Demolition Specify color of color thru tile: Submittal Fee $ 6(06 r Permit Fee $ 300 ¢r CCF $ '5 • 6 Cn CO/CC $ Scanning Fee $Fl_ Radon Fee $ LI ^�� DBPR $ U . ,c10 Notary $ LI Technology Fee $ - Training/Education Fee $ 11 - 2-/ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 2-1--i (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. Signature P✓ ����G G�f��' OWNER or AGENT The foregoing instrument was acknowledged before me this da/y of i,...) , 20 /S by V,J`ee /4 Oi-%kbise / , who is personally known to me or who has produced iF as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Ji /lam% Seal: —. .2 'LLQ ***********+R**********i+k******i****i•********ek**#*********R***R*+R+t*****+k*********+R**i+k*******R+t************* JIM D. PAMPLIN Notary Public - State of Florida My Comm. Expires Jan 13, 2017 Commission # EE 864892 CONTRACTOR The foroing instru ent was acknowledged before me this day of 71•413 / 20 /1.-- , by Chi -da- Cj..A '<50..; who is personally known to me or who has produced_YV..ocr/d?J? O.57a identification and who did take an oath. NOTARY PUBLIC: Sign: RON TERRY NELSON N #FF081120 "1.4„4" EXPIRES October 8, 2017 (407) 398.0153 Florklallota Service.com as Seal: APPROVED BY (Revised02/24/2014) f/,L r5 Plans Examiner Structural Review Zoning Clerk a BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA: CLIVE G NELSON PLUMBING INC Business Name: Receipt#:PLUM IONG%LWN SPRNKL/CONTRA Business Type:(CERTIFIED PLUMBING CONTR) Owner Name: CLIVE GEORGE NELSON Business Opened:09/09/2002 Business Location:10218 SW 23 CT State/County/CertfReg:CFC058016 MIRAMAR Exemption Code: Business Phone: 954-801-6038 Rooms Seats Employees 1 Machines Professionals For Vending Business Only Number of Machines: Vend inn Typo: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost TotalPaid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY iN YOUR PLACE OF BUSINESS i THIS BECtSMES A TAX RECEIPT WHEN VALIDATED Maiting Address: CLIVE GEORGE NELSON 10218 SW 23 CT MIRAMAR, FL 33025 This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 2015 - 2016 Receipt #01A-14-00007938 Paid 07/14/2015 27.00 '4 R®® CERTIFICATE OF LIABILITY INSURANCE DATE oil o 15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORAAATION 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(ies) 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). PRODUCER 1st Allegiant Insurance, LLC 2419 Hollywood Blvd. Ste. I£ Hollywood PL 33020 NCAO frACT Leighton Campbell PHoNe Pa' (954) 378-3235 (AX AM.Nod: (954)323-5477 gmm:leighton@lstallegiant.com INSURER($) AFFORDING COVERAGE NAIL 6 INSURERa:Ohio Casualty Insurance Co 24074 INSURED Clive G. Nelson Plumbing Inc. 10218 SW 23rd Ct Miramar PL 33025 INSURER B :8'UBA Workers Comp INSURER C : $ 1,000,000 INst)RERD: INSURER E : OCCUR INSURER F: $ 100,000 CERTIFICATE NUMBER:1 Basic Certificate THIS 1S 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 POUCIES UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TYPE OF INSURANCE ? t ADOL Wel POLICY NUMRER aNSU POUCY Y Y! POU ( MID[ AW11 LIMITS A X COMMERCIAL GENERAL LABILITY 138955358402 12/1/2015 12/1/2016 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGERENTED TO ) $ 100,000 MED EXP (Any one person) S 10,000 PERSONAL BADV INJURY S 1,000,000 GEN'L X AGGREGATE POUCY OTHER: LIMIT APPLIES JPEC PER i LOC ( GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 Ems Bens* S AUTOMOBILE — _ — 1 rush ITV ANY AUTO ALL OOS ED HIRED AUTOS —AUT i i SCHEDULED AUTOSNON-OWN® COMBINED SINGLE LIMIT (Ea =Henn s BODILYINJURY (Per person) S BODILY INJURY (Per accident) � IDAMAGE S S UMBRELLA UAB EXCESS LIAR, OCCUR ' , EACH OCCURRENCE AGGREGATE $ DEO RETENTION $ f $ B WORKERS COMPENSATION AND EMPLOYERS' LIAa1UTYY IN i I ANY PROPRIETOR/PARTNER/EXECUTIVE OF EXCLUDED? n1 N /A In Ntq I 'l It y d under SCRIN?TION OF OPERATIONS betake 10646246 12/13/2015 12/13/2016 PER 0T1 -I - STATUTE ER E L EACH ACCIDENT 6 1,000,000 ELDISEASE-EAEMPLOYEE $ 1,000,000 EL DISEASE -POLICY LIMIT $ 1,000,000 1 DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be altaehed it more space Is resulted) Certified Plumbing Contractor - License 8 CPC - 058016 CANCELLATION ( ) - Miami Shores Village Building Department 10050 NB 2nd Ave Miami Shores, 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE Leighton Campbell/LC ,�-— ACORD 25 (2014/01) INS02S muunil ©1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD kC cc — x-01 �S— `SO7