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REV-16-2711 Miami Shores Village C 711 i_: Building Department o r o4 2016 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 Y: i Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No. QC, 3 . 6- PERMIT APPLICATION Sub Permit No. RN � V Ito- I ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL 'PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 'City: Miami Shores County: Miami Dade Zin: 3313 Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): acoe Phone#: Address: IL1a0 ( Ib3 City: n11PtYY,N1 SlnbreS State: IFL Zip: 331 ,�(3 Tenant/Lessee Name: Phone#: Email: �' " CONTRACTOR:Company Name: (.c.r ludo%�� V Cd'G Phone#: V 'Address: City: State: Zip: 3 3 DSy "Qualifier Name:e,'og Q ,p��/ 2G�lO�'-7 Phone#: State Certification or Registration#: _� �`(� LI 26Z6 / Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: ',Value of Work for this Permit:$ Square/Linear Footage of Work:,,C� Type of Work: ❑ Addition ❑ Alteration//)) 91 New ❑__Rrrepair/Replace ❑ Demolition 0 S Description of Work: SL CA k0c�, Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ _e5 Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ po TOTAL FEE NOW DUE$ � (Revised02/24/2014) i i . 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. 1 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. Als ,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seve ( ) days after the building permit is issued. In the ab nce of such posted notice, the inspection will not b ec ion fee will be charged. Signat Signature NER or CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 0� 20 k�P by _ day of ( ' • 20�( by Ai'1(Lt2. l l- ay► ��? who isrsonally known to P-eAtLo 6 u-zyy ar, who i rsonally know to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign•, _�W1k) Sign•r�,al✓11D� Print: N... Print: ;r MYCOMMISSION M FF 242181 ? „= MY COMMISSION N FF 242181 Seal: Seal: . : EXPIRES:October 18,2019 : EXPIRES:October 18, 2019 3• �R Sanded Thru Notary PW*und"iteR ••,!i;,1R'° Bonded Thru Notary Public Underwriters r; 1(—/4 APPROVED BYlad 10— 1 "/4' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ACORN CERTIFICATE OF LIABILITY INSURANCE DA TE(MMIDD10/04/16m) PRODUCER Excellence Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 3801 SW 107 Avenue ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami,FL 33165 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305)226-3900 Fax (305)226-3997 INSURERS AFFORDING COVERAGE NAIC# INSURED PSG Plumbing Service, Inc. INSURER A: Scottsdale Insurance Company 41297 3892 NW 125 Street INSURER B: Infinity Auto Insurance Company _, _ 11738 Opalocka, FL 33054 INSURER c: Ascendant Commercial Insurance Co. 11398 INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 ADD'L I POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE M/DDm LIMITS GENERAL UABILITY EACH OCCURRENCE I 3,000,000.00 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CPS2525345 08/22/16 08/22/17 PREMISES Ea occurencej I 300,000.00 f❑❑ CLAIMS MADE [1/1 OCCUR MED EXP(Any one person) 5,000.00 A j❑ I PERSONAL&ADV INJURY 1,000,000.00 ❑ GENERAL AGGREGATE 3,000,000.00 GENT AGGREGATE LIMIT APPLIES PER-1 PRODUCTS-COMP/OP AGG 3,000,000.00 ❑ POLICY ©PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000.00 [:1 ANY AUTO 509-55946-6827-001 07/09/16 07/09/17 (Ea accident) i ALL OWNED AUTOS B El SCHEDULED AUTOS BODILY INJURY (Per person) © HIRED AUTOS [] NON OWNED AUTOS BODILY INJURY (Per accident) Comp$500.00 Ded PROPERTY DAMAGE I Coll $500.00 Ded (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT C ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 2,000,000.00 EBU 067946468 08/22/16 08/22/17 © © OCCUR ❑ CLAIMS MADE I AGGREGATE 2,000,000.00 A ❑ DEDUCTIBLE �-- ❑ RETENTION $ WORKERS COMPENSATION AND [V] WC STATU- ❑ OTH- EMPLOYERS'LIABILITY WC-66349-1 11/18/15 11/18/16 _TORY LIMITS ER _ C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT _ 1,000,000.00 OFFICER/MEMBER EXCLUDED? N i E.L.DISEASE-EA EMPLOYEE 1,000,000.00 If yes,describe under SPECIAL PROVISIONS below _ E.L.DISEASE-POLICY LIMIT 1,000,000.00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Plumbing Contractor Lic#CFC1426257 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL VILLAGE OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 Northeast 2nd Avenue THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Miami Shores, Florida 33138 AUTHORIZED REPRESENTATIVE FAX:305-756-8972 ACORD 25(2001/08)QF ©ACORD CORPORATION 1988