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REV-17-846'REVI1- 64b `� Q�cti/, 11 5 H Miami Shores Village RECEIVED !CDIEE:`" Building Department MAR 2 2017 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 2011-I54 BUILDING Master Permit No. �' �C' �r L "i " 8 PERMIT APPLICATIO Sub Permit No.y BUILDING ❑ELECTRIC ❑ F R ION ❑ EXTENSION ❑ RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WO F CANCELLATION ❑ SHOP C CT DRAWINGS JOB ADDRESS: O /UC City: Miami Shores Countv: Miami ade V1 Zio: 3313A Folio/Parcel#: i) �? 0�5-0 D 1 SO Is the Building Histori Ily Designated: Yes NO Occupancy Type: Load: nConstruction Type: Flood Zone: BFE: FFE: OWNER: Name (FeeSimpleTitleholder): 1^ ` �� "..e) /L A-A>Ce 4 Gv'' VQ. Phone#: Address: �� 3 t AP-6 /G[ C,E- City: /�r �� U-U ,5 4o reS State: ,AC z' Zip: 3 3 13 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: r- d A.� e- (10 h TY 'LA--o ►'- Phone#: t (c' Address: 20 (Iz o G nR�A <-. --. City: �� O l ��( B O CL State: Ic-L Zip: 3.7 ©Z O Qualifier Name: L �('s ® LC101. a_x:� Phone#: State Certification or Registration #: C Co C / Lr Certificate of Competency #: DESIGNER: Architect/Engineer: etc ra � l�Gl�. Phone#: .�� f� Rp8f Address: ZZ Y 414AP9k 5 T ' d'cn e %%8 —City:"/ AP?/ A?boa4 State: Zip: Value of Work for this Permit: $ /?JrWSquare/Linear Footage of Work: Type of Work: ❑ Additi n ❑ Alteration ❑ New 11111!Repair eplace ❑ Demolition Description of Work: /I� A101- 0O 1IJ�41 C C 4 4 al' 4FCe-� ItW S Ct011 Specify color of color thru We: Submittal Fee $_ dz Permit Fee $ Q CCF $ 10' 93 CO/CC'$ Scanning Fee $ l Radon Fee $ DBPR $ ?J Notary $ Technology Fee $_ E I Training/Education Fee $ Double Fee $ �n Structural Reviews $ �Ga ' Bond $ TOTAL FEE NOW DUE $ f0 (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Zip 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. 4 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 absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. /0 ,/ I Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of t": (A✓C V 20 it by �-� iS Qn I c,,r w�erso avAaQwn to me or who has produced identification and who did take an'oath. NOTARY PUBLIC: Sign: Print: _�T—Vii as The foregoing instrumentacknowledged was (ckknowledged before me this Z2 1* day of ' `k/"� by v4Q� who is personally k n to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Pri ------------- Seal: �`�r Notary t b�State of Florida Seal: Jorge Ottigow Dioney; c My Commission FF 240546 Notary Public State of Flcride Expires 06/16/2019 FF 952774 - Exp 02.07.2020 6 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) CER"nFICATE OF LIABILITY INSURANCE Date 3/24/2017 producer. Plymouth Insurance Agency This Certificate s issued as a matter of information only and confers no 2739 U.S. Highway 19 N. Holiday, FL 34691 rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. (727) 938-5562 Insurers Affording Coverage NAIL # insured: South East Personnel Leasing, Inc. 8t Subsidiaries 2739 U.S. Highway 19 N. Holiday, Ft_ 34691 Insurer A: Lion Insurance Company 11075 Insurer B: insurer C: Insurer D: Insurer E: Coverages The policies of insurance listed belowhave been issued to t insured named above for the policy period indicated. NotwithsWiding arry 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 term, exclusions, and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. INSR LTR ADDL INSRD T of Insurance Type Policy Number Y Policy Effective Date Policy Expiration Date Limits (@AlldtflQ�''1') (MM1DD/YY) GENERAL LIABILITY Each occurrence t Commercial General Liability Claims Made11 Occur Damage to rented premises (EA occurrence) Med Exp Personal Adv Injury eneral aggregate limit applies per: General Aggregate PrtKy project 'wc 0 Pmduas - ConV10p Agg UTOMOBILE LIABILITY Combined Single Limit Any Auto (EA Accident) Bodily Injury All Owned Autos Scheduled Autos (Per Person) Bodily Injury Hued Autos Non -Owned Autos (Per Accident) Property Damage (Per Accident) EXCESSIUMBRELLA LIABILITY Each Occwence Occur ❑ Claims Made Aggregate Dedticlibie A Workers Compensation and WC 71949 01/01/2017 01/01/2018 X WC Statu- OTH- Employars' Liability I tory Limits ER E.L. Each Accident $1,000,000 Any proprietor/partnertexecubve officer/member excluded? NO E.L. Disease - Ea Employee 31.000,000 If Yes, describe under special provisions below. E.L. Disease - Policy Limits S1,0oD.oOo oftr Uon insurance Company is A.M. Best Company rated A- Excellent). AMB # 12616 Descriptions of Operatlons/LocationsNehlcles/Excluslons added by Endorsement/5peclal Provisions: Client ID: 92-68-303 Coverage only applies to ac we employees) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company": Eddie. Contractor Corp Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s), while working in: FL. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Oient Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-SS62. Project Name: ISSUE 03-24-17 (BP) Reblit Date, 11212017 CERTIFICATE HOLDER CANCELLATION MIAMI SHORE VILLAGE BUILDING DEPT. Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer viol endeavor to mail 30 days written notice to the certificate holder named to the left, but failure to do so shall Impose no obligation or liability of any kind upon the insurer, its agents or representatives. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 A, *4R Z� Tuesday, March 22, 2017 City of Miami Shores Att. Building Department Ref. Harke Residence Permit (RC-6-16-1778) As per your request, find below our change order # 003 cost from our project at 1037 NE 915t Terr. Please let me know if you need any other information. Change Order # 003 1 $17,500.00 Labor Materials Perimeter tie beam $10,500.00 $6,000.00 $4,500.00 Columns and Fill Cells $7,000.00 $4,000.00 $3,000.00 ** Front of the house Total 1 $17,500.00 Sin y, lis Har e Owner