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MC-16-983Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Cc t--3C�7 Inspection Number: INSP-256775 Permit Number: MC -4-16-983 Scheduled Inspection Date: October 24, 2016 Inspector: Perez, JanPierre Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138 - Project: <NONE> Contractor: H LAMM INDUSTRIES INC Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: Addition/Alteration Phone Number (863)688-747_ Parcel Number 1132060100010 Phone: (954)491-8929 Building Department Comments HVAC MECHANICAL - DUCT WORK CHANGES. Infractio Passed Comments INSPECTOR COMMENTS False voi Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments October 21, 2016 For Inspections please call: (305)762-4949 Page 6 of 44 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 Project Address Parcel No.. 1.a 1, Permit NO. MC -4-16-983 LiPermit Type: Mechanical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 4/25/2016 Expires: 10/22/2016 Tract No. Block No. Lot No. Section Township 9050 BISCAYNE Boulevard Miami Shores, FL 33138- 1132060100010 Owner Information Address Phone Cell PUBLIX SUPERMARKETS, INC P 0 BOX 407 LAKELAND FL 33802-0407 (863)688-747_ Contractor(s) Phone Primary Contractor H LAMM INDUSTRIES INC (954)491-8929 Yes Proposed Construction / Details HVAC MECHANICAL - DUCT WORK CI-IANGES. Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Amount $21.00 $15.75 $15.75 $7.00 $1,050.00 $3.00 $28.00 Total: $1,140.50 Valuation: Total Sq Feet: $ 35,000.00 0 Total I Amt Paid I Amt Due $ 2,190.50 $ 1,140.50 $ 1,050.00 Required Inspections: For Inspections call 1(866) 701-3365 Inspection IVR See Permit Record Building Department Copy Monday,(pril 25, 2016 2 RICK SCOTT, GOVERNOR (CENSE NUMBER KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 'he MECHANICAL CONTRACTOR larged below I$ CERTIFIED • irtdei the provisions of Cbal5tet 489FS. :xpirat on date.. AU'Ga1,,2oi HAWK, JEFFERY H. LAMM INII� .4425- N,IE EOIZ LAS ISSUED: 07/01/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1407010001676 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA: Business Name: H LAMM INDUSTRIES INC Owner Name: HELMUT LAMM Business Location: 4425 NE 6 TERR OAKLAND PARK Business Phone:491-8929 Rooms Seats Employees 30 Receipt #:ALL THSR4TYPES CONTRACTOR Business Type:MEC%iA,NiCAL CONTRACTOR) Business Opened:o7/16/1993 State/County/Cert/Reg: CMC1249606 Exemption Code: Machines Professionals For Vending Business Only Number of Machines: Vending Tvpe: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 81.00 0.00 0.00 0.00 0.00 0.00 e 81.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: H LAMM INDUSTRIES INC 4425 NE 6 TERR OAKLAND PARK, FL 33334 This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 2015 - 2016 Receipt #1CP-14-00020500 Paid 08/07/2015 81.00 A►C 1 CERTIFICATE OF LIABILITY INSURANCE HLAMM-1 OP ID: RAL DATE (MMIDD/YYVY) 04/04/2016 1,, 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(fes) 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 Brown & Brown of Florida, Inc. 1201 W Cypress Creek Rd # 130 P.O. Box 5727 Ft. Lauderdale, FL 33310-5727 James F. Murphy INSURED H. Lamm Industries, Inc. 4425 NE 6th Terrace Oakland Park, FL 33334 COVERAGES CERTIFICATE NUMBER: CONTACT NAME: PHONE E 1NdU No, Ext): ADDRESS: FAX..... _ (A1C Noy 954-776-4446 INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: Hartford Fire Insurance Co. 19682 ,INsuRER.B Bridgefield Casualty Ins Co 10335 INSURER c;North River Insurance Company 21105 INSURER D : INSURER E: INSURER F : ISION N(JMRER' 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. 1NtR LTR TYPE OF INSURANCE , 1 JNSD 1110' iMVD POLICY NUMBER iotidirt MM)DDIWYy} A21"'ll t tiit�. ;MhVDOfYYYYj _... LIMITS A X COMMERCIAL GENERAL LIABILITY J CLAIMS -MADE x J OCCUR 21UUNZP3237 04/01/2016 04/01/2017 EACH OCCURRENCE "OA%7ACE TCS'RE3`J1'EO pRE 14 # MED EXP (Any one person) 5 1,000,000 . _. v...._..,_....» .- _ G 300,000 $ 10,000 $ 1,000,000 PERSONAL BADV INJURY GEN!. AGGREGATE POLICY [ x°i" UMIT APPLIES PER' 1 f LOC GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ 2,000,000 $ 2,000,000 OTMBRs $ AUTOMOBILE LIABILITY �X.� COM4IDIEci SINGLE LIMIT ne50kp1U $ 1,000,000 $ $ .». ..'.... .... .._... $ $ A _ ANY AUTO ALL AUTOS�ED HIRED AUTOS AUTOSULED NON -O ED AUTOS 21UUNZP3237 04/01/2016 04/01/2017 �{E@ BODILY INJURY (Per person) BODILY INJURY (Per accident) YY 6XliaG`I:— ,.,(Peracctdent C 1 X UMBRELLA UAB EXCESS UAB X OCCUR CLAIMS -MADE 5811065586 04/01/2016 04/01/2017 EACH OCCURRENCE AGGREGATE S 2,000,000 $ 4,000,000 DED 1 X RETENTION $ 0' $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY B IANY PROPRIETOR/PARTNER/EXECUTIVE YIN ;OFFICER/MEMBER EXCLUDED? 1(Mandatory In NH) i If yes, describe under DESCRIPTION OF OPERATIONS below N i A 19605940 04/01/2016 04/01/2017 x / PEROTH ,,,,„«, €, STATUT,�„ I. ER E . EACH ACCDENT .««.�.., ESL, DISEASE - EA EMPLOYE E L. DISEASE - POLICY LIMIT _„ d $ 1,000,000 $ 1,000,000 $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mo e apace Is required) RE: CMC1249606 CERTIFICATE HOLDER CANCELLATION MIAMISH Miami Shores Village Attn: Building Dept. 10050 NE 2nd Avenue 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 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD • _ 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 BUILDING PERMIT APPLICATION ED BUILDING ❑ ELECTRIC ❑ ROOFING ❑ PLUMBING El MECHANICAL ❑ PUBLIC WORKS JOB ADDRESS: 9050 Biscayne Blvd. R CEIVEC Ri. 2016 FBC 20 q Master Permit No. CG -k-2-45-53Q52 Sub Permit No. MC. (C. l83 ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-010-0010 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Nrthem Trust Bank ETAL % Publix Super Market Phone#: 863-688-1188 Address: Post Office Box 32025 City: LakelandState: FL Zip: 33802 Tenant/Lessee Name: Publix Super Markets Location #0794 Email: Phone#: CONTRACTOR: Company Name: i4. La n{i S Ne_i Phone#:9S' (-- -/ 1 Address: Lr L JS A L (o ( err a Com, City: F%. L..rw oto_rcD( cL k State: L zip: .?3 3 3 Qualifier Name: TC K Phone#: 9 Yui q —0 J33- State 3 -State Certification or Registration #: C M C ( a..14 1 j » 0 (c' Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 2 0 TO Square/Linear Footage of Work: Type of Work: El Addition A -i Iteration ❑ New ❑ Repair/Replace�❑ Demolition 1 t(krA-C l•C Q,� r D ki cA- 6000 K c ivy r S Description of Work: Specify color of color thru tile:. �, r /� Submittal Fee $ ] . Permf� Or $ 1 v r D0CCF $ al. OD coicc $ Radon Fee $ I .R5 DBPR $ 15•-R5 Notary $ Scanning Fee $ • 00 Technology Fee $ 253 • Training/Education Fee $ • COO Double Fee $ )21 Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ �, O —IO Sv Bonding Company's Name (if applicable) N' Bonding Company's Address 1 City State Zip Mortgage Lender's Name (if applicable) N f4& 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 (J OWNER or AGENT The foregoing instrument was acknowledged before me this nd day of Crybrf/ , 20 /5 , by 1 day of t r`1 f , 20 1 b , by ho is personally known to , who isersonally know o me or who has produced - _ as me or who has produced as Signature The foregoing instrument was acknowledged before me this identification and who did take an oath. NOTARY PUBLIC: Sig identification and who did take an oath. NOTARY PUBLIC: Sign: Prin t! WJ. L l �e%i�� Print: *„`;"•'•".4,, JOOIL.SLOAN Seal: * . t . �= * MY COMMISSION # FF 184644 0, '1' ` EXPIRES: February 5, 2019 q7 r r1.040p Bonded Thru Budget Notary Services Q�G�✓itn�tti Seal: APPROVED BY (Revised02/24/2014) \.1 1 ` Plans Examiner -1..4 Notary Public State of Florida Julie C Lamm %J My Commission FF 164693 a pd` Expires 10124/2018 Zoning Structural Review Clerk RICK SCOTT, GOVERNOR CENSE NUMBER CIVC1249606 re MECHANICAL -CONTRACTOR 3thed below fS CERTIFIED talc the provisions of Chapter 489 FS. :Oration_ date: "AUG 31,.2016 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTIQt INDUSTRY LICENSING BOARD HAWK 4E ERY• t- t'AMM 1; ,. S 45 NE 6 "-. FORT LA .4, 5 •d • • ,•• \ 1 •'.,> ISSUED: 07/01/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1407010001676 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA: H Business Name: LAMM INDUSTRIES INC Owner Name: HELMUT LAMM Business Location: 4425 NE 6 TERR OAKLAND PARK Business Phone: 491-8929 Rooms Seats Employees 30 Receipt #:189-19344 e;ALL OTHER TYPES CONTRACTOR •M Business Type: MECHANICAL coNTRACTOR) Business Opened:o7/16/1993 State/County/Cert/Reg: CMC1249606 Exemption Code: Machines Professionals For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 81.00 0.00 0.00 0.00 0.00 0.00 81.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. WHEN VALIDATED Mailing Address: H LAMM INDUSTRIES INC 4425 NE 6 TERR OAKLAND PARK, FL 33334 2015 - 201.6 Receipt #1CP-14-00020500 Paid 08/07/2015 81.00 HLAMM-1 OP ID: RAL ACORO" CERTIFICATE OF LIABILITY INSURANCE �'� °A 04/0412016TE Y) 04/04/2016 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 pollcy(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 thls certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER BrownW & Brown of Florida, Inc. P 01 Box yprre7ss Creek Rd tY 130 Ft. Lauderdale,7FL 33310-5727 James F. Murphy CONTACT NAME: A o . Exit 1 (ac, No): 954-776-4446 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Hartford Fire Insurance Co. 19682 INSURED H. Lamm Industries, Inc. 4426 NE 6th Terrace Oakland Park, FL 33334 INSURER B: Bridgefield Casualty Ins Co 10335 INSURER c: North River Insurance Company 21105 INSURER D : INSURER E : CLAIMS -MADE X OCCUR INSURER F : $ 300,000 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. ILTR TYPE OF INSURANCE 'AM )NSD SUER MD POUCY NUMBER RIMY EFF (MM/DDIWYY) POLICYERP (MMIDDAMYY) LIMITS A X COMMERCIAL GENERAL UABIUTY 21 UUNZP3237 04/01/2016 04/01/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR 'PRE56Nloccurrence) $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES pi] POLICY JECT OTHER: PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 $ A AUTOMOBILE X — UABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — ^AUTOS SCHEDULED AUTOS NON -OWNED 21 UUNZP3237 04/01/2016 04/01/2017 COMBINED SINGLE UMIT JEa accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per soddent) $ $ C X UMBRELLA UAB EXCESSLIAB X OCCUR CLAIMS -MADE 5811065586 04/01/2016 04/01/2017 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 4,000,000 DED X RETENTION S 0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE EJ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) II yes, describe under DESCRIPTION OF OPERATIONS below N 1 A 19605940 04/01/2016 04/01/2017 X PER OTH- STATUTE ER E,L, EACH ACCIDENT 5 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E L. 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) RE: CMC1249606 CERTIFICATE HOLDER CANCELLATION Miami Shores Village g Attn: Building Dept. 10050 NE 2nd Avenue Miami Shores, FL 33138 l MIAMISH • 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