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RC-16-1256 (4)0-- --t t --P .S 123110-I:A 4 . — 41 1.3-� NMI& _ 60(01 • o0 MU" .— I O t 220 . So. �F I It r4.s-- -.-20 01 y; 9ra.2 0? -01-16_ BUILDING PERMIT APPLICATION 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 REC-FTVED OCT 222015 BY: FBC 20 I 0 Master Permit No. )i:) 5L4 Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL El PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION IN SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores %o5 County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): AX.l es /D a. z?4 4 S /'C. Address: 70 �x .2. 91 ?ea 566 ! S / 7 City: < State: 4 472:de ... Zip: 33 `3 9 Tenant/Lessee Name: Phone#: 3 lac S 6 / Si 47/ t � Email: CONTRACTOR: Company Name: 0 0.: UtrlS4 I doeJ 0LOC11 O,J Address: 944 e IJ lt1 Phone#: v`)I 2 380 13 cm City: oLJ, ; ¢ H-t,..� /� State: 1 p ; G1 0•. zip: _3316a p L;J Qualifier Name: ►Acd, Phone#: State Certification orRegistration #: eye. iv 3 q s3 Certificate of Competency #: �J Phone#: DESIGNER: Architect/Engineer: Address:' City: State: Zip: Square/Linear Footage`of U1/ork:'s/i.-. Value of Work for this Permit: $ '' -9 00 Type of Work: ❑ ❑ Addition ❑ Alteration ❑ New Repair/Replace,. n Demolition Description of Work: Y a Ore xw ; Specify color of,;W6:'r.�;t rile Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ q.:� Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ �� 80 ` w Bond $ Structural Reviews $ TOTAL FEE NOW DUE $ ‘CO"1 . a) (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, BOILERWEATERS, 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 b copy of the notice of commencement and construction lien law • •chure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of comm cement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issu In e abse e of such posted notice, the inspection will not by approved and a reinspection fee will be charged. Signature OWNER or AGENT Signatur CO `TRACTOR The foregoing instrument as acknowledged before me this The foregoing instrument was acknowledged before me this i day of , 20 / by 2( day of , 20 by . s /14- , who is personal)kir .nown to me or who has produced as wn to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: .mac Eivarsoro � Seal: * . ; * MY COMMISSION iFFOWN EXPIRES: September 21, 2011 two. ° Banded Pm; Bmis Notary Wei *********************************************************************************************************** APPROVED BY (Revised02/24/2014) Plans Examiner Structural Review Zoning Clerk C.0d CERTIFICATE OF LIABILITY INSURANCE 1.,.....-- DATE(MANDDfYYYY) 11/20/2015 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 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 FrankCrum Insurance Agency, Inc. 100 South Missouri Avenue Clearwater, FL 33766 CONTACT NAME: PHONE (NC, No, Ext): 1-800-277-1820 x4800 FAX (A/C, Not (727) 797-0704 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER k Frank Winston Crum Insurance Co. 11600 INSURED FrankCrum UC/F Universal Group, Inc. 100 South Missouri Avenue Clearwater, FL 33756 INSURER e: INSURER C: INSURER 0: INSURER E: S INSURER F: DAMAGE TO RENTED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER: 330473 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED TO THE INSURED NAME 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANOE - ADDL.SUER INSRD INVD POUCY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) WAITS GENERAL LIABILITY COMMERCIAL GEN UABILITY EACH OCCURRENCE S DAMAGE TO RENTED PREMISES (Ea occurrence) SERAL CLAIMS -MADE OCCUR MED EXP (Any one person) S PERSONAL & ADV INJURY S GENERAL AGGREGATE S GEML AGGREGATE MIT APPLIES PER: n PROJECT EILOC PRODUCTS.COMPIOP AGG S —1POLICY 3 AUTOMOBILE LIABILITY MY AUTO ALL OINNEO AUTOS_ HIRED AUTOS __ — SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE UNIT (Ea ncddan) 3 BODILY INJURY (Per person) S BODILY INJURY (Per Resident) S PROPERTY DAMAGE (Per eeddentl S 3 UMBRELLA MAB EXCESS UAB — OCCUR CLAIMS -MADE EACH OCURR£NCE _J AGGREGATE S OED RETENTION 3 • • • S A WORKERS COMPENSATION AND EMPLOYERS LIABILITY YM ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER OCCLUDED/ a (Mandatory In NH) dyes, *sales under DESCRIPTION OF OPERATIONS below N/A WC20150D000 01/01/2015 01/01/2016 YYC�TATUTORY ?t I • L rS DTH- 1 ER •• • • y• e • /., VGWIDEta . • *" • PIM*" • Sb *GE -EAE WYE• ••;j 4PPIAll • EA! eleosi-PouCY Uj s • • 11.000.000 • • •••• • •• •••• • • • •• •• •••• • • • • • • • • • • • • • • •• •. • ••• • • •• • s • • • • • • • • DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks, Schedule, If more space Is required) Effective 11/30/2015, coverage Is for 100% of the employees of FrankCrum leased to Universal Group, Inc. (Client) for whom the client Is reporting hours to FrankCrum. Coverage Is not extended to statutory employees. Projects: Project 1-5 NE 105 St Miami Shores, FI 33138, Project: 2 897 NE 91 Ter Miami Shores, FI 33137. Project: 3- 361 NE 101 S Miami Shores, FI 33138. CERTIFICATE HOLDER CANCELLATION Miami Shores Villages 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 REPT)VE ...*------- ACORD 26 (2010106) The ACORD name and logo am registered marks of ACORD 01988-2010 ACORD CORPORATION. Ali rights reserved. Exteiimi a-tu 9 6. • 468 E. 9 STREET HIALEAH; FL 33010 P.O. BOX 1418 HIALEAH, FL 33011-1418 PHONE: (305) 885-4966 FAX: (305) 885-4969 Notice of Preventative Treatment for Termites (As required by Florida Building Code (FBC) 104.2.6) 105 NE .' N M I aon i Aven,cz,(tel I am i F� -112o I�c.o. MCMI fit, �5 Address of Treatment or Lot/Block of Treatment 1: o0 pry) M. Comas Applicator Time Izi O�o C-�rx u Product Used Chemical used (active ingredient) D ✓ •'. Percent Concentration POf'(ZOYlifi.l 63D 60 It Number of gallons applied Area treated Linear feet treated Stage of treatment (Horizontal, Vertical, Adjoining Slab, retreat of disturbed area) As per 104.2.6 - If soil chemical barrier method for termite prevention is used, final exterior treatment shall be completed prior to final building approval. If this noti : "s '.;,te.final exterior treatment, initial and date this line Authorized Signature ACO Ii CERTIFICATE OF LIABILITY INSURANCE `..--- DATE(MM/DD/YYYY) 01/25/2016 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 FrankCrum Insurance Agency, Inc. 100 South Missouri Avenue Clearwater, FL 33756 CONTACT NAME: PHONE (A/C, No, Ext): 1-800-277-1620 x4800 FAX (A/C, No): (727) 797-0704 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE MAIC# INSURER A: Frank Winston Crum Insurance Co. 11600 INSURED FrankCrum L/C/F Universal Group, Inc. 100 South Missouri Avenue Clearwater, FL 33756 INSURER B: INSURER C: INSURER D: INSURER E: $ INSURER F: DAMAGE TO RENTED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER: 353826 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED TO THE INSURED NAME 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 LTR TYPE OF INSURANCE ADDL INSRD SUER WVD POLICY NUMBER POLICY EFF (MM/DDNYYY) POLICY EXP (MM/DD/ YYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [] PROJECT []LOC PRODUCTS-COMP/OP AGG $ -I $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED- AUTOS HIRED AUTOS - SCHEDULED AUTOS NON -OWNED AUTOS( COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per occident) $ - $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE - EACH OCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS bebw Y/N N/A WC201600000 01/01/2016 01/01/2017 X WC STATUTORY OTH- LIMITS 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 (At ach ACORD 101, Additional Remarks, Schedule, if more space is required) Effective 11/30/2015, coverage is for 100% of the employees of FrankCrum leased to Universal Group, Inc. (Client) for whom the client is reporting hours to FrankCrum. Coverage is not extended to statutory employees. Projects: Project 1-5 NE 105 St, Miami Shores, FI 33138, Project 2 - 897 NE 91 Ter Miami Shores, FI 33137. Project 3 - 361 NE 101 S Miami Shores, FI 33138. ERTIFICATE HOLDER CANCELLATION 1 05 Shores Villages 0 h 2nd AFL 3 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 RE SENTATIVE ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved.