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MC-15-575Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 CTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION NOV 2 g 2015 �?3Y: FBC /20 Master Permit No. AC/S----- _ 2� Sub Permit No. me_ Lc; ,r7S BUILDING ❑ ELECTRIC ❑ ROOFING cgl REVISION ❑ EXTENSION El RENEWAL 0PLUMBING %MECHANICAL El PUBLIC WORKS j CHANGE OF CONTRACTOR JOB ADDRESS: ❑ CANCELLATION SHOP DRAWINGS 4)290 /V. Qaf V/ Pr City: Miami Shores County: Miami Dade Zip: 33/.3g Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: ACtki CoonstructionaType�: �Q/►Flood Zone: BF/E:: FFE:d�1OWNER: Name (Fee Simple Titleholder): \ 11Y t1LL � Phone#:' 1. L 49-0-5 1 4 1 Address: 43 2.430 /�/V. Bity,a,Drt De. City: /14,;A1. 'Ph, ✓N State: 1---t-- Zip: 33/38 Tenant/Lessee Name: Phone#: Email: vicce to 4HAc/.n.Ia,v1edAJ erc..CBS. tv-w, CONTRACTOR: Company Name -A .B4 lee Ad [ c 4Q'f /�!%✓/f9; Phone#: 78 4 7'i 7S 3 0' Address: /SrGj1 /OS r, m in se j`Cet.auP. � P '�` .33i`3!o City: AU /u4 State: Pt—Zip: / n t Qualifier Name: keit f IC df i U3 600,1 Phone#: 76‘• � �j '/3J b State Certification or Registration #: Cite— CS72 24 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: Value of Work for this Permit: $ IZ u ltOd Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Description of Work: f4K's 4,Q 41001 CTL'neal4 Z 14V At- u rat:— VS ciattn NAi 1 &MA &Z _ VlivkelobAk 6 riOAK. 1- 04Leafqii6'/1& 1 �Ar.1 _ DeLeTT 1 1 NIG"*lL Pi FRS Et . Specify color of color thru tile: Submittal Fee $ Permit Fee $ - l� CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ .S '� City: State: Zip: ❑ New ❑ Repair/Replace ❑ Demolition (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 brochur will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of comment- ent must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is i j d. 1 - absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signatur ual< c1aCki44 Signatu OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The for::. ing instrument was acknowledged before me this tO day of N u o eml0,z r , 20 15 , by 10 day of h 0 U CAA 6 el , 20 r f , by 1—k C. % LOY\Gion , who is personally known to C-• 0L 3Q Sys ble`- , wh s perso nown to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ChriS�j�c� P CHRISTINA FRIGO MY COMMIISSION # FF229344 104.. dr EXPIRES: May 11, 2019 ********* *******)a****** **************************************************** CYU me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: • JORGE RO:472: COMMISIO9045 EXPIRES MA8 (407) 398-0 53 FloridallotaryService.com APPROVED BY Sltl (PI ns Examiner Zoning (Revised02/24/2014) Structural Review Clerk Project Address Miami Shores Village 10050 N.E. 2nd Avenue N Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit Ivo. MC -3-15-575 Permit Type: Mechanical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 7/2812015 Expiration: 01/2412016 Parcel Number Applicant 9290 N BAYSHORE Drive Miami Shores, FL 33138- 1132050270240 Block: Lot: RICKI LONDON Owner Information Address Phone Cell RICKI LONDON 9290 N BAYSHORE Drive MIAMI SHORES FL 33138-2949 9290 N BAYSHORE Drive MIAMI SHORES FL 33138-2949 Contractor(s) Phone AA MASTERS MECHANICAL AIR MOV (305)559-7004 Cell Phone Valuation: Total Sq Feet: $ 8,300.00 00 Tons: Additional Info: Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: PROVIDE NEW NC SYSTEM Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $5.40 $4.36 $4.36 $1.80 $290.50 $9.00 $7.20 $322.62 Pay Date Pay Type Amt Paid Amt Due Invoice # MC -3-15-54814 07/28/2015 Check #: 403 $ 322.62 $ 0.00 Available Inspections: Inspection Type: Final Rough Duct Review Mechanical 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 proper 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 c ify thf all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Fu ermo , I authopze the above-named contractor to do the work stated. Authorized SignaturOwnei" / Applicant / Contractor / Agent Building Department Copy July 28, 2015 July 28, 2015 Date 1 BUILDING PERMIT APPLICATION ❑BUILDING ❑PLUMBING JOB ADDRESS: City: ❑ ELECTRIC MECHANICAL 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 FBC 20 16 Master Permit No. RL/ S7.6 Sub Permit No. /4() / ' 4? ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑J RENEWAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP \ CONTRACTOR DRAWINGS D -G t\F 8-et01-VC 0 C • -31w ey , Miami Shores County: Folio/Parcel#: 1 1 — �G�S—v�� -•� Occupancy Type: Load: Construction Type: Flood Zone: Miami Dade Zip: Is the Building Historically Designated: Yes BFE: NO FFE: OWNER: Name (Fee Simple Titleholder): Pi_1 Phone#: Address: \ 4 C-1 sMt Avic City: 1 P°OM ( State: �L Tenant/Lessee Name: Phone#: Email: fI Gi l -,loLAw1 G; 4110,,)1,01 Qn-t- PSC )15sCS _ 04 1 1,1 •-.N.'5(--) �J 7 O `-i CONTRACTOR: Company Name:A-A 1sTEes M&L�Phone#:/D%OJ• Address: ,14 /-55-641 S w !o(.p TQjJjr AO? City: M\ R r' i State: Zip: 331 2.t. Qualifier Name: �r?w S r, [;'?t) e'riA Phone#: l g(p % 9330 State Certification or Registration #: C AC 03-'7 27 Co Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address:22 City: State: Zip: Value of Work for this Permit: $ U 300 Square/Linear Footage of Work: Type of Work: ❑ Addition. rW Alteratiop Description of Work: rAf,t, •{{ 4/c Jyd . tk,49 cx/l 6Y ❑ New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ D.A‘ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 32 2 .6 2. (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..ft I ' 1 401 "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." 1 I� ,) r 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. _ \ O Signatur Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 2., day of T C-- , 20 1 L , by i 0 day of M f c_H , 20 1 7 , by 12 -1C -46-t L ' Oma-' , who is personally known to .3-.f6t, Qi✓ Pr , who is personally known to me or who has produced t D as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ,t1e is 81 die • ` `� Sign: � • , �r /4 16 •`�' Print: _ C�rr'�Rr>°Ug��� cn . F I/lissr Seal:173p9 APPROVED BY (Revised02/24/2014) 31� identification and who did take an oath. NOTARY PUBLI• I • Sign: Print: Seal: Plans Examiner ;� JORGE k4YEXPit (4 1) at*d41 3 Fbfbtt u Frii9x)as Y4 2018 Ott, Go mm ************************************************ Zoning Structural Review Clerk • r- . Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The copulf_ a pzovided.apxaffdayj,utating that he or she will be the only person allowed to work on our pfoject. In these circumstances, Miami Shores Village does not req re verlfi ion of rkers Tompensation"insurante'coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature:t w Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this By kiLKr' L,ez- Lc, nylon Notary: SEAL: day of /?) ,I QCki , 20 17 . as identification. • JORGE ROSSEA ( ) MY COMMISSION 111FF11. • EXPIFES May 4 20 o1) 391 5S fko derweeySernce colt' • Date: 03./a. /5 State of Flo 2 1"FA ,4 Mets7 MtviAlocAc AID vii4 CP/4',i✓erg.i/1(6 SyS em s C2f /s59 / S'W /as4 1eg2 P►-ee 5-.1-C Mie,'L4 fL 33'9(_ County of 1)A74 Before me this day personally appeared Y $N S 6Ve OA 4 who, being duly sworn, deposes and says: ,/va7 40-24 ,P-eA~ 1 t- ho Sworn to (or affirmed) and subscribed before me this Jaiit5g.6drrtp, , JORGE: ROSSE'.AU ); To: Page 2 of 2 2015-07-07 19:22:11 (GMT) 18883301123 From: Gretell Gonzalez '"`l"`�' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/07/15 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(tes) 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 Usa General Insurance 5841 S.W. 137th Ave. Miami, FL 33183 Phone (305) 386-3305 Fax (888) 330-1123 CONTACT AME CT GRETELL GONZALEZ PH Na Ems). (305) 386-3305 1 rAA/c, No). (888) 330-1123 tt ADDREss• gretettgonzalezcyahoo.com INSURER(S) AFFORDING COVERAGE NAIC II INSURER A : GRANADA INSURANCE COMPANY N INSURED AA MASTERS MECHANICAL AIR MOVING & ENG SYSTEMS CORP 15591 SW 105 TERR #525 CONTRACTOR LICENSE #: CFC 1426169 Miami, FL 33196 (305) 244-0667 rrtvconr_me ,,,.-„�,r„-_... _, _,,, - INSURER B : 05/06/2015 INSURER C : EACH OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person INSURER E : CLAIMS -MADE Q OCCUR INSURER F : : • • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. THE WVD LISTED BELOW HAVE BEEN ISSUED TO THE TERM OR CONDITION OF ANY CONTRACT OR INSURANCE AFFORDED BY THE POLICIES DESCRIBED LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID — POLICY NUMBER I(MMIDD YLICY YYY) INSURED NAMED ABOVE FOR THE POLICY PERIOD OTHER DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR (MM/DDF IYYYY) —.......__............._._.__..._.._.—.___ - — LIMITS A GENERAL LIABILITY ra COMMERCIAL GENERAL LIABILITY N N 0185FL00045507 05/06/2015 05/06/2016 EACH OCCURRENCE s 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person $ 100,000.00 CLAIMS -MADE Q OCCUR S 5,000.00 : • PERSONAL & ADV INJURY S 1,000,000.00 ■ GENERAL AGGREGATE S 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 31 POLICY El jFa ❑ LOC AUTOMOBILE LIABILITY N COMBINED SINGLE LIMIT (Ea accident) $ II ANY AUTO BODILY INJURY (Per person) 3 • AUTOS ALL NEO • AUTOSSCHEDULED BODILY INJURY (Per accident) $ I.HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident)S S ■ UMBRELLA LIAB ■ OCCUR EACH OCCURRENCE 3 • EXCESS LIAB • CLAIMS -MADE AGGREGATE S • DED III RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR;PARTNER/EXECUTIVE OFFICERIMEMBER N / A I I $ WC STATU- OTH- • TORY LIMITS • ER E.L. EACH ACCIDENT $ EXCLUDED? (Mandatory In NH) It yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 5 I I 1 DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) LIC # CAC 057726 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI FL 33138 ACORD 25 (2010/05) QF 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 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD