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REV-17-10BUILDING PERMIT APPLICATION ❑BUILDING IELECTRIC 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 ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WOR JOB ADDRESS: VI1 N t A 92 CitV: N. 0. Y: c` EJVED JAA 032017 5Th C Lfo ^2 0,3 BC 20 14 - Master Permit No. t\I 16 -&12..k. Sub Permit No.?' O/ 1 1 — ( v VISION ❑ EXTENSION RENEWAL TION ❑ SHOP RAWINGS Folio/Parcel#: Occupancy Type: Load: Construction Type: Is the Building Historically Designated: Yes 0 Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Phone#: Address: City: State: Zip: Tenant/Lessee Name: Phone#: j N FO e c1F, h t7 Email: CONTRACTOR: Company Name: ( S (41/4477/Y Address: 2/V�I v( �e 36 '?'ve U / 12 City: / 7Z 7h-. 01,4 - Qualifier Name: Zal,e- State: Phone#:7f Vic/ P r Zip:. ? / A O Phone#: 7/d' VVk' / p' State Certification or Registration #: Z. t; Q d d 3 / 7r- Certificate of Competency #: Phone#: 305-332- 114 Z3 DESIGNER: Architect/Engineer: Address: [ tti- `►G.ftil'' QS 2 Value of Work for this Permit: $ Type of Work: ❑ Addition Alteration n New ❑ Repair/Replace Description of Work: -r- reemr 4Jyou 0E0 TH (5 sA iLSe) lmcep p m5 2(.)t ‘5rz City: t.) H � State:F ' Zip:, �P Z Square/Linear Footage of Work: ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) CCF $ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ , 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 the‘gt— Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before rrmee-��this The foregoing instrument was acknowledged before me this 2. \ day of f� y hV 0�.•- , 20 (V . by / day f ,7i" �^'.� .= , 20 / ? , by #% (Q l-�0 1 , who is personally knowi o / �'� �� )Y -r C " who is persiatiy"known to me or who has produced H Uh S t o n Pa as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: *y, =�: ' • i -C. •cn " 1 ********************* APPROVED BY (Revised02/24/2014) •°:!3 NOISs0 me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: as a$$ia y CASSANDRA NEBBIA Notary Public - State of Florida om Comm. Expires Jul 25, 2020 Bonded through National 'rt uy ******************************************************************************** ✓z 1—A--f/'YPlans Examiner Structural Review Zoning Clerk ACOR.J ,. DATE (MM/DD/YYYY) 12/27/16 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(les) must be endorsed. If SUBROGATION 1S 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 Insurance Industries 953 N.E. 125th St. N. Miami, FL 33161 Phone (305)891-2808 Fax (305)891-6367 CONTACT STACY PARKS NAME: (NC. No. (305)891-2808 (Nc,No)' (305)891-6367 ADDRESS• stacy@insuranceindustriesinc.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ARCHsSPECIALTY INSURANCE COMPANY Y INSURED L S CURTIS INC. 20341 NE 30 Ave #108-6 AVENTURA, FL 33180- (305) 892-0115 INSURER B : MERCURY INSURANCE COMPANY 12/09/2016 INSURERC: UNITED STATES LIABILITY INSURANCE COMPANY EACH OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E : VCOMMERCIAL GENERAL LIABILITY INSURER F : $ 5,000.00 COVERAGES 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 POLICY PERIOD INDICATED. NOTWITHSTANDING 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 TYPE OF INSURANCE NSR WVD POLICY NUMBER (MMIDD/YYEYYY) (MM/DDYn�) LIMITS A GENERAL LIABILITY Y Y AGL0043614-00 1778310 12/09/2016 12/09/2017 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 VCOMMERCIAL GENERAL LIABILITY MED EXP (Any one person $ 5,000.00 El • CLAIMS -MADE Q OCCUR ❑ PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 ❑ POLICY 0 JE8-F • LOC $ B AUTOMOBILE LIABILITY ❑ ANY AUTO Y Y BA090000008429 04/20/2016 04/20/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident' $ D AUTOS NED SUTOSCHEDULED NON PROPERTY DAMAGE (Per accident) $ -OWNED 0 HIRED AUTOS 0 AUTOS C v UMBRELLA LIAB v OCCUR Y Y XL1574975 10/26/2016 10/26/2017 EACH OCCURRENCE $ 2,000,000.00 EXCESS LIAB • CLAIMS -MADE AGGREGATE $ 2,000,000.00 ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION EMPLOYERS' UABIUTY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑ WC TORSTATU- • OTH R AND E.L. EACH ACCDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ELECTRICIAN:scheduled auto: 2008 lexus es350.blanket additional insured. waiver of subrogation.Additional Insured/Certificate Holder: CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED CANCELLA I MIAMI SHORES VILLAGE 10050 NE 2 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 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE 5/110 0 6 THIS CERTIFICATEIS 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 have ADDITIONAL INSURED provisions or 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 AUTOMATIC DATA PROCESSING INS AGCY 250717 P: F: PO BOX 33015 SAN ANTONIO TX 78265 CONTACT NAME: PHONE FAX (AIC, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Twin City Fire Ins Co 29959 INSURED L. S. CURTIS INC. 20341 NE 30TH AVE APT 108 AVENTURA FL 33180 INSURER B : INSURER C : INSURER D: INSURERE: INSURERF: $ MBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYY}) POLICY EXP (MM/DD/YYYY) LIMITS LTR COMMERCIAL GENERAL LIABILITY OCCUR EACH OCCURRENCE $ CLAIMS -MADE DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT PRO- JECT APPLIES PER: LOC GENERAL AGGREGATE S POLICY PRODUCTS - COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S DED RETENTION $ S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YM OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NiA 76 WEG TR4959 05/01/2016 05/01/2017 X PER OTB - STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1, 000, 000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Those usual to the Insured's Operations. License #EC0003175 VGR1 Irulsn11_ IIVIa,I_I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE Miami Shores Village DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 10050 NE 2ND AVE AUTHORIZED REPRESENTATIVE 7a --r ---17Qt,,a.,--- MIAMI SHORES, FL 33138 .. . _.. II 11 ..,..l../.............••••,.., ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 CURTIS, LEWIS STEVEN L.S. CURTIS INC 20341 NE 30TH AVE APT 108 AVENTURA FL 33180 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfioridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! RICK SCOTT, GOVERNOR STATE :OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSION4 L REGULATION EC0003175 � ISSUED_ 06/23/2016 CERTIFIED ELECTRICAL -CONTRACTOR CURTIS, . LEWIS,tSTEVEN. L.S. CURTIS INC ' IS CERTIFIED under the provisions of Ch 489 FS. Expiration date AUG 31, 2018 L150623001113 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD LICENSE NUMBER The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under theprovisions of Chapter 489 -FS. Expiration date: AUG 31, 2018 CURTIS, LEWIS STEVEN L.S:.CURTIS,INC;" 20341 NE 30TH AVE #108 AVENTURA FL 33180 • ISSUED: 06/23/2016 DISPLAY AS REQUIRED BY LAW SEQ # L1606230001113 001467 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - 00 NOT PAY 5108006 BUSINESS NAME/LOCATION L S CURTIS INC 20341 NE 30 AVE 108 AVENTURA FL 33180 OWNER L S CURTIS INC Worker(s) RECEIPT NO. RENEWAL 2427060 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Cotte Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EC0003175 PAYMENT RECEIVED BY TAX COLLECTOR $45.00 07/12/2016 CREDITCARD-16-039366 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit. ora certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory Jaws and requirements which apply to the business. The RECEIPT NO. above must be displayed an all commercial vehicles - Mianti-Dade Code Sec 8a-216. For more information, visit www miamidade aovhaxc thestor