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EL-19-71Cr )7019 ED Miami Shores Village JUN Building Department BY:t,- 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 20 BUILDING Master Permit No. d2C,t(— t2 --:33 70 PERMIT APPLICATION Sub Permit No. fE7� D(— to l I ❑BUILDING E/ELECTRIC ❑ ROOFING VREVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: [a% AA7 01 (6 5-A. ,� y-� City: Miami Shores County: Miami Dade Zip: 53e Folio/Parcel#: �� "Kt�rnL7I�i 121,3 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): �i► iC�Q j'IQ7C9 Vt Phone#: g5os S9 t7 —asn Address: 10 City: iGfJl( </°Q ( State: f::C. Zip: �1� Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: rl' l') t r CD C• Phone#: 2NO"I's- !RS— 60 Address: 102— Tani l J City: State: Zip: Qualifier ame: 1 Phone#: State Certification or Registration #: 15LI ? t3 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ /^ICJ. dJ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration El New ❑ Repair/Replace ❑ Demolition (( Description of Work: B.J e V011A —6 UE14-ec�- rtAC,( el( (j)Q, � py- 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 $ a Double Fee $ Bond $ TOTAL FEE NOW DUE $ 45,-[ ., C'Jz (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 State Zip Zi 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 $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. 00, Signature OWNER or AGENT The foregoing instrument was acknowledged before me this day of 20� by U who is personally known to e or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal: P - LUZ P. ERLICH MY COMMISSION # GG199267 "� 9r EXPIRES. May 30. 2022 C Signatures& CONTRACTOR The foregoing instrument was acknowledged before me this % day offiit 120 �`� by (/ � who is rson n to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: :6— Seal: LUZ P. ERLICH YMY COMMISSION # GG 199267 ,�a EXPIRES: May 30, 2022 as ************************************************************************************************************ APPROVED BY ��GP6M Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 'Q '� � CERTIFICATE OF LIABILITY INSURANCE °AT ;;;�,1°'s ' 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 pollcy(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 CONE cY MARWBOBBY Kava Insurance And Financial Srvc PHONE (954) 583-5377 fa , No); (954) 727 9206 1217 N W 40th Ave EMAIL MARIADP@KAVAINSURANCE.COM Lauderhill, FL 33313 INSURE S AFFORDING COVERAGE HAIL S Phone (954)583-5377 Fax 954)727-9206 1NSURERA: SCOTTSDSALE INSURANCE COMPANY 41297 INSURED INSURERS: ONLY ELECTRIC CO INC INSURERC: 348 NW 102nd Terrace InevRtRu: Plantation, FL 33324- (954) 817-5617 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LTR TYPE OF INSURANCE ADD ORyyK SUBR POLICYNUMBER POLICY EFF MWD POLICY EXP MWDD/YYYY) LIMITS GENERALLI►BILITY EACH OCCURRENCE S 1,000,000.00 PEER SEGE T EaEocaxrence $ 1,000,000.00 ❑/NTED COLWERCIAL GENERAL LIABILITY MEDEXP(Any one person)_ $ 5,000.00 �'"-.--'- A ❑ ❑ CLMMS-I,IADE © OCCUR ❑ N N CPS3031379-01 04/14/2019 04/14/2020 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ s 2,000,000.00 GENERAL AGGREGATE _ GENLAGGREGATE LIMITAPPLIESPEP. PRODUCTS -COMPJOPAGG S 2,000,000.00 ❑ POLICY ❑ PRO- ❑ LOC JECT $ AUTOMOBILE LIABILITY E MBEen? tANGLE LIMIT BODILY INJURY (Per person) $ ❑ ANY AUTO ❑ ALLOWNED SCHEDULED AUTOS ❑ AUTOS NON -OWNED ❑ HIRED AUTOS ❑ AUTOS BODILY INJURY (Par accident $ .....__-..___ P BOPERDAMAGE $ — $ ❑ D ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑ CLAII.dS-I,"MF AGGREGATE $ ❑ DED ❑ RETENTIONS $ -- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ❑ WC STA LS ❑ ETH- TORY ANY PROPRIETORIPARTNERIEXECUTWE C OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE S $ If yes, descr be under OESCRIPTION OF OPERATIONS belay EL DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORO 101, Additional Remarks Schedule, if more space is required) ELECTRICAL WORK WITHIN BUILDINGS. CERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPT 10050 NORTHEAST 2nd AVENUE MIAMI SHORES, FL 33138 ACORD 26 (2010106) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRO ISION AUTHORIZED REPRESENTATIVE VLADIMIR ©1986-2 OR V60ORAW. All rights reserved. The ACORD name an logo are registered marks of ACORD