REV-16-648\Q$D\So
BUILDING
PERMIT APPLICATION
® BUILDING
PLUMBING
JOB ADDRESS:
City: Miami Shores
Folio/Parcel#:
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
FBCn20
Master Permit No. Re..- e. % ° /969
Sub Permit No�F V ) b "' 0-1Y
❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ MECHANICAL 0PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
w me -ren-
County:y:
113).000 3ot3o
Occupancy Type: Load:
Miami Dade Zip: 3313
Is the Building Historically Designated: Yes NO
Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ` v` t C.irialkE r
Address: '3ivc '9 Prez
City: 41,,4m, S,zgs
t��►N P Phone#: .6,1• 601
State:
Zip: 33 /3
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: M i[i t Et- "
g"VA AAA
Address: / it0� c' �
Phone#: 7$6 • S'S1f '460/7
City: Mtvim t g? -9 air6 State: FL Zip: 33138
Qualifier Name: I l te..KA`,-L Vlb t" Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: - Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 4bO
Type of Work: ❑ Addition ❑ Alteration
Description of Work: V eJ$41 c:2b f
F-ir ViAima / t
Square/Linear Footage of Work: ao
❑ New ❑ Repair/Replace ❑ Demolition
PAL-PT/OA t.t) 4 L Avu/) J4A0 S I OF"
/od4.ST
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ X57,P,
CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $ 0 - CZ
(Revised02/24/2014)
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ GC( .
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 i// Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
ii day of`i , 20 by day of , 20 , by
o ho is personally known to , who is personally known to
me or who has produced FPL.._____as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign
Print:
Seal:
Pl'aG Notary public State of Florida
r ^ Joanna M Feliciano
My Commission FF 082753
8di� oe
of Expires 01/1212018
Sign:
Print:
Seal:
**********.. * **********************************************************************************
1
APPROVED BY
(Revised02/24/2014)
G
Plans Examiner Zoning
Structural Review Clerk
03/30/2016 12:52 9549723220
A1QUALITYPLUMBING
PAGE 01/01
ACIORO® CERTIFICATE OF LIABILITY INSURANCE oTE /03/2016
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES
ERTNSTECAFFORDED
BELOW. THIS CERTIF CERTIFICATE OF INSURANCEDOES NOT CONSTITUTE BETWEEN THE ISSUINGINSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pofcy(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 endoraement(J.
PRomUCER
AUTOMATIC DATA PROCESSING INSURANCE AGCY INC
1 ADP BLVD MS 625
ROSELAND, NJ 07068
(877) 677-0428
INC, N0, : ;(s77)0774420 (NC, Nol: ((77) 077-0430
E-MAIL Iced ant.Can
INSUROR(S1 AFFORDING COVERAGE
INSURER A 1 SNE TRAVELERS INDEYNETY COMPANY OF ANlgaCA
INSURED
A-1 QUALITY PLUMBING
CORPORATION
1055 NW 31ST AVENUE
POMPANO BEACH, FL 33069
INSURERS
INSURER C :
INSURER O:
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INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER: 039298631251650
REVISION NUMBER:
THIS IS TO CERTIFY THAT
INDICATED. NOTWITHSTANDING
CERTIFICATE MAY BE ISSUED
EXCLUSIONS AND CONDITIONS
THE POLICIES
ANY REQUIREMENT,
OR MAY
OF SUCH
OF INSURANCE LISPED BELOW HAVE
TERM OR CONDITION OF
PERTAIN. THE INSURANCE AFFORDED
POLICIES. LIMITS SHOWN MAY HAVE BEEN
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ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
BY THE POUCIES DESCRIBED HEREIN I3 SUBJECT TO ALL THE TERMS,
REDUCED BY PAID CLAIMS. _
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03/16/2017
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DESCRIPTION OI'' UPERATIONS 1
TYPE OF CONTRACTOR:
LOCATIONS /11EI4C1.ES (ADof0101, AdditI nal Bente*, Seheaula may ba utGaired H mac Wen hi requited)
PLUMBING, LICENSE #027526 .
CERTIFICATE HOLD
MIAMI SHORES VILLAGE
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL 66 DELIVERED 1N
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTNDR112FAREPREOENrATRfE P
ACORD 25 (2014101)
0 1988 2014 ACORD cOIIPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
1Somfiti(.
\73
PERMIT
MIAMI SHORES VILLAGE
APPROVED.
BY
ZONING
STRUCTURAL
ELECTRICAL
PLUMBING
MECHANICAL
BLDG, `
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1
DATE 7 rf,
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SUBJECT TO COMPLIANCE WITH ALL FEDERAL
STATE AND COUNTY RULES AND REGULATIONS
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