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MC-18-64Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-295097 Permit Number: MC -1 -18-64 Scheduled Inspection Date: January 25, 2018 Inspector: Perez, JanPierre Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 415 NE 105 Street CHURCH BLDG Miami Shores, FL Project: <NONE> Contractor: MODERN MIDWAYS Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)758-0539 Parcel Number 1122310430010 Phone: (305)234-7776 Building Department Comments TEMPORARY CHURCH CARNIVAL Infractio Passed Comments INSPECTOR COMMENTS False / 2�1 \i -c6 Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments of -vv January 24, 2018 For Inspections please call: (305)762-4949 Page 13 of 30 ADAM H. PUTNAM COMMISSIONER MODERN MIDWAYS 22901 SHERMAN ROAD STEGER, IL 60475 Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection EVENT REPORT Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com INVOICE#: 2970116 PURPOSE: Scheduled EVENT NAME: ST. ROSE OF LIMA CATHOLIC CHURCH FALL FESTIVAL EVENT ADDRESS/LOCATION: 415 NE 105TH STREET EVENT CITY/COUNTY: MIAMI SHORES/DADE OPEN DATE: 01/26/2018 INSPECTION #: 1708-24895 # Rides: 19 # Rides Passed: 19 # Rides Failed: 0 # Rides Not Ready: 0 # Go Karts: 0 # Go Karts Passed: 0 # Go Karts Failed: 0 # Go Karts Not Ready: 0 USAID Theme Name Status IC/RT # Deficiency OST # Unit 05492 MARDI GRAS Pass 195992 07009 SLIDE Pass 195993 07960 FROG HOPPER Pass 195994 09690 THUNDERBOLT Pass 195995 Structural - Structural Integrity: Corroded cables 12884 #16 Attachments - Carrier/Tubs: Other 12976 1 Attachments - Carrier/Tubs: Damaged 12869 10 Structural - Pins/Bolts/Keys: Bolt loose 12944 12 Structural - Bearings/Spindles/Axles: Bushings missing 12387 14 Attachments - Carrier/Tubs: Other 12939 6 11074 TEA CUPS Pass 195996 11143 DRAGON WAGON Pass 195997 11521 SCOOTER Pass 195998 Attachments - Restraints: Other 12860 4 Operation - Rpm Check: Operations check failed 12942 7 Attachments - Restraints: Shocks worn 12888 BLUE#1 Attachments - Restraints: Shocks worn 11590 'URPLEff Attachments - Restraints: Shocks worn 11957a YELL 1 Attachments - Restraints: Shocks wom 11957 YEOO#1 11822 MINI JET DINO Pass 195999 12404 CENTURY WHEEL Pass 196000 Structural - TireslWheels/Casters: Other 12847 14 12423 MERRY GO ROUND Pass 196001 Attachments -,Carrier/Tubs: Not properly secured 12943 1 Attachments = Carrier/Tubs: Improper - 12940 21_ __ Structural - Bearings/Spindles/Axles: Bearings wom 12941 D Structural - Bearings/Spindles/Axles: Bearings wom 12938 Q Structural - Bearings/Spindles/Axles: Bearings wom 12937 X 13153 VERTIGO Pass 196002 13876 TOUCHDOWN Pass 196003 14397 ZIPPER Pass 196004 Attachments - Carrier/Tubs: Damaged 12867 10 Attachments - Carrier/Tubs: Primary latches not working 12393 11 Attachments - Carrier/Tubs: Damaged 12868 3 Attachments - Carrier/Tubs: Primary latches not working 12364' 6 14421 SPIDER Pass 196005 Attachments - Camer/Tubs: Damaged 12841 2 14457 MOTORCYCLES Pass 196006 14844 COLORADO EXPRESS Pass 196007 14882 ALI BABA Pass 196008 Attachments - Restraints: Interlocks not operational 12697 17 Attachments - Restraints: Missing 12616 18 Attachments - Carrier/Tubs: Secondary latches not working 12618 22 14894 CLIFFHANGER Pass 196009 Operation - Clearance: Clearance issue to another ride/joint 11764 1,2,3 ❑I acknowledge that all identified rides issued a stop operation order (RT #) and/or carriers or components issued an out of service (OST #) are not in compliance with Florida Statute 616.242 and/or Rule Chapter 5J-18, F.A.C. Further deficiencies may still exist and ride(s) shall not operate until it passes a subsequent inspection by the Department. Tx.eas Inspgctor's Name 0? Owner/Manager Run Date: January 25, 2018 5:26 PM /-2S-l2 Date Page: 1 of 2 Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection EVENT REPORT Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com INVOICE #: 2970116 PURPOSE: Scheduled MODERN MIDWAYS EVENT NAME: ST. ROSE OF LIMA CATHOLIC CHURCH FALL 22901 SHERMAN ROAD FESTIVAL STEGER, IL 60475 EVENT ADDRESS/LOCATION: 415 NE 105TH STREET EVENT CITY/COUNTY: MIAMI SHORES/DADE OPEN DATE: 01/26/2018 INSPECTION #: 1708-24895 USAID Theme Name I Status 15063 '-IYPERLOOP/STREETFIGHTER Pass IC/RT # 196010 Deficiency OST # Unit Run Date: January 25, 2018 5:26 PM Page: 2 of 2 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. MC -1-18-64 Permit Type: Mechanical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 1/24/2018 Expiration: 07/23/2018 Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC C Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD MIAMI FL 33138-2970 (305)758-0539 Contractor(s) Phone MODERN MIDWAYS (305)234-7776 Cell Phone Valuation: Total Sq Feet: $ 400.00 0 Tons: Additional Info: Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved: : In Review Type of Work: Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.00 $0.00 $0.00 $0.00 $500.00 $3.00 $0.00 $503.00 Pay Date Pay Type Amt Paid Amt Due Invoice # MC -1-18-66082 01/24/2018 Check#: 1033 $ 503.00 $ 0.00 Available Inspections: Inspection Type: Ventilation Final Rough Rough Duct Duct Detector Test Review Mechanical 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 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. Futhermore, I authorize the above-named contracjoyto do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy January 24, 2018 Date January 24, 2018 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: MECHANICAL JOB ADDRESS: 41fi E 105 Street RECEIVED JA 092018 BY• FBC20IN. Permit No. Master Permit NoJC 1 GL/ City: Miami Shores County: Miami Dade zip: 33162 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Address: 9401 Biscayne Blvd. Phone#: (305)727-6243 City: Miami Shores State: FL zip: 33138 Tenant/Lessee Name: St. Rose of Lima Catholic Church Phone#: (305)758-0539 Email: CONTRACTOR: Company Name: Modern Midways, Inc. Address: 10420 SW 115 Street Phone#: (305) 234-7776 City: Miami State: FL zip: 33176 Qualifier Name: Brian L. Morrissey Phone#: (786) 586-9568 State Certification or Registration #: Certificate of Competency #: Contact Phone#: (305) 234-7776 Email Address: bmorri9495@aol.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 400.00 Square/Linear Footage of Work: Type of Work: DAddress ❑Alteration ❑New ❑Repair/Replace Description of Work: Amusement rides for temporary Church Carnival Jan. 26-28, 2018 ❑Demolition ***************************************Fees******************************************** Submittal Fee $ Permit Fee $ DO Gel() CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ TOTAL FEE NOW DUE $ 503.00 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 b 'pp #ved and a reinspection fee will be charged. Signature Owner or Agent Signature q Contractor The foregoing instrument was acknowledged before me this 8 iv The foregoing instrument was acknowledged before me this T day of 5-74a, , 20 ? , by f2''`'-i9ncX o./F ?l r day of � AIV` , 2014 by Aixse who is ersonally kno to me or who has produced who isersonally know to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: C y • CArn1,4i7_i2n Print: Ca --H) My Commission Expires: ON # GG023712 ugust 23, 2020 �a3, ar)ao NOTARY PUBLIC: Sign: Print: My Commission E ******************************* *************************************************************************** APPROVED BY Plans Examiner Structural Review (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Zoning Clerk AIMS INTERNATIONAL P.O. 503 93389 NASHVILLE. TN 37709 (714)1.75.3747 (7141778-9868 Fax Brian Lee Morrissey Certified Operations Technician, Level I Expiration Date: March 31, 2019 Timo KlausRichard Achard President, AIMS International Chair, Certification Committee 153 Member No. 2017 Brian Morrissey LeisureTimeAssociate Miami, FL Leonard Cavalier Executive Director ,'1620_072- - 9-0 rJ LEE ,;ORRISES 10420 SW 115TH ST MIAMI. FL 33176-4045 • 10-09-1940 SE), M t 08 -2i -2',1'0,,G1 5-10 c 10-p1.20.-., +EST A -, cryli4 SAFE CiRtVER a NNI(M Vli k ".'_Nr[ne9 Cl1IF9MF1 IQ NATIONAL ASSOCIATION OF AMUSEMENT RIDE SAFETY OFFICIALS CERTIFIED SOF 'SEMFM7 AMUSEMENT RIDE INSPECTOR Brian Morrissey LeisureTimeAssociate LEVEL 11 (Advance) Number Expiration Date CN- 310 03/31/2019 President Local Busi ness Tax Recei pt M iami-Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY 7233187 BUSINESS NAM EILOCATION MODERN MIDWAYS @ IMMACULATE CONCEPTION 125W45ST HIALEAH, FL 33012 OWNER MODERN MIDWAYS Unit(s) MIAMI.DADE Kann RECEIPT NO NEW BUSINESS 7518818 SEC. TYPE OF BUSINESS LBII EX PIRES SEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 PAYMENT RECEIVED 191 CARNIVAL - BY TAX COLLECTOR SPONSORED 240.00 10/12/2017 10 0208-18-000231 This Local Business Tax Receipt only con"rns payment of the Local Business Tax. The Receipt is not a license, permit, or a certi "cation of the holder's qual i "cations, to do business. Holder crust comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECBPT NO. above must be displayed on all commercial vehicles - Mianti-Dade Code Sec 8a-276. For more information, visit www.niamidadegov/taxcollector ACORO® Le......" , . , , CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/24/2017 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 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 Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CONTACT NAME: Joanne Manion PHONE 425-454-3386 FAX 425-451-3716 (A/C Nq Fxt)• (AIC. No): ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :T. H.E. Insurance Company 12866 INSURED BRIGTRA-01 Briggs Transport, Inc. Modem Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER B : CPP010090207 INSURER C: 4/3/2018 INSURER D: $1,000,000 INSURER E : INSURER F : X VERAGES CERTIFICATE NUMBER: 396245632 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 LTRINSD TYPE OF INSURANCE ADDL SUBR WVD POUCY NUMBER POLICY EFF 1MM/DD/YYYY) POUCY EXP IMMIDD/YYYY) UMITS A x COMMERCIAL GENERAL UABILITY CPP010090207 4/3/2017 4/3/2018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) $Excluded PERSONAL & ADV INJURY $1,000,000 GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $1,000,000 $ A AUTOMOBILE X UABIUTYCOMBINED ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY X X SCHEDULED AUTOS NON -OWNED AUTOS ONLY CPP010090207 4/3/2017 4/3/2018 SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA UAB EXCESS LAB X OCCUR CLAIMS -MADE ELP001021008 4/3/2017 4/3/2018 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DED X RETENTION$0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WCP0004670005 10/29/2017 10/29/2018 X STATUTE ETH 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) St. Rose of Lima Catholic Church & School; The Archdiocese of Miami; Archbishop Thomas Wenski and Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions - policy form CG133C 07/95. Event Dates: January 26 - 28, 2018 CERTIFICATE HOLDER CANCELLATION Village of Miami Shores c/o Budding Dept 10050 NE 2nd Avenue Miami Shores FL 33138 USA 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 tHO ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD