WS-16-1756 A L��c Miami Shores Village 1R1ECFT*V-F
Building Department JU 23 2016
IIS b g
lQ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:- A
Tel: (305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 S l
FBC 20 t `4
BUILDING Master Permit No. iA (� — 1gs(o
PERMIT APPLICATION Sub Permit No.
%BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /y ly /,,0 A�G�
City: Miami Shores 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),ALv 4- I / f Phone#:230S
Address: X70 1/.)ALa�'l /C
City: D41 eyylo C j`%J3 ,Q State: 0/cZip: G3/3z
Tenant/Lessee Name: /f�l� I�� /r I�5 Phone#:
Email: �cfr.�(�— "Y k�o(7dM
CONTRACTOR:Company Name: r G/ /G l- tAp p6 ze-) ��-Phone#:..'JO3 &'-
Address: /
City: �� 1 Zip: 3 3 I6,✓
Qualifier Name: f • to)eg—)W� �yl,
Phone#: ? c.SCJ
State Certification or Registration#uLlz&�10 A- (G� 0 G1.g6.6 D Certificate of Competency#:
DESIGNER:Architect/Engineer: �ri�l�iG�L✓ MJt'cff2 6G Phone#:.
Address: City: Dd l6o0 State:� Zip: 33C)2,
Value of Work for this Permit:$ U Square/Linear Footage of Work:
Type of Work: ❑,Adclition--E-].-Alteration I] New Repair/Replace ❑ Demolition
k 4 a 5`f'b •rte •
Descriptionof'Work L��✓L�Cr %`-� �DUf2.4 C.'lh
1 ct .� •'i tq k . .. :,'+}�.r A ' jd ::1 4. ( 2:.'u:fT • ,. ,
t •
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ c2-90 ' CA3 CCF$ CO/CC$
Scanning Fee$ 00 Radon Fee$ l-�S DBPR$ Notary!')
Technology Fee$* 2 6 Training/Education Fee$ U Double Fee$ so
Structural
Structural Reviews$ ( 2G - W Bond$ 171'
TOTAL FEE NOW DUE$
(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, 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.volue 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
OWNER or AGENT � CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoin iris was acknowledged before me this
day of ��Ri� 20 14 by r. day of '41 % 20 16 by
!. I �r personally /'0�2
/a L, t-/T� � / S,who is ersonall known to ,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: t
MYRD UMMER
I IES PL
r •. ^c MY COMMISSION 0 FF
Sign: ` ': M Sign: 2912
I MY COMMISSION k FF EXPIRES May 16.2017
Print: ':; . 2912 Print: �ac�,aseo sa
KU5 May 16.2017
Seal: '`' ,"
39A-D! rb�uaHou• Seal:
############################## #### ### #################################################################Plans Exa
L
APPROVED BY � � miner Zoning
Structural Review Clerk
(Revised02/24/2014)
A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrYYY)
01/25/2016
PRODUCER THIS CERTIFICATIONTTER OF INFORM-ATI N
IBR INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
5900 BROADWAY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
WEST PALM BEACH FL,33407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
561-841-0067 insurance@interbankers.com www.interbankers.com INSURERS AFFORDING COVERAGE NAIC#
INSURED
INSURERA f.London
POINCIANA DEVELOPMENT GROUP INSURER B:
1600 NW 3rd Ave INSURER C.
MIAMI 33136 INSURER D:
INSURER E:
COVERAGES
THEPOUCTW OF INSUFUNCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED V rOR PERIOD I D C
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 ADDl UCY EFFECTIVE—POUCV EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MIDDMf DATE MM1D LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A X COMMERCIAL GENERALLML4TY LTMXW-1 01/21/2016 01/21/2017 DAMAGE TO RE47ED
PREMISES EA Occae.ce 5 100000
CLAIMS MADE OCCUR MED EXP(Amy ane parsc�n) 5 1000
PERSONAL S ADV INJURY S 1000000
GENERALAGGR_GATE $ 2000000
GENIAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S + 1000000
POLICY TECT1 Loc
f S
r AUTOMOBILE LIABILITY `COMBINED SINGLE LIMIT
AUTO
ANY
�(Ea aadCenl) S
L ALL OWNED AUTOS
I BODILY INJURY
SCHEOULEDAUTOS (Perperscn) S
HIRED AUTOS --
BODILY INJURY
NON-OWNED AUTOS (Per aoccen:) S I
PROPERTY OA-NAGE S _ k
(Per a=denk)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO
OTHER THAN EA ACC S
AUTO ONLY AGG S
EXCESSIUMBRELL.A LIABILITY EACH OCCURRENCE is
OCCUR EICLAIMS MADE AGGREGATE ' S K
5
DEDUCTIBLE S
FIr RETENTION S S
WORKERS COMPENSATION AND TORY UM TI 3 f I R
EMPLOYERS'LIABILITY _
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED)
H yes,Cescnbe unCer E.L.DISEASE-EA EMPLOYE S
I SPECIAL PROVISIONS bokm E.L.DISEASE•POLICY LIMIT S
OTHER
}
DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES t EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CGC049650
I
CATFHOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TME EXPIRATION
1 Miami Shores Village Dept DATETHEREOF,THE ISSUING INSURER 10 g g p DAYS WRITTEN
10050 NE 2 Av
Miami Shores,FI 33138 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY MIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE _
'*CORD 25 200108 M%IVRD
I r
I'
"
1
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
**CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. °
EFFECTIVE DATE: 9/25/2014 EXPIRATION DATE: 9/24/2016
PERSON: FORREST LINDA M
FEIN: 651046450
BUSINESS NAME AND ADDRESS:
POINCIANA DEVELOPMENT GROUP INC
9024 ABBOTT AVE
SURFSIDE FL 33154
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL
CONTRACTOR
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section
may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only
within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be
exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,
the person named on the notice or certificate no longer meets the requirements of this section for Issuance of a certificate.The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609
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