MC-18-978Miami 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
-' F1BUILDING ❑ ELECTRIC ROOFING
F—IPLUMBING Q MECHANICAL ❑ PUBLIC WORKS
JOB ADDRESS: 114 NE 106th Street
APR 1 2018
BY- ---
FBC 2010
Master Permit No.
Sub Permit No. ' 1 C
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-2136-005-0070 Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee simple Titleholder): JACQUELINE E IRWIN Phone#: 954.410.4695
Address..114 NE 106 ST
City: Miami Shores State: FL. Zip: 33138
Tenant/Lessee Name: Phone#: 954.410.4695
Email: lirwin@gmail.com `-
CONTRACTOR: Company Name: <�V�Dfy 1; �_'o up
Address: 5-9 0 CTV0_56 v 0
City: f5r /6 e�YtzH-1 State: Zip: 33 4 V Q
Qualifier Name: S 121\8 0 A!k:?' Phone#: V .
State Certification or Registration #: (�- V 6 L, I L,-n "I L, 0 (/Certificate of Competency #:
DESIGNER: Architect/Engineer: Mark A. Campbell Phone#: 305.754.2318
Address:373 NE 92nd Street City. Miami Shores state: FL. Zip: 33038
Value of Work for this Permit:
Type of Work: K Addition
Description of Work:
Square/Linear Footage of Work:
M Alteration ❑ New
MMW�F=2]m
❑ Repair/Replace ❑ Demolition
Specify color of color thru tile: vo
Submittal Fee $ SO Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ Z Z. oc) DBPR $ 2 - w Notary $
Technology Fee $,
Training/Education Fee $
Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $ nn
TOTAL FEE NOW DUE $ 9r.V
Bonding Company's Name (if applicable)
Bonding Company's Address __
city
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
M
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 wilinotbe approved and a reinspection fee will be charge
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
— day of 'JV 1,1 20 .._C7 by
!� (2VF'I'vtOi(Lrv"'J who is personally known to
U.
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 5�11R 20 L J , by
45—V pic api.s 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 PUB • NOTARY PUBLIC:
Sign: Sign:
Print: GAq-5.1' CAMP F-11L
Print: j
Seal- •Y"r• CHASE CAMPBELL
MY COMMISSION N FF 200055 Seal: ?o�"Ar PJ/" c
EXPIRES: February 17, 2019 LAURAFARLEY
* * MY COMMISSION IFF 1027
...... '* Bonded Thru Notary Public Underwriters EXPIRES: March 16, 2019
************************* ****** ****** *•r*j#z****s**ses********FPfia\****endedThru *****B*dgs* x**esrs**F********ss**
APPROVED BY
Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)
gcoRV CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
L 1 12/1/2017
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(ies) 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 NAME CT Rand1 Arnold —
Frank H. Furman, Inc. 1 FAX
No): (954)992-6310
PHONE (954) 943-5050
(A/C, No, Ext): _
1314 East Atlantic Blvd. E-MAIL randi@furmaninsurance.com
ADDRESS:
P . 0. BOX 1927 INSURERS) AFFORDING COVERAGE -I NAIC #
Pompano Beach FL 33061 INSURER A:United—Specialty Ins Co _12537
INSURED INSURERB:U S Fire Insurance Company (us) __21113
Sansone LLC dba: Sansone Air Conditioning INSURERC:GuideOne National Insurance Company 14167
590 Goolsby Blvd. INSURER D:Bridgefield Employ_ers_Ins Co _ 10701
INSURER E : _
Deerfield Beach FL 33442 1 INSURERF: I I
ICrfTlclfATC uuAmmom ?nl 7-9ni A TA whi 1 i tv Csart- RPVISICIN NIIMRFR-
VVYLIV`�V VV -
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, THE INSURANCE 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.
I
INSR AODL SUBR IPOLIC YYFF I MM DD/YYYY
LTR I TYPE OF INSURANCE POLICY NUMBER
LIMITS
I X
COMMERCIAL GENERAL LIABILITY
j
EACH OCCURRENC1,000,000
��
A
CLAIMS -MADE X OCCUR
DAMAGETO RENTED
_PREMISES_(Ea occurrence) _1 $
100,000
,
LIG0004400 12/1/2017 12/1/2018
MED EXP (Anyone person) I $
PERSONAL & ADV INJURY $
5,000
1,000,000
I
_
GEN'L AGGREGATE LIMIT APPLIES PER:
�'I (-GENERAL
AGGREGATE _ r $
2,000,000
PRO-
POLICY LOG
j
PRODUCTS - COMP/OP AGG 1 $
_---__-
2,000,000
JECT --I
$
OTHER:
COMBINED SINGLE LIMIT $
1,000,000
AUTOMOBILE LIABILITY i
_(Ea _accident)___ __
f
X I
BODILY INJURY (Per person) $
B
ANY AUTO
ALL OWNED 1 SCHEDULED 133-742742-3
12/1/2017 12/1/2018
'BODILY INJURY (Per accident) { $
AUTOS AUTOS
y NON -OWNED
---
PROPERTY DAMAGE $
�r
--
X HIRED AUTOS I X AUTOS I
Per accident)
1 $
X
UMBRELLA LIAB OCCUR
EACH OCCURRENCE j $
5,000 , 000
C
EXCESS LIAR CLAIMS -MADE
j
AGGREGATE is
5,000,000
1 560000088-00 12/1/2017
12/1/2018
Is
DED (RETENTION$
WORKERS COMPENSATION
X PER OTH-
(
AND EMPLOYERS' LIABILITY
-__STATUTE _ _ER
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE - 'NIA
E.L.EA--- - - $
__- _ _ _ _ _ -�.
1,000,000
_ _. __ _._.._
OFFICER/MEMBER EXCLUDED? .I 083054159 1/1/2018
�
D (Mandatory in NH)
1/1/2019
,,_ __ _
E.L. DISEASE - EA EMPLOYEE $
_
1,000,000
-
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
1,000,000
i
I
�
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: MECHANICAL CONTRACTOR LICENSE # CMC1249260
CERTIFICA
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Dirk DeJong/RA -&�-p
V lytSif-LUT4 Al.VKL7 l.vRrvlCAl wrr. rul Myrna reacivuu.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
_- BFQD COCi1TY LAL BUiESS TAX RECEtP1' _.
115 S.-Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2017 THROUGH SEPTEMBER 30, 2018
pgq; Receipt #:348
IfGAT NG/AIRCONDITION CC
Business Name: SANSONE AIR CONDITIONING Business Type: (MECHANICAL CONTRACTOR)
Owner Name: SCOTT J SANSONE/QUAL Business Opened: 12/11/2003
Business Location: 590 GOOLSBY BLVD State/County/Cert/Reg:(-'MC.1249260
DEERFIELD BEACH Exemption Code:
Business Phone: 954-428-8919
fRooms Seats Employees Machines Professionals
75
es
For Vending Buslns Only
Number of Machines: Vending lype: -
Transfer Fee NSF Fee Penalty Prit r yeaI Collection Cost Total Paid
b.00 b.00 0,00 7`} —_---- 0'00 150.GO
Tax Amount
150.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non -regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location. This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
SCOTT LTSANSONE/QUAL Receipt 404B-16-04011869
590 GOOLSBY BLVD pa;_d 09/25/2017 150.00
I DEERFIELD BEACH, FL 33442
i
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
ORLDA
Phone: (305)795-2204
Permit NO. MC-4-1$-g78
Permit Type: Mechanical - Residential
rillWork Classification: A/C Replacement
Permit Status: APPROVED
Issue Date: 5/1/2018 1 Expiration: 10/28/2018
Project Address Parcel Number Applicant
114 NE 106 Street 1121360050070
Miami Shores, FL 33138-2037 Block: Lot: JACQUELINE IRWIN
owner mrormation Address Phone Cell
JACQUELINE IRWIN 114 NE 106 Street
MIAMI SHORES FL 33138-
114 NE 106 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone
SANSONE CORPORATION 954-428-8919
ins:
dditional Info: NEW AC AS PER APPROVED PLANS
lassification: Residential
oproved: In Review
Denied:
nning: 1
Fees Due
Amount
CCF
$2.40
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.80
Permit Fee
$133.00
Scanning Fee
$3.00
Technology Fee
$3.20
Total:
$146.40
Valuation: $ 3,800.00
Total Sq Feet: 0
Date Approved:: In Review
Type of Work: NEW AC AS PER APPROVED PLANS
Pay Date Pay Type Amt Paid Amt Due
Invoice # MC-4-18-67150
05/01/2018 Check#: 2045 $ 96.40 $ 50.00
04/12/2018 Credit Card $ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Final
Review Mechanical
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 t all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction a oning. Fut m , I authoriz the abov -n med contractor to do the work stated.
✓�� May 01, 2018
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
May 01, 2018 1