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PW-03-22-653Miami Shores Village 10050 N E 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 9353 NE 9TH AVE, Miami Shores, FL 33138 1132060010040 Contacts 9353 FLORIDA LLC Owner PEOPLES GAS SYSTEM INC Contractor 9353 NE 9TH AVE, Miami Shores, FL 33138 ANGEL QUANT 5101 NW 21 AVE 460, FORT LAUDERDALE, FL 33309 Mobile: 9544530811 arroche@tecoenergy.com Inspection Requests: Description: install gas service line Valuation: $ 1,000.00 Total Sq Feet: 11.00 Fees Amount Education Surcharge $0.20 Public Works Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $111.70 Building Department Copy Payments Date Paid Amt Paid Total Fees $111.70 Check # 4489 03/21/2022 $111.70 Amount Due: $0.00 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 that all the foregoing information is accuyate a�tha all work will be ne in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above nccont c o gktheyo,rj�.ted. Authorized Signature: Owner / Applicant / Contractor / March 21, 2022 Date Page 2 of 2 z MAi; 14 2022 -..,t Miami Shores Village Public Works Department $Y (305)795-2210 Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores, FL 33138 PUBLIC WORKS PERMIT APPLICATION Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property Permit# W -03 " Z2^(S3 Name of Applicant (if utility see below): PEOPLES GAS SYSTEM Owner off the following described property: Legal Description: Lot 4 Block Subdivision MARILYN HGTS Folio #; 11-3206-001-0040 Address: 9353 NE 9 AVE Miami Shores, FL 33138 UTILITY NAME: PEOPLES GAS SYSTEM Qualifier/Authorized Agent: Ansel Quart Address: 5101 NW 21 AVE. SUITE. 460 City: FT. LAUDERDALE State: FL ZIP: 33309 Telephone: 954-453-0806 Email: MCABRERA@TECOENERGY.COM State Certification or Registration #: E2100068 Certificate of Competency # CONTRACTOR NAME: PEOPLES GAS SYSTEM Qualifier/Authorized Agent: Angel Quart Address: 5101 NW 21 AVE. SUITE. 460 City: FT. LAUDERDALE State: FL ZIP: 33309 Telephone: 954-453-0806 Email: MCABRERA@TECOENERGY.COM State Certification or Registration #: E2100068 Certificate of Competency #:_ Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of way: TO INSTALL A NEW GAS SERVICE LINE (3/4") PLASTIC) BY DIRECTIONAL BORE Type of Work: ❑ Paving ■❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation ❑ Landscape ❑ Antenna ❑ Other: DESIGNER: Architect/Engineer: TECO PEOPLES GAS Address: 5101 NW 21 AVE. City: FT. LAUDERDALE State: FL ZIP: 33309 Telephone: 954-453-0806 Email: MCABRERA@TECOENERGY.COM Registration #: Value of Work for this Permit: $ 1000 Permit Fee $ 100.00 Notary $ Bond $ Square/Lineal Footage of Work: 11 *****Fees***** -Train ing/Education $ 0.20 Technology Fee $ 0.80 Scanning $ (if required) Total Fee Now Due $ Bonding Company's Name (if applicable): Bonding Company's Address: City: State: ZIP: Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in this jurisdiction. I understand that separate permits must be secured for APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with applicable laws regulating construction and specifically construction in the right-of-way. "WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value exceeding $2,500, 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 the 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 public works permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection will be charged. Signature Signa Applicant or Authorized Agent Company/Utility Ag6t The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before me this day of 20 , by me this / `f day of N'%/a-rLG(� 20 Z2 by who iJ 511 C r who is personally known to me or who has produced rsonally known tome or who has produced as as identification. NOTARY PUBLIC: Sign: Print: SEAL: identification.�� HUSERTNUNEZ NOTARY BLIC 11 MY COMMISSION#HH128865 EXPIRES: September 11, 2025 Sign: Bonded = Public UndeWt,, Print: SEAL: * * ****** ********************************** APPROVED BY: , Public Works Director, or Designee 2017-04-15 � N w � = O N x O w �D 0 ? N O W it II II I qp LU 0 00� I I I I I I I I II II II I ° I I I o� I ILU glI w II I Q II I Qcr II I m� LL�3w I IN IN, }� Q�Ln I I I a° u uo o° QI I Q °N° I Icc °z Ljj m zQLLJa I Iuj W aQ _ ¢2Ll QN z I ICI I•. oW Lu W rr�p v W bf O k"I X KO I cc x bbf I 2 W� LU �Wo I IILnII II o l II II I' Ln Ln I oo� I a NQ �3a 3 IV IV W N � l l I I cn o° I I I I I I d W N Q � x � �00 z�M o M M rn�w L` 0 a o - _ o H -.EE- f 3 v_- .. v N` m s v 3 =' II II II v o w v v h Q F- N o �n � X t to �. 4 �_ 3 L �' 3� W LL� rn � C s m a .. = 1- o �. .� - h 0 3 a � • 8 Z N M o v1 W W �N 2 O ti O C U O w NOISIA3N 2 O O N � h � Q j O z w y, = o 0 O x w lD 0 ? N 4 O n h Nvq 311w3 E av w N F- �q w i N 3 In m m ut > N ^I `o c- W N pv � x ., ' m w a o 2 f 1= (n W W Z II I TIE—IN SVC.I TO, GAS M IN ITH T.T./T.F./E.F.V. . W I ' W z ' 4 5' • � I 3I � cc «' o 3 I L`' I �i 5I 41 I 31 110' 47' '— 1 __-LI GAS GAS GAS I I I 4' i ; PROP. 1 114" PLASTI GAS SVC. TO BE I I DIRECTIONAL BORED I I I I II I I I ; I I II I EXIST. 2" C.S. I��GAS MAIN 1-3 I I I � 1 I II 1 I 1 II I� LU Ln 3 I LO ILU �i PROFILE 45' PROP. NEW2RISER WITH 1 114" GAS SERV.� ------------------ GAS GAS GAS — 1' S P/L D. I� w 1 10 i PROP. 1 114" PLAS'11 I 9 GAS SVC. TO BE 36" MIN. DIRECTIONAL BORED I 6 I 1 7 /i GAS 16 GAS MAIN �` W.M. I VERIFY DEPTH 5 6" MIN. BEFORE STARTING EXCAVATION 1 4 SCALE: 1:40 (V) 1"=1' (H) 1"=2' 3 2 SCAL&C-20' LEGEND T CENTER LINE IA MONUMENT LINE R/W RIGHT OF WAY P/L PROPERTY LINE E.O.P. EDGE OF PAVEMENT T.T. TAPPING TEE T.F. TRANSITION FITTING E.F.V. EXCESS FLOW VALVE SVC SERVICE LINE ALL EXISTING UTILITIES SHOWN ON THESE PLANS ARE TO BE CONSIDERED APPROXIMATE & SHOULD BE VERIFIED BY THE CONTRACTOR PRIOR TO THE START OF WORK OPERATIONS. rn 0.0 AL M i LOCATION MAP (N.T.S.) GENERAL NOTES 1. REPLACED BASE MATERIAL OVER DITCH SHALL BE TWICE THE THICKNESS OF THE BASE, MIN. 8" AND MAX. 18" 2. BASE MATERIAL SHALL BE PLACED IN 6" MAX. (LOOSE MEASUREMENT) LAYER AND EACH LAYER THORVU�riL.' ROLLED OR TAMPED TO 98% OF MAX. DENSITY PER AASHTO T-180 3. ASPHALT CONCRETE PAVEMENT JOINTS SHALL PE MECHANICALLY SAWED 4. SURFACE MATERIAL SHALL BE CONSISTENT WITH SURROUNDING SURFACE MATERIAL (1.5" MIN. THICKNESS) 5. BASE MATERIAL SHALL HAVE A MIN. LBR. OF 100 AND A MIN. CARBONATE CONTENT OF 70% (60% FOR LOCAL STREETS) 6. CONTRACTOR SHALL SOFT DIG TO VERIFY LOCATION OF EXISTING UTILITIES Miami Shores Village Building Department Zoning Dept. Date Building Dept. Date Subject to compliance with all Federal, State and County rules and regulations. Permit# i,j' 4: 3 .1 ? U' G BYI . _ -. MAIN ova 0 14 0 2 0 NZ co i d 0 W 031 LO co 0 m w m 4 m 0 0 r SOD RESTORATION E ES VILLAGE 1 "TrT'i 0 PUBLIC WORKS REVIEW� a INO. or suers: 1 APPROVEC}G� ®ATE�.AV sT�No.:i ClqConstruction Trades ualifyIng Board BUSINESS CERTIFICATE OF COMPETENCY E2100068 PEOPLES GAS SYSTEM INC D.B.A.: QUANT, ANGEL Is certified under the provisions of Chapter 10 of Miami -Dade County ACORO' CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 5/21/2 5/21 /2021 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 CONTACT NAME: Marsh Canada Limited PHONE 1-416 868 2600 a,Ic, No, Exf FAX (A/C, No); 416 349 4564 120 Bremner Blvd, Suite 800 Toronto, ON M5J OA8 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Associated Electric & Gas Ins. Svcs. AA-3190004 INSURED INSURER B: Associated Electric & Gas Ins. Svcs. AA-3190004 INSURER C: Associated Electric & Gas Ins. Svcs. AA-3190004 Peoples Gas System 702 N. Franklin St. Tampa, FL 33602 INSURER D: Associated Electric & Gas Ins. Svcs. AA-3190004 INSURER E: LM Insurance Corporation 42404 INSURER F: COVERAGES CERTIFICATE NUMBER: 20/21-037-GAEW REVISION NUMBER: 1 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 LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY X CLAIMS -MADE F—IOCCUR XL5692905P 06/01/2021 06/01/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ X MED EXP(Any one person) $ SIR $1,000,000 PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT ❑LOC GENERAL AGGREGATE $1,000,000 PRODUCTS - COMP/OP AGG $ $ OTHER B AUTOMOBILE LIABILITY XL5692905P 06/01/2021 06/01/2022 COMBINED SINGLE LIMIT Ea accident $1 ,000,000 X ANY AUTO Self Insured Retention: $250,000 BODILY INJURY (Per person) $ ALLOWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR OCCUR C XL5692905P 06/01/2021 06/01/2022 EACH OCCURRENCE $1,000,000 )CC X EXCESS LIAB X CLAIMS -MADE AGGREGATE $1,000,000 DED RETENTION $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Employer's Liability: XIP-R-TATUTTk E.L. EACH ACCIDENT $1,000,000 Y PROPRIETOWPARTNERIEXECUTIVE NO FFICERIMEMBER EXCLUDED? XL5692905P E Mandatory in NH) f yes, describe under ESCRIPTION OF OPERATIONS below NIA Excess Workers' Compensation: 06/01/2021 06/01/2022 E.L. DISEASE - EA EMPLOYEE $1 �QQQ�QQQ EW5-B7N-171272-020 SIR $1,000,000 12/01/2020 12/01/2021 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) License #E1608 Excess Liability policy provides insurance in excess of Peoples Gas System's Self -Insured Retention as stated above. The above noted policy placements were made by Marsh USA Inc. Marsh Canada Limited has only acted in the role of a consultant to the client with respect to these placements, which are indicated here for your convenience. CERTIFICATE HOLDER CANCELLATION Miami Shores Village Bldg. Dept. 10050 NE 2nd Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved.