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PL-08-20-1825, 9119 N Miami AveMiami Shores Village7.14 �o�y Building Department �- 10050 N.E.2nd Avenue, Miami Shores, Florida 33138,31. ~ Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 h FBC 20(-"� BUILDING Master Permit No.2c'_0-4, 19_ 1 k-0-i8 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC M ROOFING M REVISION ❑ EXTENSION QRENEWAL F(PLUMBING ❑ MECHANICAL [PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION M SHOP CONTRACTOR DRAWINGS JOB ADDRESS: qi q N . PZ City: Miami Shores County: Miami Dade Zip: ' Folio/Parcel#: I ' , P b iw a I � 00- 'Q Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: ' 23 lood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Phone#i:= �" { Address: City: State: Zip: Tenant/Lessee Name: Phone#: Email: 1,- CONTRACTOR. Company Name: 1je j AN14-9 _ f l.CA L r , * �.4 ls' Phone#: Address: l? S �� C C, City: 4n r"/YL - State: '% Zip: 3 31 7 16 , Qualifier Name: c' `� `�� 4� ( d Phone#: 3oS-274215?0-2 State Certific ion or Registration #: _ C FC jK Z "j Z ( 40 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ C> Square/Linear Footage of Work: r :..-L Type of Work: ❑ Addition Alteration ❑ New ❑Repair/Replace ❑Demolition Description of Work: Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Technology Fee $ Training/Education. Fee $ Structural Reviews $ _ (Revised02/24/2014) Notary $ Double Fee $ Bond $ _ TOTAL FEE NOW DUE $ 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. 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. Signatur 7 OWNER or AGENT The foregoing instrument was acknowledged before me this ,� '� day of cSvvt_ , 20 ;-a by G Or,s ta. r de— Nn r{a,( u.S who is personally known to me or who has produced C as identification and who did take an oath. NOTARY PUBLIC: Sign: ti Jam' t Print: Seal: APPROVED BY (Revised02/24/2014) 1Ci'2 a2� 7Y0r i%cE ,! Signature CONTRACTOR The foregoing instrument was acknowledged before me this —: day of20 7e , by C50�AA) 1 1 c who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Print: Seal: ALFR Notary Public - Slate of FIDi d3 �1\ Commission N Gc 176990 My Comm Expires "day 12 2022 Bo ld lhtogh Nato," No,wy Assn, Plans Examiner Structural Review Zoning Clerk Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. / COPY OF QUALIFIER'S STATE LICENCES B. :: 7COPY OF LOCAL BUSINESS TAX RECEIPT C. OPY OF LIABILITY INSURANCE" D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ■■rrrrrr�rrrrrrrrr a rr a rrrrrrrrrrrrrrLrr n rrrrrrrrrrrrrrrrrrrrr a rrrrrrrrrrrrrrrrrrrrr■•■■ BUSINESS NAME: BUSINESS ADDRESS: % 1�`�t CITY ; STATE i, zip 3 1 me BUSINESS PHONE: (_) FAX NUMBER ( ) CELL PHONE C21,S) 2Z rf W QUALIFIER'S NAME: eXi� F . QUALIFIER'S LIC NUMBER: - II I -� `f RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY dbpr STATE OF FLORIDA DEPARTMENT OF BUSINE,$S,7kN,.1DnPR QFESSIONAL REGULATION CONSTRU THE PLUM EXPIRATIONAY 31,2020 Always verify licenses online at MyFloridaLicense.com UNDERTHE Do not alter this document in any form. ❑ This is your license. It is unlawful for anyone other than the licensee to use this document. 007416 i:oca1 Business Tax Receipt tdtiafi—Dade County, State of FloridaLBT ,;'HIS IS NOT A-51LL - DO NOT PAY 5980165 w BUSINESS NAME/LDIATION RECEIPT NO. EXPIRES DEL MAR PLUMBING INC RENEWAL SEPTEMBER 30, 2©20 13707 SW 91 CT #C 6238745 Must be displayed at place of business MIAMI FL 33176 Pursuant to County Code Chapter BA - Art. 9 & 10 S MR SEC. TYPE OF BUSINESS PAYMENT RECEIVED DEL MAR PLUMBING INC 196 PLUMBING CONTRACTOR BYTAxcoL,ECTBR CFC1427248 $75.00 07/09/2019 Worker(s) 1 CREDITCARD-19-052622 This local Business Sax Receiptoaly confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the voider s qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. We RECEIPT NO, above must be displayed on all commercial vehicles - Miami -Bade Code Sec 6e-276. For more information, visit www.miamidade nayBexeaBactm: CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIPM 08/11/2020 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 endorsement(s). PRODUCER Madison insurance Group 15190 SW 136th Street Suite 21 Marti, FL 33196 CONTACT Eddy Gaza Fit -- ---- (305) 597 8771 �r (305) 597-8773 MA: egoza@nadlsonionsgroup.com .........----.... _.... ...... ------- INSURERIS) AFFORDING COVERAGE NAic 4 _ INSuIIA: GRANADA MUl"CECO _ 16870 INSURED Del Mar Fturrbing, Inc. " B: Infinity Auto Ins Oo 11738 13707 SW 91 GT Unit 11-1 wsur:ERc: Florida Citrus, Business & Industries Fund A0201 - _—_-- — Marti, FL 33176_— ttMURERE: INSURERF: 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. NOR -- TYPE OF INSURANCE .ADDL]SUBRj -- POLICY NUMBER MLICY EFF POLICY EXP —�-- - LAWS A COMMERCIAL GENERAL uAsLrrY r`� CLAIMS.MADE I—v J OCCUR 0185FL00109111 04l14/2020 - 14I2021 EACH OCCURRENCE $ 1,000,000 DAMAGETO $ 100,000—�— MED EXP (Any one person) $ 5,0W — �- ---- _— PERSONAL & ADV INJURY --- 1,000,000 $ GENLAGGREGATE .LIMIT APPLIES PER: t/ POLICY �. JJCCCTT LOC OTHER. _ GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGO i_._....__...___ - $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO SCHEDULED AUTOS ONLY AUTOS -._... _ BRED i NON -OWNED ._. AUTOS ONLY [.._......1 AUt05 ONLY 509800013894001 11/14/2019 11/14/2020 COMBINED SINGLELIMIT $ 100,000 _ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) ------- $ PROPERTY DAMAGE ..,LPer accidentL__-_�_ $ 100,000 $ UMBRELLA LIAB OCCURI EXCESS LIAR CLAIMS -MADE ! i i EACH OCCURRENCE It AGGREGATE $ DED ! RETENTION $ --'_--' --- $ C WORKERS COMPENSATION AND EMPLOYERS' NSATI N ANY PROPRIETORlPARTNERIEXECUTIVE IYIN . ED? OFFICERWEMBEREXCLUD (Mandatory in NH) de —be yes, debe under DESCRIPTION OF OPERATIONS below N / A ) E 162027 10/1112019 j 10/11/2020 PER STATUTE ER - E.L. EACH ACCIDENT -......_.._...._-- $ 1,000,000 -- E.L. DISEASE - EA EMPLOYEEE $ 1,m0,00o E.L. DISEASE -POLICY LIMIT -$ - 1,000,000 $ I :DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) Flurrbing (bntractor Csty of Marti Shores 10050 NE 2nd Ave Marri Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPRATION DATE THEREOF, NOTICE WILL BE DELIVERED M ACCORDANCE WITH THE POLICY PROVISIONS. AUrM WED REPRESENTATIVE ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD DelMar Plumbing Date: State of Florida County of Miami -Dade Before me this day personally appeared (`=n ,) Okt,1 who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: Contractor Signature The foregoing instrument was acknowledged before me this day of 20 2 by _!g,,4AK t , who is personally known OR produced Print- {.: ■1 1 as identification. Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 758.8972 Notice to Owner Workers' Compensation Insurance Exem 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 Rill -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 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Al Signatur& Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of L-i' , 20. By who is personally known to me or has produced t �F I A, -As identification. tu'EAL: