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PLC-18-1338 Permit NO. PLC-5-18-1338 `yHgR Miami Shores Village Permit Type: Plumbing-Commercial 10050 N.E.2nd Avenue NE Work Classification:Gas Miami Shores,FL 33138-0000 Pe �'�� Olt Permit status:APPROVED Phone: (305)795-2204 issue Daft:6/1112018 Expiration: 12/08/2018 F Project Address Parcel Number Applicant 602 NE 96 Street 1132060141410 Miami Shores, FL Block: Lot: MIAMI SHORES PRESBYTERIAN Owner Information Address Phone Cell MIAMI SHORES PRESBYTERIAN 601 NE 96 ST (305)751-5917 MIAMI 38 FL 33138-2741 Contractors) Phone Cell Phone Valuation: $ 2,400.00 SECURE GAS SERVICES (239)770-4418 Total Sq Feet: 0 Type of Work:35KW PROPANE GENERATOR ASSOCIATED G Available Inspections: Type of Piping:35KW PROPANE GENERATOR ASSOCIATED G Inspection Type: Additional Info:35KW PROPANE GENERATOR ASSOCIATED G Final Classification:Commercial Press Test Scanning:3 Review Plumbing I Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.00 Invoice# PLC-5-18-67587 DBPR Fee $0.00 05/17/2018 Credit Card $50.00 $28.00 DCA Fee $0,00 Education Surcharge $0.00 06/11/2018 Credit Card $28.00 $0.00 Permit Fee $75.00 Scanning Fee $3.00 Technology Fee $0.00 Total: $78.00 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations per6ining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the properauthorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for E ECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS A F DAVIT: that all the foregoing information'is accurate and that all work will be done in compliance with all applicable laws regulating I r" t construction d zoning. �ket 0 re authorize the above-named contractor to do the work stated. June 11, 2018 Al Applicant / Contractor / Agent Date BuXig Department Copy June 1 018 1 Miami Shores Village �.�, Building Department AY 7 2 18 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 ' FBC 20 BUILDING Master Permit No.CC-51$-133b _ PERMIT APPLICATION Sub Permit No. P6G4W-1594 BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION [—]RENEWAL FE-jPLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF [—]CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS ,OB ADDRESS: 602 NE 96 Street ' City: I Miami-Shores County: Miami Dade Zip: Folio/Parcel#:1132060141410 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: I OWNER:Name(Fee simple Titleholder):Miami Shores Presbyterian Church Phone#:305-745-9541 Address:602 NE 96 ST City. Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Verizon Wireless Phone#:561-226-9516 Email: CONTRACTOR:Company Name: Secure Gas.Seryices Phone#: 239-770-4418 Address: 6951 St Edmunds Loop.. city. Fort Myers state: FL Zip: 33966 Qualifier Name: Brad Schehr Phone#: State Certification or Registration#:i32386 Certificate of Competency#: 29259 DESIGNER:Architect/Engineer: Klmley Horn & Associates Phone#: Address: 1920 Wekiva Way City: WPB state: FL Zip: 33411 Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Q New ❑ Repair/Replace ❑ Demolition Description of Work: Installation of NG fuel line to Verizon Wireless Generator. re,nlac�e bLsGb I?�—l9 ...f .A. Specify color of color thru tile:•�, -,, ... .. __.,�, _ __s Submittal Fee'$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ _ TOTAL FEE NOW DUE$ (Revised02/24/2014) r r Bonding Company's Name(if applicable) Bonding Company's Address R ` City State Zip Mortgage Lend'er's Name(if applicable) Mortgage Lender's Address CityState 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. 4n the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. J Mcg.• C.� d� U Signature Signatur OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this Ldayof lVaLL 20 /9 by 104)'4— day of I`l OLU r 20_' 18 ,by who is personally known to Brad Schehr :• 'I—who is personally known 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: Sign: Print: 11 �� Print•• JIANA It OADWI. MY COMMISSKIN t FF 845218 ,;1,PY► C Seal: LAUDETTt MAK __ EXPIRES:December 20,2019 Seal: .• commission#GG 198270 ritfh Bonded ihru NotaryPubrc Underwriters :"' t fz Ex Tres M9 14,2022 ;`,oF?;Y`'` BoMedTlxi+TroyFalnlnaurenca800as'101s ***s*ssssssss***s*ssssss*s***ssssss**sssssssssss****sssss*sssss***ssssssss**ss*s**s;ssssssssssss************ APPROVED BY `v - Plans Examiner Zoning " r Structural Review Clerk (Revised02/24/2014) AC' DATE(MM/DD/YYYY) A,,.. CERTIFICATE OF LIABILITY INSURANCE 6/8/2017 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(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 CONTACTNAME: Mildred Krau'alis 12660PHONE t Insurance-Ft Myers ' .239-418-2114 FAX 239-936-8288 12660 World Plaza Ln Bldg 73 E-MAIL .mkrau'alis lut ertinsurance.com Fort Myers FL 33907 1 @ 9 INSURERS AFFORDING COVERAGE NAIC N INSURERA:Scottsdale Insurance Co. 41297 INSURED SECUR-7 INSURER B: Secure Gas Services, Inc. INSURER C: 6951 Saint Edmunds Loop Fort Myers FL 33966 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1160559487 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, THEINSURANCE 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 TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPS2575618 10/19/2016 10/19/2017 EACH OCCURRENCE $1,000,000 I CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $100,000 f MED EXP(Any one person) $5,000 PERSONAL BADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO F—]LOC JECT PRODUCTS-COMP/OP AGG $2,000,000 - OTHER: $ AUTOMOBILE LIABILITY $ Ea accident ANY AUTO BODILY INJURY(Per person) $ AUTOS�ED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per.accident I L - 1 $ UMBRELLA UAB [d OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT �- $ ' OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ t F —�ILa DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ti more apace is required) 1 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Dept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores FL 33138 Y AUTHORIZED REPRESENTATIVE I iAl ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I X too, MUM Miami. . Village Building g De a p� `rtment R11 1,6660 N.E.'2n4-Avenue Mia"mt Sh6dq§ Flo33138` rida r Tel: (305)'79'5.22134 Fax: (305) 756.8972 ' Notice t&Owher — workers' Com ensation Ins uranc-e.fxem tion t Florida,Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes; Fla. Stat. § 440.05 allows corporate office`rs,,iti the construction industry to exempt themselves from'this requirement for any construction project prior',to obtainings building permit. Pursuant to the Florida Division of Workers''Compensation Ennployer Facts Brochure. An e to er in the:construction industry ` mp y : try who employs one` or more`part=time" or fiill-time employees,including'the owncx,must obtain workers'compensation,coverage Corparate.offic'ers or members of a-limited liability company (LIC} in the construct on'industrY,,may,elect to be exempt if 1. The officer owns-at least°10 percent=of°the-stock of the corporation,or in the case'of an.LLC,a statement attestingto the minimum 10 percent ownership; , 2. The officer is"listed=as an officer;of the corporation,in the records of 1 he;#lorida Department of State,Division ofCoiporations;and 3. The corporation:is,registered and listed as-active with the Florida Dbepartment;b£. State,Division of Corporations. f No more than three corporate officers per corporation or limited liability company members are- allowed'to be exempt. Construction exemptions are valid for a xperiod of,two`years or,until,a voluntary revocation is filed.or:the exemption is revoked-by the Division. r 'Your,contractor;is requesting apermit under this workers'compensafion'exemption and has acknowledge'that he;or she will notuse day labor;.part-time employees or subcontractors.for.your,project•The contractor has provided an affidavit stating that lie or she;will be the only person allowed to work on your project In these7circumstances;Miami Shores Village does not regUirrWerificution of workers'compensaiion,insurance coverage from the contractor's company.for'day labor,parttime'employees or subcontractors. BY 'SIGNING BELOW: YOUACKNOWLEDGE THAT YOGI HAVE READ T11IS NOTICE AND UNDERSTAND ,ITS `CONTENTS. Sign ure: ' Owner f State of-Florida County of Miami"-Dade; 1 The faregoing;was acknowledge'before,me'this: day ofQ, MI-7 Byl1CUdleq JU lel Ir -who is personally known to`rne or has produced as identification: r N ' _ Commission#FF 123287 SEAL, ' ` Expires May 14,2018 ' mf oe�°'�'• Bonded Thru Troy Fain Insurance 90038;-7019 }