REV-16-650Miami 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
RECEIVED
MAR 11, 2016
FBC 20
BUILDING Master Permit No. c26. 8' IS 1989
PERMIT APPLICATION
❑BUILDING ® ELECTRIC ❑ ROOFING
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Sub Permit No.
❑ REVISION ❑ EXTENSION
6 6G
❑ RENEWAL
JOB ADDRESS: 95 AVE 9/ "
City: Miami Shores
County:
Miami Dade Zip: 3' )' IP
Folio/Parcel#: KI 3®1O OO 3®\30 Is the Building Historically Designated: Yes NO (
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): M►Lti Net_ Moi -A ki A Phone#: 784 ° 0 601?
Address: 9S,) NE 9 r Tcft-
City: r " ` /44im r e-P1o//i 5 State: FL Zip: 33130
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 2.4401 Gl EC M)(._ Phone#: 0SY- s73- 839
Address: ,a/L//9 / 3fi.'2 CT
L
City: Fr ALIO State: r1. Zip: 33305
Qualifier Name: 2 uai..t 459,14-12.? Phone#: OIS`/ °N.S73' 83 943
,r -
State Certification or Registration #: ,C. C_ / 3ct) /3 vg Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 0000 Square/Linear Footage of Work: 1.00
Type of Work: ❑ Addition tg Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
ADD TUU OttAS Lu trc-5 (Dyck
LAJAtL 4\10vvJr) �rry\JAhTL/ INA MOJL' 6Fl
MoN N44.... L.Gcoli torJ
Specificolor of color thru >tile : d.
Submittal Fee $ _ Permit Fee $ �j CCF $ CO/CC $
Scanning Fee $ 3 ,
Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
e3 - 03
(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
O NER or AGENT
The foregoing instrument was acknowledged before me this
!i day of 1974P®Ch , 20 , by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
S
S
rant:
'0 °Ud^. Notary Public State Joanna M Felicianoi��da
MY Commission FF 082753
�'Forhot� Expires 01/12t2018
as
The foregoing instrument acknowledged before me this
ii)* day of N(f,(.!�(iL'1
e.��✓�PrtSwe-[ ,whoi
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
A LANZO
COMMISSION FF999956
MY EXPIRES February 09.2020
4404 39A.0•!.7
/Inrdallobyssvbe.oan
********************************************************************************************
APPROVED BY J
(Revised02/24/2014)
Plans Examiner
Zoning
Structural Review Clerk
MAR -11-2016 10:28 From:5619959677
Page:1/1
coIs? CERTIFICATE OF LIABILITY
INSURANCE
DATE /1 tt20l (Y1/1
3/I rl2i.►Ib
THIS CERTIFICATE LS 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, aubJeCt 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 llou of such endorsement(s).
PRODUCER Ahone: f561)995-9577
lrax: (5(iI')995-9677
Van Amcringcn's Insurance and Financial Servinea
902 Clint Moore Rd
SUiIC 132
I3ttea Raton, Florida 33487
NAME/ Renee SI MII
PHONE (561)995-9577 FAX (-561)945.9677
AID No EXAq' (A(C. Not: •
reneethYaRanierinrits- Om
WSURERIS) AFFORDING COVERAGE
RAO r)
INSURER A : Scottsdale [NSW -MCC Company
41297
W(IURED
LRWDT ELECTRIC, INC.
EC 13001388
2] 49 NE 63RD Cf.
FORT LAUDERDALE, FL 33308 0
INSURER B
INSURER C :
$ 1,000,000
asuRER D
INSURER E
J CLAIMS -MADE I J I OCCUR
INSURER F :
CERTIFICATE NUMBER: 125
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AEwOVE FOR THE POLICY PERIOD
INDICATED. NUIWIIHSI'ANDING ANY REQUIREMENT, TERM OH UONDI1ION OF ANY CUM ItACT 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 COND1TIO_Ns OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
N!'R
TYPE OF WBt�ANC,E %IIID,.
1Nsn
SUER--
lou
-"
POLICY NUMBER
POLICY EFF
(MMmD/YYYY
POLICY EXP
IMMmn • %
LMrr$
1
COMMERCIAL GENERAL LIABILITY
('P'p3R4617
_
EACH OCCURRENCE
$ 1,000,000
A
J CLAIMS -MADE I J I OCCUR
( /3/2016
1/3/2017
DAMAGE :UHtRiEU
PREMISES (Ea occtmonco)
$ 100,000
MED EXP (Any N
OM
$ 5. 000
pyaty,)
PERSONAL& ADV INJURY
$ 1,000,000
CIEN•L
AGGREGATE LPIITAPPLIES PER
....I
GENERAL AGGREGATE
$ 2:000,000
✓
POLICY n mg: 1 LOC
PRODUCTS-COMP/OP AGC
$ 2,000,000
•THF.R:
$
AUYOMOBILS
LI/mart
COMBINED SIN ,LF L M
(Ea eca:WM
$
„
ANY AUTO
BODILY INJURY (Per person)
$
AUTOS
_
AUTOS
NON-OwNEHIRED
BODILY INJURY (Per aCCidant)
$
AUTOS
D
PROPERTY DAMAGE
(Per accident)
$
3
UMeRE„ w LWs
_
OCCUR
EACH OCCURRENCE
I
EXCESS UAB
MAIMS -MADE
AGGREGATE
DEO RETENTION $
$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
RTATUTS 1 ER
XECUTNE
OOF ICER/MEMBER EXCLuPROPRIETOR/PAR�bEb
Pi / A
E.L. EACH ACCIDENT
$
(Mantleto(y In NH)
dryeg deacrlbe under
E.L. DISEASE -EA EMPLOYEE
$
OkSCO IPYION OF OPFRATIONE Wow
C.L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Rematite Schedule, may be Maenad IT more space Is required)
REFERENCING T,TCRNSF it T1C17001333
ELECTRICAL CONTRACTING
ANCELLATION
Holder's Nature of interest • Cenifk'ate Holder
VILLAGE OF MIAMI SHORES
10050 NE 2ND AVE
MAIM, SHORES, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION BATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOEPREDENrATIVE
D 1988.2014 AGGRO COR • ., TIO '11 rights reserved-
ACORD 25 (2014101) Tho ACORD name and logo ere registered marks of ACORD
OF FLORIDA
DEPARTMENT F F VICES
DIVISIONOMP NSATIO
CERTIFICATE OF ELEC`ION TO SE EXE PT FROM
WORKER° _ �z
EFFECTIVE A
PERSON: SPAS NC
., •r- aa.. •..V.�. ma•a. a v,
NE TER CE