REV-17-576Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
305) 795-2204 Fax: (305) 756-8972
UMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
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BUILDING ❑ ELECTRIC
El PLUMBING ❑ MECHANICAL
JOB ADDRESS:
City:
❑ ROOFING
❑PUBLIC WORKS
jDS
El -REVISION
rmit No. C- s - i c - +Z -5G
ermit No. ZE\l J S7ko
❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO ad---
Occupancy
L
Occupancy Type: S f Load: Construction Type: Cr3 S Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Address: 1 LSO
City: VL - i 15 cos c i•
G 'o-iP f
Phone#:
State:
Tenant/Lessee Name: Phone#:
Email:
Zip:
CONTRACTOR: Company Name:
Address:
City:
11-.3 11-0 Phone#: $ rc)2
(-Ho S 7A -
State: C- Zip: 9'; o z( -
Qualifier
(
Qualifier Name: Hu -o Z/V i ..dei Phone#: cw .••-. •¢
State Certification or Registration #: CG -i- 1512 if i S Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $
10
Square/Linear Footage of Work: '1
Type of Work: ❑ Addition n Alteration ❑ New
❑ Repair/Replace ❑ Demolition
Description ofaWork: e i -4a 61(--0.:c.t..4--* , 'w,, x,0,4 w C.,(o�j
ttiFiz a.:iq r� Aroi.. A.
1 r. In'Y f �-i i►, fit hi:raii::.;LLJ 5 Yr
: ~
�C�,STS7� bi01.2�iitfiiJ.)`(O r' t'
E'0';.i s!fidr; J R:'.:3i
Bonding Comp ny's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable) •" " —
Mortgage Lender's Address ,-��" � k 4 I, ` a i t '""" r .r.r��
CityState o• �. , �l,a 1r1 5 J .. _y
Zip
Application is hereby made to obtain a perm'it.to do thwork 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
Signature
WNER or AGENT 9 TRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
' day of r L,'1-'1 , 20 I Z by 1 day of C c - L.,,,,•/ , 20 (1 by
ik". con �-iO , who is personally known to &c}, I-•e-ti.A4, .- Let , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
,,;;;';'4; ....
as me or who has produced as
Ivo MY CO ISSION #FF178894
••4‘'„
� EXPIRE November 23, 2018
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(407) 39N9-0153 FloridallotaryService.com
APPROVED BY
(Revised02/24/2014)
7 J)
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
oFti EXPIRES November 23, 2018
407) 998-0153 Florldallota Service.com
Plans Examiner Zoning
Structural Review
Clerk
CERTIFICATE OF LIABILITY INSURANCE
Date
3/6/2017
Producer: Plymouth Insurance Agency
2739 U.S. Highway 19 N.
Holiday, FL 34691
(727) 938-5562
This Certificate is issued as a matter of information only and confers no
rights upon the Certificate Holder. This Certificate does not amend, extend
or alter the coverage afforded by the policies below.
`
Insurers Affording Coverage
NAIC #
Insured: South East Personnel Leasing, Inc. & Subsidiaries
2739 U.S. Highwa19 N.
y
Holiday, FL 34691
Insurer A: Lion Insurance Company
•
11075
Insurer B:
Insurer C:
Insurer D:
Insurer E:
Coverages
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. Aggregate
limits shown may have been reduced by paid claims.
INSR
LTR
ADDL
INSRD
Type of Insurance
Policy Number
Policy Effective
Date
(MM/DD/YY)
Policy Expiration
Date
(MM/DD/YY)
Limits
-
GENERAL
LIABILITY
Commercial General Liability
Each Occurrence
$
Damage to rented premises (EA
occurrence)
$
Claims Made Occur
Med Exp
$
Personal Adv Injury
$
General
3
aggregate limit applies per:
Policy ❑ Project ❑ LOC
General Aggregate
-
$
Products - Comp/Op Agg
$
AUTOMOBILE
LIABILITY
Any Auto
All Owned Autos
Scheduled Autos
Hired Autos
Non -Owned Autos
Combined Single Limit
(EA Accident)
$
Bodily Injury
(Per Person)
$
Bodily Injury
(Per Accident)
$
PropertyDamage
(Per Accident)
$
EXCESS/UMBRELLA
LIABILITY
Occur ❑ Claims Made
Deductible
Each Occurrence
Aggregate
A
Workers Compensation and
Employers' Liability
Any proprietor/partner/executive officer/member
excluded? NO
If Yes, describe under special provisions below.
WC 71949
01/01/2017
01/01/2018
XI WC Statu-
tory Limits
I 1OTH-
ER
E.L. Each Accident
$1,000,000
E.L. Disease - Ea Employee
$1,000,000
E.L. Disease - Policy Limits
$1,000,000
Other
Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616
Descriptions of Operations/Locations/Vehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 91-67-612
Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company":
AJ. Fulton Contractors, Inc.
Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s), while working in: FL.
Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity.
A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562.
Project Name:
ISSUE 04-04-16 (PH). REISSUE 03-06-17 (PH)
- Begin Date 1/6/2014
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF MIAMI SHORES
BUILDING DEPARTMENT
10050 NE 2ND AVENUE
MIAMI SHORES, FL 33138
Should any of the above described policies be cancelled before the expiration date thereof, the issuing
insurer will endeavor to mail 30 days written notice to the certificate holder named to the left, but failure to
do so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives.
X""'K• r*^.