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PL-16-2281Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION El BUILDING ❑ ELECTRIC ❑ ROOFING RE's", A G 29 2 0 16 BY: FBC20('43 VA Master Permit NOT -e_ (, -`2,0Y 3 Sub Permit No T t- (6 2.. Za 1 REVISION ❑ EXTENSION ❑ RENEWAL ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: _ -2r , l cam'-- T U No- - City: Miami Shores Folio/Parcel#: Occupancy Type: Load: County: Miami Dade zip: 3 3 (3 S Is the Building Historically Designated: Yes NO Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): �j e0Tog Phone#: � ,47 J `J 2 1 Address: 'i li /VG : p` S/ U1��t �- C-- Ci ( (� State: T L-- Zip: SI J - 3-2-93 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:(A)C2 Name: C2 �' (U( ? (U `1\1‘b' Vl) Cf -AT Address: ..i0u S L() 113 AV f City: 11®1 ? cum p State: 1 t IOi) Qualifier Name: (`i3C,.Co-t? Phone#: Phone#: '3 910 -1-1/6 State Certification or Registration #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ /9 OD Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration 0 New ❑ Repair/Replace ❑ Demolition Zip: .33 /`� C F C_ (y 7 1"-S-1 °Certificate of Competency #: Description of Work: 1210 V\fOQ LA/ca A. fic-kAc,v1 c?vK Specify color of color thru tile: Submittal Fee $ Permit Fee $ /5-6 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ I S Ct . iO (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. The foregoing instrumen. was acknowledged before me this day of 4109' ;j4, /7/ 20 / , by el9A'I'Ie/1/ , ®p ' Z, who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBUC: Sign: Print: Seal: CONTRACTOR The foregoing instrument was acknowledged before me this � J/ day of ( � 1 , 20 / t' , by vt/Al ! t�?41 ?erre-z..,', who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: EL HA -II1M:•�.' Notary Peelle - State o or '•- 1 197803 nr7pn<�'oc -Vat,;a:;.• My Comm. Expires Feb 9, 2019 #####MM#M##MMi Ile* #i#F#####Mi#*IP i##iiMM#MMM#########M###MiiM#MM#MM#M##i#i##########le* M####MMM#########M##M##M# APPROVED BY (Revised02/24/2014) Plans Examiner Zoning Structural Review Clerk WALTER PLUMBING CORPORATION 4054 SW 113TH AVE MIAMI, FL. 33165 TEL: 305-970-7116 FAX: 786-254-7580 EMAIL: WalterPlumbing@bellsouth.net FOR FORBES CONSTRUCTION ATTN: MARK SAAB EMAIL: MSAAB@FCDMIAMI.COM TEL: 561-267-3182 JOB ADDRESS: Ritz 3400 SW 27th Ave Miami, FL UNIT #1002 CHANGE ORDER DATE 6/21/2016 We are pleased to submit a change order request to perform the additional work requested for the above referenced project. This additional work will result in a change to the original contract as noted below: Description of the Change: - 2 NEW wall hung toilet - 2 NEW Lavatory - NEW shower - Concrete cutting for new shower - TOTAL for NEW labor -Credit for previously included labor for 2 floor mount toilet, 2 bidet, 2 lavatory, 1 shower and 1 tub (from estimate 11/16/2015) Amount of the change: Additional days needed for this change: $6,000.00 ($3,400.00) $2,600.00 2 weeks Terms and Conditions: Walter Plumbing Corp will proceed on this work only upon a fully executed change order. GC understands and acknowledges that failure by them to execute this Change order within seven (7) days will create additional delays in the completion of construction. The failure by GC to timely execute the Change Order within seven (7) days will be the basis for the addition of corresponding time to the construction schedule for the delay, as well as the additional days needed to complete the Change Order work. IN WITNESS THEREOF, the parties herto have executed this Change Order by their proper officers or duly authorized agents. Date: Project Manager Plumbing State Contractor Lic. #CFC1427510, Under Ground Excavation CUC1224638 Backflow Prevention Assembly Tester Certification MC2012-03 MCICK 3GOTT, OOVERNOR • I. KEN LAWCON, CECRETAr2Y STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CFC1427510 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 GUTIERREZ, WALTER A WALTER PLUMBING CORPORATION 4054 SW 113TH AVE MIAMI FL 33165 ISSUED: 06/09/2016 DISPLAY AS REQUIRED BY LAW RICK SCOTT, GOVERNOR SEQ # L1606090000951 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CUC1224638 The UNDERGROUND UTILITY & EXCAVATION CO Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 GUTIERREZ, WALTER A WALTER PLUMBING CORPORATION 4054 SW 113TH AVE MIAMI FL 33165 ISSUED: 06/09/2016 DISPLAY AS REQUIRED BY LAW 002266 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 6121131 BUSINESS NAME/LOCATION WALTER PLUMBING CORPORATION 4054 SW 113 AVE MIAMI FL 33165 OWNER WALTER PLUMBING CORPORATION Worker(s) 1 RECEIPT NO. RENEWAL 6384093 SEQ # L1606090001303 LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter BA - Art. 9 & 10 SEC. TYPE OF BUSINESS PAYMENT RECEIVED 196 SPECIALTY PLUMBING CONTRACTOR BY TAX COLLECTOR CFC1427510 $75.00 08/04/2015 CREDITCARD-15-039718 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec Sa-276. For more information, visit www.miamidade.gov/taxcollector .4co/ao® CERTIFICATE OF LIABILITY INSURANCE ‘.....-- DATE(MMIDDNYY`1) 07/13/2016 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), 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 A&A Underwriters Inc. 8778 SW 8st Miami FL 33174 CONTACT NAME: Pablo M Conde PHONE Exc); (305) 220-7447 FAX . No): (305) 220-4821 moss:pmc@aaunderwriters.com INSURER(S) AFFORDING COVERAGE NAIC 5 INSURERA: ARCH SPECIALTY INSURANCE COMPANY 21199 INSURED WALTER PLUMBING CORPORATION 4054 SW 113th Ave Miami FL 33165 INSURER B: MAPFRE Insurance Company 10805 INSURER c: BRIDGEFIELD EMPLOYERS INSURANCE CO. 10701 INSURER D : $ 1,000,000 INSURER E: INSURER F : OCCUR COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POIJCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING 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 CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDDNYYY) POLICY EXP IMMIDDNYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY AGL005612-02 10/25/2015 10/25/2016 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X X UABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS Comp/ Coil X X SCHEDULED AUTOS NON -OWNED AUTOS PIP $10,000 4150140009587 01/24/2016 01/24/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y IN Y NIA 830-38516 10/26/2015 10/26/2016 X PPEERTUTE ETH EL. EACH ACCIDENT $ 1,000,000 EL. DISEASE- EA EMPLOYEE $ 1,000,000 EL. DISEASE- POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) License # CFC1427510 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Ave Miami Shores, FL 33138 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 ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD --Foy iNA; c \6•k.: a.e. \-r ;- a APT 4 co ACC)6279 I p, I 11 lidII II AMUSSN