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PLC-20-849RECEIVED Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax:1305) 756-8972 INSPECTION LINT? PHONE NUMBER: (305) 762-+4949 R 2 9 2020 BY: FBC 20 J� BUILDING Master Permit No. e-"-- CN5 - l9 --1 t/oy PERMIT APPLICATION Sub Permit NoD Q � y - ,Zo $4-q []BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION ORENEWAL 52(PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION [] SHOP CONTRACTOR DRAWINGS JOB ADDRESS: g 7 2,5 P a .2 Aq rw% A wl 4�(aPAT _ 7 (! _ City: Mjam ho es _ County: _Miami Dade _ Zip: 3 3 LW Folio/Parcelli:_I (3 Zp <p4 I ?b 4'Z ( & _ Is the Buikliing Historically Designated: Yes NO /V Occupancy Type: . Load: — _ _ Construction Type: Flood Zone: 8FE: — — — FIFE: OWNER: Name (Fee Simple Tltlehokker): 4-oia— Phone#:9 Address: _I V54- 0 141X- City: State; _Zip: 3301� Tenant/Lessee Name: _ _ _ Phone#:_ _ Email: t+i QJEZ_ �► _�!AToRtniv, Gvt _ 63.05�tiv,l(o-70 CONTRACTOR: Company Name: _ �.�ll(AK5U►JE Phone#:-Ae%D 5496� iQ�6 Address: CRY: VA P&&i, State: _ — --Zip: _ — Qualifier Name: ��,.�{�1-2-'I tJ _Phone#: '�tf� State Certification or Regl ation #: �/_ � �..iA (0 �` _Certificate of Competency #: _ DESIGNER: Architect/Engineer. _!Sly— LLAc,_(24 ,444 _Phone#: (-q4j(ot 4-' -1TO) Address: .i( Id) WQww-,.�cn "(f 1tom/^fs CitY.,B4&JA%460•-) State: 1�-,_zip: 3331Z Value of Work for this Permit: $ I U UO _ � — - Square/Linear F000 a of Work: _ +?J Type of Work: El Addition ❑ Alteration ❑ New [I Repair/Replace ❑ Demolition Description of Work: 're fie_ -i c. W vj l- E -r Specify color of color thru tile: Submittal Fee $ _ Permit Fee $ _ CCF $ _ _ _ CO/CC $ _ Scanning Fee $ Radon Fee $ _ _ _ _ _ DBPR S Notary; Technology Fee S _ Trabdng/Education Fee $ _ Double Fee $ Structural Reviews S _ _ _ _ Bond $ TOTAL FEE NOW DUE $ 1.k Q . 3.O (Rew5eWZ/Z4na14) 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: 1 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 $2SOO, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure w111 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 ins ect' whkh occurs seven (7) days after the building permit Is issued in the absence of such posted notice, the Inspection will r> t be approved and a reinspection fee will be charged. The foregoln� aZ_da G� Signature —— OWNER or AGENT CONTRACTOR ent was acknowledged before me this II L 20 7.2,. by Flo is personally known me or who has produced as Identification and who did take an oath. NOTARY PUBLIC: r , ike Vazquez Sign:_ ae B_ ISSION # GG29193 — Print 's � Bb�T��J Seal: � The foregoing instrument was acknowledged before me this _ G day � of �,(��,�,�- 20 _ o by lidencation —Y_tC,�` (1i mown to has produced as and who did take an oath. UBLIC: Sign: P,� BARBARA CARMONA c . oR Lary Public - State of Florida Print: C0mr1issinn_#_FE949354 — My Comm. Explres May 7, 2020 Seal: Bonded through National Notary Assn. �+tittt/itttttttttttttttfttttttttttttftfttfttftttttttttftttittiftttttftfftttfttftftfftftffttft►fttfftfffttt�t APPROVED BY G�--� _5, je, Plans Examiner _ Zooin B Structural Review _ _ _ _ Clerk (Revl3ed02/24/2024) , 4 A4COR�® I `.I CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 04/16/2020 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 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 endorsements . PRODUCER CONTACT NAME: Egglls Cepero PA CNN Ert ; (305) 264-3636 FAX No): (305) 264-3357 Lopez Insurance Agency Inc. d/b/a Statewide Ins E-MAIL ADDRESS: alis.ce ero statewideins.net gg P G 2555 NW 102 AVENUE SUITE 204 INSURERS AFFORDING COVERAGE NAIC Y INSURERA: GRANADA INSURANCE COMPANY Doral FL 33172 INSURED INSURER B : INSURER C : Y & M Plumbing, Inc. INSURER D : 4601 SW 127 CT INSURER E : INSURER F : Miami FL 33175 CAVFRAGFS CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR ILTR TYPE OF INSURANCE ADDL S BR POLICY NUMBER MMIDCY EFF MMID LICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR N PREMISES Ee occurrence $ 100,000 MED EXP (Any one person) $ 5,000,00 $ 1,000,000 A n n 0185FL00044843 04/15/2020 04/15/2021 PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY JEo LOC I PRODUCTS - COMP/OP AGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee e...nt $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per e..dent $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMBER EXCLUDED? �Y N / A PEROTH- STATUTE ER E.L. EACH ACCIDENT $ ,AND (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Plumbing Services License Number: CFC 1426681 MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 Avenue MIAMI SHORES 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 FL 33138 vm. amwo 9)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AFRO' CERTIFICATE OF LIABILITY INSURANCE 04/28/2020 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 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 endorsements . PRODUCER CONTACT Paychex insurance Agency Inc PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE PHONE0. . 877-266-6850 FAX 585-389-7426 E-MAILADDRESS, Certs@paychex.com ROCHESTER, NY 14620 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Technology Insurance Company 42376 Y & M PLUMBING INC 4601 SW 127 COURT INSURER B: INSURER C: MIAMI, FL 33175 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. NSR TR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP LIMITS MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADEE�OCCUR DAMAGE TO RENTEDPREMISE (Fa occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY y GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: POLICY = PROJECT= LOC PRODUCTS - COMP/OP AGG $ E AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUUTTOSSyy HIRED AUTOS AUTOS NED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION i $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TWC3853256 01/13/2020 01/13/2021TORY X WC STATU- OTH- LIMIT ER E.L. EACH ACCIDENT $ 100,000.00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? � E.L. DISEASE - EA EMPLOYEE $ 100.000.00 E.L. DISEASE - POLICY LIMIT $ 500.000.00 (Mandatory In NH) I N I N/A 11 yes, desvbe-der DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) PLUMBING SERVICES; Lic # CFC1426681 CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2nd Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores, FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) @1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Miami Shores Village 10050 NE 2nd Avenue Miami Shores, FL 33138 ACORD 5566022 0040/17138648