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CC-18-2250Miami Shores Village 10050 NE 2 Ave Miami Shores F133138 305-795-2204 Location Address IL A( issue Date:11/05/2018 Parcel Number 9600 NE 2 AVE, Miami Shores, FL 33138 1132060132510 Contacts Permit No.: CC-8-18-2250 Permit Type: Building (Commercial) Work Classification: Alteration Permit Status: Approved Expiration: 03/18/2019 PALAZZO LEONI LLC Owner PALAZZO LEONI LLC Applicant TODD LEONI TODD LEONI PO BOX 381703, MIAMI, FL 33238 PO BOX 381703, MIAMI, FL 33238 NEWMAN & NEWMAN GENERAL Contractor CONTRACTORS INC ROBERTO NEWMAN 7705 SW 86 ST B-115, MIAMI, 33143 Business: 3058987526 ROBERTO@NEWMANGC.COM Description: FOOD PREP EQUIPMENT LAYOUT AND NEW ADA Valuation: $ 12,000.00 Inspection Requests: BATHROOM. NEW ELECTRICAL PLUMBING ARE WITHIN THE —j f0S-762-4949 SCOPE OF WORK. Total Scl Feet: 617.00 UNIT# 175 NE 96 ST Fees Amount CCF $7.20 CO/CC Fee $200.00 DBPR Fee $5.40 DCA Fee $3.60 Education Surcharge $2.40 Notary Fee $5.00 P&Z Review Fee $35.00 Permit Fee $360.00 Plan Review Fee (Engineer) $120.00 Preliminary Plan Review $500.00 Scanning Fee $12.00 Structural Review ($90) $90.00 Technology Fee $9.60 Total: $1,350.20 Building Department Copy Payments Date Paid Amt Paid Total Fees $1,350.20 Credit Card 08/22/2018 $620.00 Credit Card 10/26/2018 $200.00 Credit Card 11/05/2018 $530.20 Amount Due: $0.00 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 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 ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above named contracto o the work stated. �cdI ., I t /oq/zot�) Authorized Signature: Owner / Applicant / Contractor / Agent Date November 05, 2018 Page 2 of 2 t- BUILDING PERMIT APPLICATION 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 Master Permit No Sub Permit No. OCT 2.8 2018 Col' ^ -�I �C 20��' Cei9 -22so BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS:( t jr)T City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: I 1 • _b200 - OV�) - 2`7010 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): TO'Q�-' Y � V"z UUL Phone#: ✓ - � ^ 11�� x )o Address: To �x 38(go3 City: "�xm I- State: Zip: Tenant/Lessee Name: 6wWGC Twrl Phone#: Email:5QV�-, 15GVV 10co � 'VV. (om N�c,1�l�—IJ�cu11�1� G�2AV �O�I7f\Ph�#: �30�— 0,707506 CONTRACTOR: Company pang Name: � Address: r%.7V S .5J 66 ST "g I 157 +� City: i ( State: � t"-' �--L Zip: > Qualifier Name: IL U ��1 V � EU%/�/� Phone#: wz; ` 9 T� 7S State Certification or Registration) l� #: C a c=) S'z S� 9 5 Certificate of Competency #: DESIGNER: Architect/Engineer: -\-Vtee- V Phone#: lrD'i l /� &- 55k 45 (05 are Value of Work for this Permit: $ 12 i 000- Type of Work: ❑ Addition Alteration Description of Work: City:'KkCkMi�"�ASA-Q/)State :�cZip: 53k� Square/Linear Footage of Work: `�*�-- ❑ New ❑ Repair/Replace ❑ Demolition �W� Specify color of color thru tile: Submittal Fee $ �00 - Co Permit Fee 0O CCF $ Zn CO/CC $ 2m . 60 Scanning Fee $ - G� Radon Fee $ :3 ' DBPR $ S (S Notary $ Q Technology Fee $ - li Training/Education Fee $ 2 ' `+0 Double Fee $ Structural Reviews $ k • W 0 . Bond $ 0 -FR -2-• :3G • (Jj TOTAL FEE NOW DUE $ U (Revised02/24/2014)-V(y�u ^ i N �7�lv-': SOO, c0 Bonding Company's Name (if applicable) Bonding Company's Address City State 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 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 r in ection fee will be charged. Signature Signatur J OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged beforemethis S day of OGT 20 /O by %D,0Q LLTD%/l who is personally known_to me or who has produced identification and who did take an oath. NOTARY PUB IC: Sign: 9 Print: Seal: 11nREW VOGEL MY COMMISSION # FF919683 EXPIRES: November 25, 2019 #################### APPROVED BY 1D 3� 1 (Revised02/24/2014) 12A (J as The foregoing instrument was acknowledged before me this Z day of 0 eFy LLF67=y— 20 1 y by ho.iss personally known to me or who has produced 69CArs, as identification and who did take an oath. MY COMMISSION # GG Bonded Thru Notary Public Underwriters Plans Examiner Zoning Structural Review Clerk Miami -Dade County Building Department Page 1 of 1 e-Permitting Search } r �LA �1. MIAMI•DADE Resident Visitor Business Employee Status of Plans Process: M2018017614 Application Date: 08/22/2018 Storage Location: By: Date Picked up: Review Reviewed By Est Comp Date Disp Date Disposition DERM JULIO DIAZ r 08/22/2018 10/25/2018 A FIRE RIVAS, JUAN 08/22/2018 09/17/2018 A PWIF WEB APPLICATION ID IFS 08/22/2018 10/11/2018 A WASA LEWIS, DEIDRA 08/22/2018 10/25/2018 A PAYU FEE COL 08/22/2018 08/22/2018 A Disposition Legend: A=Approved, D=Disapproved, N=N/A, P=Approved as Noted Note: PAYU relates to payment of up -front fees only. Page: 1 REVIEW STATUS INQUIRY SUCCESSFUL (NO MORE ENTRIES) BLDG Home Page I BLDG Main Menu I BLDG Permit Menu I BLDG Plans Processing Menu I Ins ecti� on Types I Address Format Home I About I Phone Directory I Privecy I Disc';imer E-mail your comments, questions and suggestions to Webmaster This page was last edited on: February 23, 2004 Web Site © 2004 Miami -Dade County. All rights reserved. http://egvsys.co.miami-dade.fl.us:1608/WWWSERV/ggvt/BNZAW972.DIA?KEY=M20... 10/25/2018 NEWMAN + NEWMAN General contractors Inc. COMPANY LETTER HEAD Date: State of County of Before me this day personally appeared4/tire>A� t3i� �' who, being duly sworn, That he or she will be the only person working on the project located at: } Contractor Signature Sworn to (or affirmed) and subscribed before me this L-0 day of 04�/C .20 4 , Personally know OR Produced Identification Type of Identification Prod uced—�>4/0EP— "4 E?�� ADRIANA LEONOR CLAVIJO MAURI gam;; Notary Public - State of Florida moo`' Commission k GG 197309 '?orr�4F' My Comm. Expires Jul 13,202, Bonded through National Notary Assn. 19>-2 111 ok Print, Type or Stamp Name of Notary 1 305.898.7526 W www.newmangc.com (9 info@newmangc.com Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction 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 attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BE OW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this ` I /J(� day of ��i , 20 By _PJ)D f! giAll who is personally known to me or has produced as identification. Notary: SEAL: nREW VOGEL MY COMMISSION # FF919683 o� EXPIRFS: November 25, 2019 NOTE: MIAMI-DADE G 11805 SW I ✓i w IC RES R 1315-2000 APPLICATION FOR MUNICIPAL PERMIT APPLICANTS THAT REQUIRE PLAN REVIEW FROM MIAMI-DADE FIRE RESCUE AND/OR ENVIRONMENTAL SERVICES PROVIDE MUNICIPAL PROCESS NUMBER HERE cn- \ "�' i . �� Job Address � "�� � \ H Cnl � Contractor No. .— Z0U. Hr W' � 3'�ji� i !j /�/ �y f rOlio 1 •� J �VYJ V l io ¢ z 00 Last four (4) digits of Qualifier No. p W' V F- ¢ Contractor Name �> a p Lot Block Z p Qualifier Name o a _j2 Subdivision PBpg o LL v? Address Metes and bounds City —Zip [ ] New Construction on Demolish [ ] Demolish ii__� ''State Current use of. pro pert y� -+� Vacant Land ( ] Shell Only -- -- - u w [Alteration Interior [ ] Addition Attached �JD� w w [ ] Alteration Exterior [ ]Addition Detached Description of Work � � o [ ]Relocation of Structure [ ] Re -Roof _� �et� IQWL� D��Cyl ZJ tli 6G`. ,f -) Ft. Units 1- Floors a [ ] Enclosure [ ] Foundation Only 2 [ ] Repair [ ] Repair Due to Fire [ ] Tent _Sq. J 'Value of Work 12 If [ ] MBLD" Q [ ] Chg. Contractor w[ Owner 4 Address a� Category [ ] MELE ] Re -Issue a [ ] Re -Stamp Cn City State _Zip cc [ ] MPLU MLPG w [ ] Revision w Phone a [ ] MMEC ( ]Not Applicable for o Last four (4) digits of FIRE Fire Owner's Social Security No. y z o Name �C. Owner Address:R?b Pt, 051L ` 5�. ruo� t kiA_ ¢ w w Address ` e City F`'�IXVY1 l Zip 3 t City State a py w Y �-z w 0.0 �nState Phone 98,b �S�D�L `w a _Zip Phone ` I am requesting a Special Request Plan Review (SRI) to be scheduled as soon as possible. There is a minimum charge of J z a g cc one -hour Please contact the Fire Department for current rate. N 15t Request: Date: w w ¢ a w 2"d Request: Date: LLLUMcc ' 31d Request: Date: If the applicant is a known named violator with: unpaid civil penalties; unpaid administrative costs' of hearing; unpaid County investigative, enforcement, testing, or monitoring costs; or unpaid liens, any or all of which are owed to Miami -Dade County pursuant to the provisions of the Code of Miami -Dade County, Florida, a hold on the review may be placed on this application. 123 )1-192 5/17 q i - ,-�, I'll CA►tEGORY BUILDING 01 1 02 08 1 10 15 29 48 5114 55 56 8. 88 91 92 95 96 97 99 0100 0101 01-07 0110 0111 0112 ELECTRICAL 04 16 38 40 PLUMBING 0020 0024 LPGX 01 '02 04 MECHANICAL 09 8 1-43 4t 48 52 FIRE 32 !, 4 JBIJILIDING PERMIT CATEGORIES DESCRIPTION' GENERAL BUILDING °COMMERCIAL SUB -GENERAL BUILDING -RESIDENTIAL CANVAS AWNING COMMUNICATION TOWER DEMOLITION METAL AWNING & STORM SHUTTER SCREEN ENCLOSURES MURAL SIGNS (NON -ELECTRICAL) SWIMMING POOL TENNIS COURTS (SURFACE PAVING) TRAILER TIE DOWN WALK-IN COOLER MARINAS LOW SLOPE APPLICATIONS (GRAVEL, SMOOTH MODIFIED, SINGLE PLY) SHINGLES (ASPHALT, FIBERGLASS) SHINGLES (METAL ROOFS/WOOD SHINGLES & SHAKE) STAGE 2 VAPOR RECOVERY SYSTEM SOIL IMPROVEMENT BULK STORAGE PROPANE TANK REMOVABLE STORM PANELS TILE ROOF WATER MAIN SITE PLAN INDOOR EVENT/EXHIBIT FIRE ALARM SPECIALTY SPECIALTY WIRING GENERATORS BUILDING PUBLIC RADIO ENHANCEMENT SYSTEM SEWER CONNECTION TO PUBLIC SYSTEM (THIS CATEGORY IS USED WHEN NO BUILDING PERMIT EXIST) INTERCEPTOR/GREASE TRAPS (REPLACEMENT OR INSTALLATION THAT IS NOT PART OF A BUILDING PERMIT) LIQUEFIED PETROLEUM GAS MISCELLANEOUS LIQUEFIED PETROL. GAS/STATE ABOVE/BELOW GROUND TANKS/PUMPS & POLLUTANT STORAGE SYSTEM COMMERCIAL HOODS FIRE CHEMICAL SPRAY BOOTHS SMOKE CONTROL RESIDENTIAL ELEVATOR FIRE SPRINKLER PERMIT TYPE MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MBLD MELE MELE MELE MELE MPLU MPLU MLPG MLPG MLPG MMEC MMEC MMEC MMEC MMEC MMEC FIRE r.: -•^�'��+,�_:.d..�.71r�f + "•i,4.%'+� ';',�i}'r'at4 #%[�r�f"=_`"�'��,;JK � •F y 1 "�'� Certificate of Completion Miami Shores Village 10050 N.E. 2nd Ave, Miami Shores, Florida 33138 Tel: 305-795-2204 Fax: 305-756-8972 Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: Description: FOOD PREP EQUIPMENT LAYOUT AND NEW ADA BATHROOM. UNIT# 175 NE 96 ST SarahLou Confections Permit Type Building (Commercial) Bldg. Permit No. CC-8-18-2250 Owner TODD LEONI Contractor NEWMAN & NEWMAN GENERAL CONTRACTORS INC Subdivision/Project Date Issued 02/08/2019 Construction Type III-B Occupancy B 4 Persons Type Square Footage 617 Flood Zone X Location If the building is located in a special flood hazard area documentation of the as -built lowest floor 9600 NE 2 AVE elevation or lowest horizontal structural member has been provided and is retained in the records of Miami Shores, FL 33138 Miami Shores Village. This certificate issued pursuant to the requirements of the Florida Building Code certifying that at the ,SNORES `, time of issuance this structure was in compliance with the various ordinances of the jurisdiction << regulating building construction or use. �' ::"'.fie. r~ � .�✓ � ly Building Officials Approval Ismael Naranjo, CBO y s .d1A. xs'NI h.;... Miami Shores Village Et; Building Department 10050 NE 2 Ave hN7� �O RIDP' Miami Shores FL 33138 :0 Issue Date:11 /5/2018 INSPECTION REQUESTS: (305)762-4949 or log on at https://bldg.msvfl.gov/energov_prod/sellservice Requests must be received by 3:30pm WORK IS ALLOWED: MONDAY THROUGH FRIDAY, 8:00AM-7:OOPM SATURDAY 8:OOAM - 6:00PM. NO WORK IS ALLOWED ON SUNDAY OR HOLIDAYS BUILDING AND ROOFING INSPECTIONS ARE DONE MONDAY THROUGH FRIDAY . NO INSPECTION WILL BE MADE UNLESS THE PERMIT CARD IS DISPLAYED AND HAS BEEN APPROVED . PLANS ARE READILY AVAILABLE. IT IS THE PERMIT APPLICANT'S RESPONSIBILITY TO ENSURE THAT WORK IS ACCESSIBLE AND EXPOSED FOR INSPECTION PURPOSES. NEITHER THE BUILDING OFFICIAL NOR THE CITY SHALL BE LIABLE FOR EXPENSE ENTAILED IN THE REMOVAL OR REPLACEMENT OF ANY MATERIAL REQUIRED TO ALLOW INSPECTION . Permit;NO. CC-8-18-22J0 Type: Building (Commercial) Worwass: Alteration Expires: 03/18/2019 POST ON SITE 1132060132510 Owner's Name: TODD LEONI Owner's Phone: Job Address: 9600 NE 2 AVE Total Square Feet: 617 Miami Shores, FL 33138 total Job Valuation: $ 12,000.00 Contractor(s) Phone Address NEWMAN & NEWMAN GENERAL CONTI (305)898-7526 7705 SW 86 ST B-115, MIAMI, 33143 Description: FOOD PREP EQUIPMENT LAYOUT AND NEW ADA BATHROOM . NEW ELECTRICAL PLUMBING ARE WITHIN THE SCOPE OF WORK. UNIT# 175 NE 96 ST Y'C913 P��i�C �E 0� Jos Ai ilh9� ✓f WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Page 1 of 1 INSPECTION RECORD STRUCTURAL INSPECTION dAIE INSP Foundation Stemwall Slab Columns (1st Lift) Columns (2nd Lift) Tie Beam Truss/Rafters Roof Sheathing Bucks Interior Framing Insulation Ceiling Grid AOF Drywall n4cxf Firewall Wire Lath Pool Steel Pool Deck Final Pool Final Fence Screen Enclosure Driveway Driveway Base Tin Cap Roof in Progress Mop in Progress Finall Roof Shutters Attachment Final Shutters Rails and Guardrails ADA compliance Soil Bearing Cert EhW Soil Treatment Cert Floor Elevation Survey Reinf Unit Mas Cert Insulation Certificate Spot Survey Final Survey Truss Certification STRUCTURAL COMMENTS i WINDOWS :DOORS INSPECTION TE INSP Attachment PUBLICWORKS INSPECTION DATE INSP Excavation ELECTRICAL INSPECTION DATE INSP Temporary Pole 30 Day Temporary Pool Bonding Pool Deck Bonding Pool Wet Niche Underground Footer Ground Slab Wall Rough Ceiling Rough Rough Telephone Rough Telephone Final TV Rough TV Final Cable Rough Cable Final Intercom Rough Intercom Final Alarm Rough Alarm Final Fire Alarm Rough Fire Alarm Final Service Work With O( ELECTRICAL CIMMENTS PLUMBING INSPECTION DATE INSP Rough or r , . Water Service 2nd Rough Top Out I Fire Sprinklers Septic Tank Sewer Hook-up Roof Drains Gas LP Tank Well Lawn Sprinklers Main Drain Pool Piping Backflow Preventor Interceptor Catch Basins Condensate Drains HRS Final III 1 'i /9 PLUMBING COMMENTS �/1f1i1 Yli6 0} MECHANICAL INSPECTION DATE 7 INSP Underground Pipe Rough Ventilation Rough Hood Rough Pressure Test Final Hood Final Ventilation Final Pool Heater Final Vacuum MECHANICAL COMMENTS Pereblys Service and Repairs Inc. 3335 w 13th Ave Hialeah, FI 33012 . 305-528-3115 BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM ADDRESS OF DEVICE: ,175 NE 96 St Miami FL33150 OWNER OF DEVICE: Westland Plumbing Inc OWNER CONTACT: PHONE:: FAX: 1 ADDRESS OF OWNER: ZIP CODE:: NAME OF TESTER: CERTIFICATION #: EXPIRATION DATE:: PHONE:: Ebl s Pereda 16230 04/17/19 305-528-3115 2 BUSINESS NAME: BUSINESS ADDRESS: ZIP CODE: Pereblys Services And Repair INC 3335 W 13 Ave Hialeah FI 33012 3 TEST KIT MAKE:: MODEL #: SERIAL #: DATE LAST CAL. SITE TUBE: Backflow artde o t MTK-15 03161399 07/13/2018 YES / NO TEST PLEASE MARK: R.P. D.C. P.V.B. MAKE OF ASSEMBLY: MODEL NO: SERIAL # SIZE: 3/4" Apollo RPLF4A 922475 LOCATION OF ASSEMBLY: Back north side of the building HAZARD/SERVICE: Domestic METER NO. 4 INITIAL TEST: ANNUAL TEST: DATE OF TEST: 12-10-2018 METER READING: SHUT OFF VALVE it: SHUT OFF VALVE 112: CLOSED TIGHT: CLOSED TIGHT: LINE PRESSURE: 50 PSI PRESSURE STABLE: YES - NO LEAKED: LEAKED: D.C.V.A. R.P.Z.A. P.V.B. CHECK VALVE NO.1 CHECK VALVE NO.2 DIFFERENTIAL RELIEF VALVE AIR INLET CHECK VALVE X FAILEDTOOPEN:_ LEAKED: N Closed Tight: Closed Tight: FAILED TO OPEN: "' Leaked: Leaked: � OPENED AT: PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK 3.3 HELD AT: 8.9 2•1 OPENED AT: PSI. PSI PSI PSI PSI IF THE ASSEMBLY FAILS FOR ANY REASON, COMPLETE THIS SECTION AND NOTE REPAIRS REMARKS / REASON FOR FAILURE (IF APPARENT): CHECK VALVE NO.1 CHECK MAE NO.2 DIFFERENTIAL RELIEF VALVE P.V.B. N CLEANED: CLEANED: CLEANED: CLEANED: cc Q REPLACED: REPLACED: REPLACED: REPLACED: d t1J D.C.V.A. R.P.Z.A. P.V.B. CHECK VALVE NO. 1 CHECK VALVE NO.2 DIFFERENTIAL RELIEF VALVE AIR INLET CHECK VALVE Closed Tight: Closed Tight: FAILED TO OPEN: FAILED TO OPEN:_ LEAKED:_ LLI � OPENED AT: HELD AT: W Oc Leaked: Leaked: PSI PSI PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK OPENED AT: PSI PSI PSI I CERTIFY THAT I HAVE TESTED THE ABOVE ASSEMBLY IN ACCORDANCE WITH THE A.W.W.A. CROSS CONNECTION CONTROL MANUAL AND THAT ALL THE INFORMATION IS ACCURATE TO THE BEST OF MY ABILITIES. SIGNATURE OF CERTIFIED TESTER: — — DATE: _qL_j_ 1 12-10-2018 NOTE: TEST FORM MUST BE COMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FOKM5 WILL tit RET URNEU. Revised: 5/27/2010 e-mail: CCC@mlamidade.gov web: http://www.miamidade.govtwater/cross-connection-backflow.asp BUILDING PERMIT APPLICATION 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 P C V DEC 12 206 dL-" nC 20114- Master Permit No. CC - 6 - 18 - Z - 5CD Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION M RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION SHOP f�77 p� CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip I SS Folio/Parcel#: is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: n Flood Zone: (8FE: FFE: OWNER: Name (Fee Simple Titleholder): 2�7 L�01J1 " P���ZZ0 Lcol ones: Address: 9 6 0 () O 1�-w 3 °vi '4-o3 il'l i e�w� ; Wit_ 3 3"z3$ City: H I.L F-A 1 S State: 1= (_0 CL ) b A-,., Zip: -?=>--Z> I Tenant/Lessee Name: Phone#: Email: N5%jj" tNr.�+` t'3 E5a w0—N1j �7 CONTRACTOR: Company Name: �CL� �-MQ C n t'c� CT 0rS I N C - Phone#: Z-?o Address: r%r%d.5 SW 8 S� 4:, r2--., 11,5 City: State: l� R 1 1i%� Zip:_z:;'5' 1 -7, G�� n Qualifier Name: RQ (�1�. l D 1J � W 1`1 R� Phone#: 305- 0 b a State Certification or Registration M CG C_. 115 7- SS 75 Certificate of Competency #: DESIGNER: Architect/Engineer: Address: City: State: Zip: co Value of Work for this Permit: $ �J _ Square/linear Footage of Work: 9 1 7 Type of Work: ❑ Addition 0 Alteration ❑ New 1 ❑ Repair/Replace ❑ Demolition Description of Work: 5 46? D IZ.A In.�l UG � 02 U)A+LCy' hC�Ci l V i S u �it�e t - Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Technology Fee $ Structural Reviews $ Radon Fee $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ `' !0 ou t (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 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 a roved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of . 20 _, by %WQQ tj�PNl . who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBUQ Sign: Q Print: ...------------------ as The foregoing instru was acknowledged before me this I1 t" day ofent CCQ m 4' r 20 by l U UY1 Cu who is p sonally known to me or who has produced Y i C q hS' Y as Identification and who NOTARY PUBU : Sign: Print: Seal: n'EW VOGEL Seal: MY COMMISSION # FF919683 EXPIRES: November 25, 2019 APPROVED BY %--�' Plans Examiner YANADY PNETO MY C0.1."1113SIO'. # FF 214431 EXPIRES: March 25. , 019 Zoning 0 Structural Review (Revised02/24/2014) Clerk