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REV-16-8634- r BUILDING PERMIT APPLICATION El BUILDING ❑ ELECTRIC ❑PLUMBING airIIECHANICAL JOB ADDRESS: 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 (5114 FBC20l�1 Master Permit No.Z--� --JIIB^/' 2‘2:, Sub Permit NoJIC ) 1 C-8 3 ❑ EXTENSION ❑ RENEWAL ❑ ROOFING [1EVISION ❑ PUBLIC WORKS ❑ CHANGE OF CONTRACTOR 11/F /®6 cT ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: / / / l2 c1 / Is the Building Historically Designated: Yes Construction Type: 6 74 5 Flood Zone: BFE: Occupancy Type: Load: NO FFE: OWNER: Name (Fee Simple Titleholder): ex. /34 /2 -,i i. / SL- '7, Phone#: G S - 2 5-5f ? Address: 2 (-7r /,C- ; -t City: ,/%/f �i /,!lXG.,ws State: f- l Zip: 7?. / Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: dd Address: / 60-e-07— 3 el -s Phone#: (3-tf) °S—SI-3k City: 1- , A � -'Q'& State: L - Zip: J.3 ei/V--- Qualiifier Name: (s1/4' -L do g /1--A-ei J Phone#: 6 5,-5F, -3.--7.•1-- State Certification or Registration #: 64 C 0. - 43, Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 'O CJ' Type of Work: ❑ Addition 0 Alteration Description of Work: A.',4/1.) 41,5' Square/Linear Footage of Work: ❑ New ❑ Repair/Replace 2-c'c' 5, 0 Demolition / cca / 7-- //c -PL. - Specify ,' I -f _ Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ 0 e 90 Structural Reviews $ (Revised02/24/2014) Permit Fee $ Radon Fee $ g • CCF $ Q . (0 co/cc $ 0 DBPR $ • Notary $ Training/Education Fee $ 0 • P3b Double Fee $ 95 Bond $ 0 TOTAL FEE NOW DUE $ 1 OB " 64 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. OWNER or AGENT The foregoing instrument was acknowledged before me this day of ___///1 � , 20 / by Fwho is personally known to t me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: 9 -am' y41 V. Frlid4r. 1iN as sssssssswss APPROVED BY (Revlsed02/24/2014) JIM D. PAMPLIN Notary Public - State of Florida rz� Qc My Comm. Expires J ra� 89 ii � �,, , ,, ,,,,,$$ Sian'#� Signature CONTRACTOR The foregoi instrument was acknowledged before me this day of ift4 rciL , 201 z , by g t 'yid/, who is personally known to me or who has produced Deem -Lee as identification and who did take an oath. NOTARY PUBLI . Sign..// Print: ' Seal: 0",8*,;k„ ALBERTO E LUZARDO Notary Public - State of Florida I My Comm. Expires Feb 23, 2018 Commission # FF 095203 8411;',1444,44:188;1444811g �Aep•seseesrsrsrrrwsssss*****wt+r*e• Tans Examiner Structural Review Zoning Clerk A, c�RO® DAfE(NIUDDWYYJ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 03/31/2016 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 certifloate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 0' 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 /leu of such endorsement(s). PRODUCER Emmanuel insurance 8 Associates, Inc. 2370 E 8TH AVE HIALEAH INSURED HAVANA AJR CONDITIONING INC OSVALDO BORRELL 887 W 34TH ST HIALEAH FL 33012-5159 License No: CAC056638. COVERAGES FL 330134236 NANTAcr Sarai Medina NAME: PHONE (A1C No. Exti: (305)693-0003 E-MIUL ADDRESS: saral@emmanuelinsuranoc ccm � , No, (305) 691-4381 INSURERS) AFFORDING COVERAGE INSURERA: Preferred Contractors Insurance Co. JNSUREt a : RetailFirts Insurance Co. NAM e 12497 10700 INSURER C : INSURER D : INSURER E: INSURER F: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. MISR LTR TYPE OF INSURANCE GENERAL LIABILITY RCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE ;!� OCCUR ADDL.' )NSR LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER GEN'L AGGREGATE LIM TAPPLIES PER n • POLICY 1-71 JEel:: n LOC AUTOMOBILE IJABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS Y . PC4405017-02 POLICY EFF POUCY EXP If(MMIDD/YYYYj IMIWODM'YY1 09/23/2015 09/23/2016 LIMITS EACH OCCURRENCE $ 1,000,000.00 DAMAGE7ORENTED $O,DOO.000 PREMISES (Ea occurrence) $ MED EXP (Any one person) g 5,000.00 PERSONAL ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 SCHEDULED AUTOS NON -OWNED AUTOS UMBRELLA LIAB EXCESS LIAR B DED J OCCUR fl CLAWIS-MADE RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORJPARTNER/EXECUTNE OFFICER/MEM3ER EXCLUDED? {Mandatory in NN) I( yea, desalbeunder DESCRIPTION OF OPERATIONS below COMBINED SINGLE LIMtr (Ea accident) BODILY INJURY (Per person) S BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) S S EACH OCCURRENCE $ AGGREGATE $ YIN N1A 052045661-0 09/10/2015 09/10/2016 XWC STATU- I OTH- 7ORY LIMITS ER EL. EACH ACCIDENT g 1,000,000.00 EL. DISEASE - EA EMPLOYEE g 1,000,000.00 DESCRIPTION OF OPERATIONS 1 LOCATIONS! VOW LES (Attach ACORD 101, Additional Remarks Schedule if more space is required) Mechanical Contractor. E.L. DISEASE . POUCY LIMIT $ 1,000,000.00 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2 AVE MIAMI SHORES, FL 33136. ACORD 2642010/05) Vd SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - S /11.2./..4;ta, ©1988-2010 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD 991.889999L 61.1!UO ipuoO a!V 9U8ADH dg V60 91. LO Ddb'