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PLC-18-67Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number 1521 NE 105 Street Number: 1-1 Miami Shores, FL Owner Information Address 1122300530490 Block: Lot: 1015 NE 105 ST CORP 1390 BRICKELL Avenue MIAMI FL 33131- Contractor(s) PSG PLUMBING SERVICES, INC Phone (305) 796-7304 CeII Phone Phone PLC-1.18-67 Plumbing - Commercial 'cation: Addition/Alteration Permit Status: APPROVE© Expiration: 07/22/2018 Applicant 1015 NE 105 ST CORP Cell (305)771-2423 [ Valuation: Total Sq Feet: Type of Work: EXCHANGE BATH TOP X SHOWER REPLACE Type of Piping: Additional Info: Classification: Commercial Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.00 $0.40 $150.00 $9.00 $1.60 $166.45 Pay Date Invoice # 01/09/2018 01/23/2018 Pay Type PLC-1-18-66085 Credit Card Check #: 1677 Amt Paid Amt Due $ 50.00 $ 116.45 $ 116.45 $ 0.00 Available Inspections: Inspection Type: Top Out Re Pipe Main Drain Heater Water Service Final Water Main Lavatory Review Plumbing Underground 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 pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities 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 ELECTRIL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDl 'IT: ;l certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction d ohin• Futh rmoreuthorize the above -named contractor to do the work stated. ,Z AuthdridSigaa►�;_4wn{_ (,_ Alicant / Contractor / Agent January 23, 2018 Date Building )Department Copy January 23, 2018 1 Address: .3 8 ' 2 L) /,1 S- $� City: 0?4 L 'c k4 Qualifier Name: pe id-0 S &)l9 yi„ State Certification or Registration #: CcG / Si 2 5 / DESIGNER: Architect/Engineer: Address: State: Email: ivl MC&S Q (Orvrn CONTRACTOR: Company Name: C." ' 5e ' l//C L /1 Phone#: 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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING XI PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS JOB ADDRESS: / S) / ,4/ /0.S-M44 FBC2010 Master Permit No. � ' b Sub Permit No. T7( l I - to-R ❑ REVISION ❑ EXTENSION (RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: 13/38 Folio/Parcel#: 1� o�-�� `" ",C� ��� Is the Building Historically Designated: irN Occupancy Type: Load: Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): / Q / c 4/ 6 % Og Address: f 5-,? / /V j (} fir 7t'� '1 City: All la flit( / U/- ' 1 State: Zip: BFE: FFE: Phone#: Tenant/Lessee Name: Phone#: FL Value of Work for this Permit: $ ' j ! 2O "l1) 3OS=-7f6.-73 V Zip: .3.3 p Sy Phone#: 3G.S=- 7i4 — /30`/ Certificate of Competency #: Phone#: City: State: Zip: Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: t /) r) € 6,01.A •/o /D y 3 hove r- .e00/ 1ce 1a, /e % a ) /Z. /ice_ %z )16,, Y Specify color of color thru tile: Submittal Fee $ (L-C) • Permit Fee $ /54) — CCF $ CO/CC $ Scanning Fee $ Radon Fee $ 2 • (JD DBPR $ Z • 25 Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ • Ib • 4J Bonding Cor*any'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 permirto 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature OWNER or AGENT The fo egoing instrument was acknowledged before me this day ofC\77/Jk&/� , 20 me or who has produced identification NOTARY PU Sign: Print: Seal: APPROVED BY � by �, who is per onally known to ylIr7 A 1 as Q,an oath. RUTH PALMA 4 s Notary Public - State of Florida Commission # GG 043761 „r1' :' My Comm. Expires Feb 23, 2021 I ` , Bonded through National Notary Assn. 4 Signature CONTRACTOR The foregoing instrument was acknowledged before me this p4 18 day of _ lei n ti , 20 / 2 , by lid 0-0 5 L�W7»,, YI,whooi��sper,,,,6onallyknownto � me or who has produced v-- ��4.,*,,,,ri..„da,dri.r tp+r n RICARDO CESAR RAMOS identification and who diq te{: ahNotdryPublic- StateofFlorida • • Commission # GG 139002 NOTARY PUBLIC: My Comm. Expires Aug 28, 2021 Sign: Print: Seal: Bonded through National Notary Assn. /641 lee 74//�* ************************************************************************* l d Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk 0110912018 15:03 (FAX) P.0011001 AC�R CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 01/09/2018 THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 Excellence Insurance Agency 3801 SW 107 Avenue Miami, FL 33165 Phone (305)226-3900 INSURED PSG Plumbing Service, Inc, 3892 NW 125 Street Opa Locke Fax (305)226-3997 COVERAGES ci5Tist AZT Beatriz Bruno PHONE J305)226-3900 ADDRESS: BBRUNO®excellencelnsurance,net INSURERIS) AFFORDING COVERAGE INSURER A: Scottsdale Insurance Company FAX Not: (305)226-3997 NAIC A 41297 FL 33054- -Itl$ovijzk:- Allied Insurance Company INSURERC Commerce & Industries fns,Company INSURER D : Berkshire Hathaway Guard Insurance Company INSURER E : 11738 11398 INSURER F CERTIFICATE NUMBER: REVISION NUMBER: THIS INDICATED. CERTIFICATE EXCLUSIONS VSR -TR IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE N IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL9UBR INSR WVD POLICY NUMBER POLICY ERR tMM/DD/YYYY! POLICY !XP (MMfD9 Y( Yfl u-IT4 4 5 COMMERCIAL GENERAL LIABILITY WI CLAIMS -MADE 0 OCCUR 0 Y Y CPS2525345 08/22/2017 08/22/2018 __ _ _ ___ ___ _ EACH OCCURRENCE _ $ 3,000,000.00 DAMAGETORENTED MISES (Ea occurrence) PREMISES $ 300,000.00 MED EXP (Any one person) $ 5,000.00 ❑ PERSONAL 8 ADV INJURY ! 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ® POLICY 0 yea . LOC ❑ OTHER GENERAL AGGREGATE S 3,000,000.00 PRODUCTS - COMP/OP AGO S 3,000,000,00 $ 3 AUTOMOBILE LIABILITY • ANY AUTO OWNED AUTOSULED 0 ACP3008325220 07/09/2017 07/09/2018 �9MBIN D SINGLE LIMIT r to accl ant) 9 1, 000,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ AUTOS ONLY HIRED M NON -OWNED PROPEBT RAMAGE er ecci en $ AUTOS ONLY AUTOS ONLY • COMP $5 ■ COLL $50 $ tIN UMBRELLALIAB ❑ OCCUR EXCESS LIAR • CLAIMS -MADE EBU097711311 08/22/2017 08/22/2018 EACH OCCURRENCE S 2,000,000.00 ' AGGREGATE $ 2,000,000.00 • DED ❑ RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N / A PSWC874175 11/18/2017 11/18/2018 W1 STATUTE n W- E.L. EACH ACCIDENT $ 100,000.00 OFFICER/MEM ER EXCLUDED? ECUTIVFT-1 (Mandatory In NH) J If see, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE • EA EMPLOYEE $ 100,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000,00 )ESCRIPTION OF OPERATIONS / LOCATIONS 1 VENICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) 'LUMBING LICENSE: Ic# CFC1426257, All Plumbing work on plans. OLDER VILLAGE OF MIAMI SHORES 10050 Northeast 2nd Avenue Miami Shores, Florida 33138 IF! 305-75(3-8972 ACORD 25 (2016/03) QF CANCELLATION SHOULD ANY OF TH THE EXPIRATION D ACCORDANCE W J! AUTHORREDREPyi?� NTATIV RIBED ABII E - - . DEL EOF, NO. • W LICY P- a -IONS. 8-2015 ACORD CORPORATION. Ali rights reserved. a ACORD name and Togo are registered marks of ACORD