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CC-10-1210Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. L° " "3 ., 13" PERMIT APPLICATION Master Permit No. e 6 r 7 - /O - / Z / FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): PA-2C Sk ° Ai � s Phone #: Address: 9 `L /� ' � a Jc' City: Vik ► S 1i o (2.27-5 State: f‘- • Zip: 3 3 / Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 7 /ilv A � City: Miami Shores County:2 . Miami Dade Zip: `3 i Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: 5o , ■ '2e cV F-7 L.- ,4 -s4.> - Phone #: gr 71 2 . 9 700 Address: 1 .7 7 d " w S) - City: F7 ---- ‘_.. + 0 . State: Fe. zip: 313 0 7 Qualifier Name: �J 2l� . t -- Phone #: State Certification or Registration #: Fa ®oa0 q -re) Certificate of Competency #: Contact Phone #: ' 712 9'7 C Email Address: & (4) 0-) S o .4) •": - C c IAA- DESIGNER: • Architect/Engineer: Phone #: Value of Work for this Permit: $ y 3 02. Ov Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: J 71 A D i ✓ G',4 -r4 Air i4 E to S A PP e- `f / ****************************** * * * * * * * * *F ********+ *****x *** * * ******** * ************ Submittal Fee $ 50 .00 Permit Fee $ /ft O& CCF $ CO /CC $ rimy Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ July 21, 2010 Burglar Alarm and CCTV to be provided by Sonitrol of Fort Lauderdale at: Park Shore Drug 9416 NE 2 Ave Miami Shores FL 33138 Devices to be installed include: One (1) Control Panel One (1) Keypad Two (2) Pedestrian Door Contacts Three (3) Audiosensors One (1) Panic Button Four (4) Cameras One (1) Power Supply One (1) DVR One (1) UPS Value: $4302.00 Master Permit # CC -7 -10 -1210 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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. Signature Signature Owner or Agent The foregoing instrument was acknowledged before me this The foreg day of , 20 _, by , day of who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Si Print: Print: My Commission Expires: APPROVED BY C• .. or g instrument was ac .. owledged before me this 1/ 20) 6 , by al,- A.)\ +44 ?Tr , own tome or who has produced entification and who did take an oath. NOT UBLIC: My Commission Expires: PA 7 J efs Y /v Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED TO THE INSURED NAMED AWVE 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 BYTHE POLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REQJCED BY PAID CLAIMS. IN5R LTR TYPE OF INSURANCE ADDL INSR `3UbI WVD POLICY NUMBER POUCYEFF (MM/DDIYYYY) POUCY !XP (MM/DD/YYYY) UMITS B GENERALLIABILIIY X COMMERCIAL GENERAL LIABILITY X OCCUR F 1018685 FbE41018685 01/29/10 01/29/10 01/29/11 01/29/11 EACH OCCURRENCE $ 1000000 PREMISES ( Eaocarrenae) $ 100000 CLAIMS -MADE MED EXP (Any one person) $ 5000 PERSONAL &PDVINJURY $ 1000000 X E &O GENERAL AGGREGATE $ 2000000 GENII AGGREGATELIMITAPPLIES PER: POLICY n RP CT n LOC PRODUCTS - COMP/OP AGG $ 2000000 $ A AUTOMOBILEUABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED ALTOS HIRED AUTOS NON -OWNED AUTOS SCP03284488 11/16/09 11/16/10 COMBINED SINGLE LIMB (Ea accident) $ 1000000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accidert) $ PROPERTY DAMAGE (Peracddent) $ $ $ B UMBRELLAUAB EXCESS LIAB X OCCUR CLAIMS-MADE CUMI000558 01/29/10 01/29/11 EACH OCCURRENCE $ 1000000 AGGREGATE $ 1000000 DEDUCTIBLE RETENTION $ 10000 $ X $ C WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANY PROPRIETORIPARTNER/EXECUTIV OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, escribe under DESCRIPTION OF OPERATIONS N/A 52038625 01/29/10 01/29/11 X WCSTATU- I OTH - TORY UMITS E E.L.EACHACCIDENT $ 1000000 E.L DISEASE -EA EMPLOYEE $ 1000000 below E.L. DISEASE - POLICY LIMIT $ 100000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES A1Attach ACORD 101, Additional Remarks Schedule, K more space Is required) Alarm & Alarm Systems Installation, Servicing & Sales Miami Shores Village 10050 NE 2nd Ave Miami Shores FL 33138 MIASHOR SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE � 4t- �� ••w••+— 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(les) 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 INSURED it CERTIFICATE OF LIABILITY INSURANCE OP ID PR Gulfstream Insurance Group Inc P.O. Box 8908 Fort Lauderdale FL 33310 -8908 Phone:954- 561 -2220 Fax:954- 566 -0673 COVERAGES CERTIFICATE HOLDER ACORD 25 (2009/09) 1770 NWl64fStt, Lauderdale LLC # Fort Lauderdale FL 33309 CERTIFICATE NUMBER: wnrw� NAME: PHONE (A/C No, Est): ADDRESS: cusTOMER SONIT -1 INSURER D : INSURER E : INSURER F : CANCELLATION INSURERS) AFFORDING COVERAGE INSURERA: Assurance Co of .America INSURER B: First Mercury Insurance Co., INSURERC: Florida Retail Federation SIS FAX (AIC, No): REVISION NUMBER: DATE (MMIDD/YYYY) 07/21/10 ©1988 -2009 ACORD CORPORATION. M rights reserved. The ACORD name and logo are registered marks of ACORD NAIC A NAME OF ESTABLISHMENT PARK SHORE DRUG INC PERMIT NUMBER 863 ' DATE OF I SPECTION 7/19/2010 DOING BUSINESS AS PARK SHORE PHARMACY DEA NUMBER PRESCRI ON DEPARTMENT MANAGER JAMES M ILLIS STREET ADDRESS 9416 NE SECOND AVE TELEPHONE tf E)(T. CITY MIAMI SHORES COUNTY 23 STATE/ZIP 33138 PRESCRIPTION DEPARTMENT MANAGER UCENSE # 30591 PRESCRIPTION DEPARTMENT HOURS REGISTERED PHARMACISTANTERN,TTcHNICIAN 1. LICENSE S Monday Tuesday Wednesday Thursday Friday Snotty Sunday Open SAM SAM 9AM 9AM SAM SAM CLOSED 2. Close 6PM 6PM 6PM 6PM 6PM 5PM 1 CLOSED 3. SATISFACTORY WA YES NO SATISFACTORY WA YES NO Curren pharmacy pemlit displayed. (4680 5(1)(a).F.S•1 X ❑ 26 An medicinal Drug Rre Madu data [8481628.140(3)0)2.F,A.C.) d. me d. © ❑ 2 Board of Pharmacy notified in waiting of current Rx department � manager. (485.Ot8.F.S] t.^1 © 27 Prescription records ideAL[y the (64816-28.140(3)(b)7,F.A.CJ dispernGing X ❑ 3 Current DEA registration. (2ICFR 1301.11] [ X ❑ 28 Complete pharmacy prescription tee . (64B16-28.140,FA.C.] ❑X ❑ 4 Re department hours open for bu3ir164a are posted and are 8 minimum of 40 hours per with. [6481628.404. FAC.] X ❑ 29 Pharmacy maintains patient profile records. (64816-27.800.FAC.) X ❑ 5 Interne property registered and supervised. (486.013,F.SJ (84818- 28.400(4) X ❑ 30 Convened sutiatantekCCOrds rot* rauieve61& [893.07.F.S ] X ❑ 6 Pharmacy technicians properly identified and supervised. [64618- 27.410,FAC.I X ❑ 31 Miit a s of pharmacist filling controlled substance (883.04(1Xo)6.F.SJ Fix. X ❑ 7 Proper pharmacist technician ratio. 8 2:1 Or 3:1 Pharmacy Manager Ms Board of Pharmacy approval. [84818. 27.410] [64818. 27.420. F.A.C.] X ❑ 32 Prescribers name1addresa!DEA 9 on alicenhoIed [a9 3.04(1xc)2.F.S.] substance Rx. X ❑ 8 PhanlV let 5 ensennewal certificate displayed. f64818.27.100(1)FA.C] X ❑ 33 PaIi8M's nBm&laddress On tomme8d al (893.04(1)(c)1.F•S4 race Rx. X ❑ 9 Pitsrmmdst On allay when Rx department open. (84816- 28.109.FAC. x 34 Date Gatboded substance Rx was fired (893.o4(l0)6,F.S.] • Rx. X ❑ 10 Generic eve sign displayed. [465.025(7) -F.S-] 4^J ❑ 4J 35 M controlled substance prescription s granary and 48aedOns Reuse. [883.04( have: drug prescribed. x ❑ Xc)4.F.S.] 11 Sign dsplayed - Rx Oept Closed' if establishment is open and Rx — Department csosetl . [64816-28.1090).FA.C.] ❑ Pate of refine widen on controlled s .,- w (893.64(1xcl6,F.SJ . . •. Rx or on compeer records. X ❑ 12 Sign with meal break hours of Pharmacist. (no more than half hour), end staling that a pharmacist is available on premises for o0ft4uketion aped 0 ❑ 27.400[8),FC.p reest. (84616 A al 37 Pharmacist's initials On conWlled • :. [883.04(1x C�,F.3.] ^- Rx relies. X ❑ designating the private patient consultation area X ❑ 13 �1 &sig F 38 Controlled substance refits limited to 5 within prescription was signed. (893.04(1)(g),F 6 months s from date S.] ❑ 14 Adequate mitten and verbal offer to counsel patients. (64816.27.820.FAC.] X ❑ 39 Controlled substance inversely taken on for I68pee8on. (893.07(1xa) a biennial test and ava8abie X ._ l 15 Adequate patient counseling by pharmacist ahem offer is accepted. )( (64818- 27.820,FAC.] ❑ ❑ 40 DEA 222 order tome Propeliy ^ (893.0T(2),F.SJ X ❑ 16 Rx dept. has sinkkunning water convenient to tat dept. (64816 - 28.1025 A.C.) X ❑ 41 Controlled substance Rx information in • [CFR 1308.22] (893.07.F.S] (84818 -28. • ... ter system is retneva*ie. 40.FAC.]• ❑ x ❑ 17 P1e8a)ptlon deparbnent has drug relrigeretgm storage. (64B16-28.104,FAC.1 X ❑ 42 Controlled subsbnce records maintained (CFR 1304.04 & 1306.221 (883.07(4)(b) for 2 year$. F,S•] X ❑ 18 Prescription departnent clears and safe. (84616-28.108FAC.) 0 ❑ 43 Schedule V drug recur prepertykept (890.08(3xa).F,S.] *) ❑ 10 Rx batiste and weights or electronic balance: Mounting trey or Omer suitable counting device: assortment of graduatea/spalulaelmafar and ❑ pestles. [64816 28.1o7(2xa d),FAC] X 44 (64Q16 dray (3 OR p x0 OR rintout (eme18••28.1400 ( • as required by section. ❑ x ❑ 20 Current reference hose and arrant copy of Laws and rules in hard copy or in X a readily amiable electronic data format (6481628.107(1). FA.G] _ _ ❑ 46 Registered pharmacist property iste ng. (64816-27.210.FAC3 ❑ © ❑ 21 Medication property labeled [64816-27.101.F AC.] M ❑ _ 46 Compounding records property • inert (64816- 28.140(4),FACJ • X ❑ ❑ 22 AR Rx medication Vein 1 6 Rx ce partment (64816.28.120(1),FAC.] X ❑ 47 Unit case records prOpeny maintained 1827.410 (1). FAC.] x 0 23 CAI Polity and Procedures and prod of quarterly meetings x ❑ (protected UndPl (74XL101.FS.] (84816 - 27.300. PAC.] 24 Outdated pharmaceuticals removed Ain active stock. [84818-28118 FA.C3 X ❑ • Questions w111► (9 may answered We f 26 Moose after/3,1W on Rx label. (64818 - 28.402[1 xh).FAC.] Q ❑ Remarks: PHARMACY IS RFJwY TO OPEN ONCE THE PERMIT ADDRESS IS UPDATED TO THE CURRENT LOCATION. Wd £9 :4£ :17 OI.OZ /61/1 uo peAlaoal L9098£ :# )uaturloop Ieu]6u0 Fite # 125 fried # 101172 PRINT NAME OF RECIPIENT POM 30591 Institutional Representative 981 359 Revised 01/07 Reelaoes 12.02 STATE OF FLORIDA DEPARTMENT OF HEALTH INVESTIGATIVE SERVICES COMMUNITY PHARMACY 1 entmaa❑ aWx1atb0 © NEW ❑ cements NOT OPRA chasm ow,er ❑ + II INSPECTION AUTHORITY - CHAPTER 465.017, CHAPTER 893.09 AND CHAPTER 456, FLORIDA $TA Note: N eatabashment Is engaged in pefentetaUenterel comfwun can 9. Ucense must so indlcste ofd a I have reed and have had this inspection report and the Isla and regulations concerned herein explained, and do effete that the intonation 9iran Neein alive art 07 -19 -2010 Date Invegtigetore3r. Pharmacist Signature 060Z661790£ — :p0JnoS 10 the test of my 16oreed9e. to mi187 PARK SHORE DRUG 9531 NE 2 AVENUE ATTN: BOB GILLIS ''`' MIAMI SHORES, FL 33138 -2704 4 4 MIAMI SHORES VILLAGE BUSINESS TAX RECEIPT Certificate Issue Date Expiration Account Numb • THIS CERTIFIES THAT PARK SHORE DRUG STORE • has paid the Business Tax to the Village Clerk's Miami Shores Village. Type Description 1407 LOCAL BUSINESS TAX RECEIPT h.., =< Address: 9531 NE 2ND AVENUE Fee: 4 ^ This Business Tax < place. A penalty • Receipt exhibited b < Miami Shores Vil a•e, Florida Date Issued:_ This Business ax Receipt is not transferrable wi • approval of the Village Clerk. Receipt must be displaed in a c is imposed for failure to keep t at your place of business. BY: eatho 6' cc Office of 0000003715 07/05/2009 09/30/2010 02639 spicuous is dut the • 4 > 4 1 1 '4 1 1 1 1 1 4. • 4 • '4 158.67 > MIAMIFDADE MUNICIPAL INSPECTION MUNICIPAL NOe2010- 046715 JOB SITE ADDRESS 941E NE 2 AVE PROPOSED USE RETAIL SALES LEGAL MIAMI SHORES SEC 1 AMD APPLICATION TYPE ALTER INT OWNER NAME MSVC LLC CONTRACTOR 0 S CONSTRU QUALIFIER SKLAR OSCA PERMIT TYPE MUNICIPAL CATEGORIES 0001 MUNI DATE: 7/23/2010 PR TOTALS DERM DERM FIRE FRWI'. 1 UP FRONT 12500 ALTERATIO 1 1ST FIRE M 7/23/2010 18008 G262 MIAMI -DADE COUNTY • • REQUIREMENTS AND RECORD 07/23 /2010 FOLIO: 1132060132780 /MINOR REMODELING `— —4— tt 5 B ..r 21 1 UNITS 1 FLOORS *AMOUNT PAID 152.00 70.00 *UPMU 0000000° IN COMM REV( IRE UPFRT FE PFRONT FEE F 311007230153 TCPM9390 CENTRAL 152.00 90.00 32.00 25.00 MIAM6DADE MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 07/23/2010 MUNICIPAL NO.2010- 046715 PROCESS ■e M2010007766 FOLIO: 1132060132780 JOB SITE ADDRESS 9416 NE 2 AVE PROPOSED USE RETAIL SALES REQUIRED INSPECTIONS FIRE 0001 FIRE INSPECTIO 200 FIRE HVDR 208 FIRE TCO 211 PRELIMINA 209 FIRE FINA MIAMI -DADE COUNTY /MINOR REMODELING REQUIRED INSPECTIONS FIRE 0001 FIRE INSPECTION 200 FIRE HYDR 208 FIRE TCO 211 PRELIMINA 209 FIRE FINA MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 07/23/2010 MUNICIPAL NO.2010-046715 PROCESS NO. M2010007766 FOLIO: 1132060132780' JOB SITE ADDRESS 9416 NE 2 AVE PROPOSED USE RETAIL SALES /MINOR REMODELING man TO SCHEDULE A FIRE INS DIGIT MUNICIPAL NUMBER INSPECTION TYPE CAN BE AND RECORDS CARD NEXT T IF YOU HAVE ANY QUESTIO PLEASE CALL FIRE PREVEN IF YOU HAVE ANY QUEGTIO PLEASE CALL FIRE ENGINE **BE ADVISED THIS IS NOT YOUR CORRESPONDING MUNIC MIAMI-DADE �� w��mu�mm�mN N�U������ COUNN 0 MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 07/23/2010 MUNICIPAL NO.2010-046715 PROCESS NO. M2010007766 FOLIO: 1132060132780 JOB SITE ADDRESS -- - �u� ��|�� 9416 NE 2 AVE _ - .-~ .- ^- ..,^ PROPOSED USE RETAIL SALES /MINOR REMODELING THE WEB AT E YOUR TEN TYPE. THE QUIREMENTS SPECTION, N REVIEW, ISSUED BY MIAMIDADE MUNICIPAL INSPECTION •REQUIREMENT RECORD MUNICIPAL NO.2010-046715 PROCESS NO. M2010007766 FOLlO: JOB SITE ADDRESS 9416 NE 2 AVE PROPOSED USE RETAIL SALES TO SCHEDULE A FIRE 'NSF WWW.MIAMIDADE.GOV/BUILDIN DIGIT MUNICIPAL NUMBER INSPECTION TYPE CAN BE AND RECORDS CARD NEXT TO IF YOU HAVE ANY QUESTION PLEASE CALL FIRE PREVENT IF YOU HAVE ANY QUESTION PLEASE CALL FIRE ENSINEE **BE ADVISED THIS IS NOT YOUR CORRESPONDING MUNIC] MIAMI-DADE m�mmm�um��m_m���u���� COUN0 Y /MINOR REMODELING THE WEB AT E YOUR TEN TYPE. lHE QUIREMENTS ISPECTION, N REVIEW, ISSUED BY RECEIPT PERMIT #: �C. i()-- I p DATE: t ° ❑ Contractor qitOwner ❑ Architect Picked up 2 sets of plans and (other) I — TA->�C ( Address: ° y ge, N -CL From the building department on this date in order to have corrections done to plans And /or get County stamps. l understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. Acknowledged by: PERMIT CLERK INITIAL: RESUBMITTED DATE: RCa, /0 PERMIT CLERK INITIAL: M iami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 . c. litatvo ogtar i Miami Shores Village Building Department 10050 N.E2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fare (305) 756.8972 INSPECTION'S PHONE NUMBER: (30S) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: MEINVIONIII !&i/ Wirt GC OWNER: Name (Fee Simple Titleholder): Pr SVC L,L.0 Phone#: 464 S — 92991 Address: 10 e :•/ %O � City: ��� >�� / State; F C.• zip: 330 2 0 Tenant/Lessee Name: aatk Shore b4' I G Sr �^ � Phoned: 3057 S V" Ic�V6 p+ Email: _____j 9& r I hew d( . .at,evl JOB ADDRESS: q v/i 1 2. 1144 Me- City: Miami Shores County: Miami Dade Zip: 3313 g Foho/Parcel#: this 1-5 821 Eiji tn 5)10 /'es Sec I f+n► P a+ 3 64' fro k 10 a 70 Is the Building Hlstorlcafy Designated: Yes NO / r 1 re -e.. J Q s m b s. FA- CONTRACTOR: Company Name: 0.4. eit 4412tornoA.) Phone# Qs4 -12.s 42,R Z Address: `'2.3110 A' o p IpS- 4i, City: d+1p YI�A�I Atoka) State: =t.. . G_� _ Zip: 53 Z Qualifier Name: 4 a , Phone#: ( Sti -9 tr -9 2q Z r State Certification or Registration #: CGC 010 CIS 1 Certificate of Competency #: C o n t a c t P h o n e # : 1 Eli' 41 •1 12 - 1 4 Email A d d r e s s : e t ' e „ o r L A 44UJ M i t ' f - e € .1-. tf)7K DESIGNER: Architect/Engineer ifie •, [ a ciAt4tv(-cnG Phone#: a l S i - 4 121'• et Z92J(102_, 110 • 326. 2 - 191 ce...L, TOTAL FEE NOW DUE $ 74 f. a Permit No. CC 1210 Master Permit No. Value of Work for this Permit: $ 1 t 5l° . -�' Square/Linear Footage of Work 11260 06*-4.. Type of Work: DAddress t3IAheration ONew )Repair/Replace ODemolition Description of Work: ve- EX1441t4 64 - ""t k to , f , C4 V 'tit. * 4 Pwrwi s1 r & nuy wo,Ul " 7 lOP. ' :¢.�, ov cis , 3 pew d &gra I t T- setz,,r• z P.e. .0e altio ev rvez7 s.,**> ***:,*s **s>x*ss k.«**, r.. w' Fees*** *s.mwe.r *a***ss>e*>pss**ssm Submittal Fee $ 250 . � Permit Fee $ C F $ CO/CC $ Perk t Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Double Fee $ Structural Review $ MIAMI -DADE COUNTY Environmental Resources Management Plan Review Services Division 11805 SW 26th Street • Suite 124 Miami, Florida 33175 -2474 T 786 - 315 -2800 F 786 - 315 -2919 Carlos Alvarez, Mayor miamidade.gov July 22, 2010 Martin .Bermudez 1832 NE Miami Gardens Drive #282 Miami, FL 33179 RE: Proposed Drug Store (DWO # 112) Dear Mr. Bermudez: This is to acknowledge that we have evaluated the scope of your project to discharge future flows from a proposed 1,260 sf drug store to the existing Miami Shores Center Treatment Plant (DWO # 112, FLA 478334) At this time no permit is required for your project by Plan Review and Development Approval Division, Engineering Section. Any modification in your plans should be submitted for review, as changes may result in permits being required. This letter does not relieve you from the need to obtain any other permits (local, state or federal) which may be required. This determination was based on the submitted information describing the proposed use of the above - mentioned property for 1,260 sq. ft. The total estimated water demand would be 63 GPD. Furthermore, at this time the Miami Shores Village Center Treatment Plant does have sufficient capacity to treat current discharge. If you have any questions, please contact our Wastewater Engineering Section, or me at 786- 315 -2800 of this office. Sincerely, Carlos Hernandez, PE Chief, Plan Review and Development Approvals Division Engineering Section. NPR File Inspection Number: INSP- 149497 Permit Number: EL -7 -10 -1354 Scheduled Inspection Date: July 30, 2010 Inspector: Devaney, Michael Owner: LLC, MSVC Job Address: 9416 NE 2 Avenue Project <NONE> Miami Shores, FL 33138- Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Contractor: OS CONSTRUCTION INC. OF SOUTH FLORIDA Building Department Comments July 29, 2010 For Inspections please call: (305)762 -4949 Permit Type: Electrical - Residential Inspection Type: R,ough Work Classification: Alteration Phone Number ()_ Parcel Number 1132060132780 -16 Phone: 954- 925 -9292 7 NEW OUTLETS, 2 RELOCATED OUTLETS, 2 NEW J BOXES, RELOCATED T -STAT Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments r/A.,/,00-/ ek 5?L' Page 11 of 11 BUILDING PERMIT APPLICATION FBC 20 Permit Type: ELECTRICAL Owner's Name (Fee Simple Titleholder) M C. G L C, Phone # ' 4 1 1 .f '1 212 ,jU"• 10 i Owner's Address '2..S1/0 w g %3 tv r> , City 'vWN .00 State 'tom • Zip 330'2 0 Tenant/Lessee Name 'b121(,... sW-prl G , Phone # '• - — 9 Odd Entail J U Pb R- v.,bi er..D ve . [.DI •1 Job Address (where the work is being done) ° I'41'to N e TAN, ,%tv E_ City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # La" I • S 1 3 2 1 - % % - t \ StoezfA Sex. 1 A ktCO' r re. 1b ip 7 a Pi WAIL Yip Is Building Historically Designated YES NO Zone 0) A---- Contact Phone 2. ,1 —/ 2. . • Miami Shores Village Building D epartment 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 E -mail Permit No. e`- `°l_ to -1354 Master Permit No. ' 4 - 1210 1 N€14, e„ i-1 s , 2 riF.uo{Aorre/o even ts. , 2 grew 4 texiES , 4,2Qoeo r p T- Sad►` s ip" -3 co i•L. Contractor's Company Name Contractor's Address 21, /Y!•O] a, 5— eve City .4-1,1 / State C— Zip .3 3 / Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. •/ L ll�d Zll Architect/Engineer's Name (if applicable) "A S K. ` A 1- CLrtme. Phone # gat i2. X1 Z 7 • Value of Work For this Permit $ Square / Linear Footage Of Work: 112100 s60- • Type of Work: ❑Addition Alteration ['New ❑ Repair/Replace ❑ Demolition Describe Work: ** ** * * * * * ** * * * * * * * * * * * * * * * *** * * ** *** ** F * * *** * * * *** * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ ��✓` o �� / ' �' � � CCF $ CO /CC $ 5 •O� pp.IP Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: ii Structural Review. $ Total Fee Now Due $; (•2.0 See Reverse side -+ Bonding Company's Name (if applicable) P 1 Bonding Company's Address P 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 properly 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 re- inspection fee will be charged. Signature �' Signature Owner or AgenVt Contractor The fore o s g instrument was ac owled a befo a me this The foregoing instrument was acknowledged before me this/ day of , 20 10, by , day of Z2,/),/ , 20 LA, by w i o is persona y known to me or who has produced who' is personally known to me or wh as produced NOTARY PUBLIC: Sign: Print: My Commission Expires: * * * * * * * * * * * * * * * * * * * * ** * * * ** (Revised 07 /10 /07)(Revised 06/10/2009) As identification and who did take an oath. l 50 � �� �0 >S n �uom a : ' 477 Nt'5. �Q /‘?Plans Examiner Engineer NOTARY Sign: Print: My Commiss as ' ation and who did take an oath. n Expired ; •., �% 44 0 F F t LUIS FERNANDFZ MY COMMISSION # DD 832441 EXPIRES: November 7, 2012 Banded Thru Budget Notary Semites **************** ******* *************** *** ****** Zoning Clerk checked THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED 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 MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OP SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I N IN A TYPE O INSU RANCE GENERAL UABIUTY ® COMMERCIAL GENERAL LIABILrrY ❑ ❑ CLAIMS-MADE !] OCCUR III N s a 8 vo POUCY NUMBER 0210000507 00 erP (JDflI YY1) 09/23/2009 (KtN� '),_, 09/23/2010 UM ITS EACH OCCURRENCE $ $1 ,000,000.00 PREMISES ( REN MO ooeu ) $ 5100,000.00 MEP EXP (Anyone person) $ 55,000.00 Psa;sONAL a ADV INJURY 5 $1,000,000.00 $ 51.000,000.00 ❑ GENERAL AGGREGATE GEM. AGGREGATE LIMIT APPLIES PER ❑ Fouc' ■ JOE& ❑ Loc PRODUCTS • COMP/OP AGG $ 51.000.000.00 $ AUTOMOBILE UABIUTY CI ANY AUTO CI ALL OWNED AUTOS COMBINED SINGLE UMIT (Es aeelde� $ BODILY INJURY (Par person) S BODILY INJURY (Per acctderd} $ SOHEDULED AUTOS PROPERTY DAMAGE par acotder ) $ ❑ HIRED AUTOS a NON •OWNED AUTOS $ $ • • UMBRELLA LIAB • OCCUR ❑ L=XCE$8 UAB • CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DEDUCTIBLE r-I 1 1 RETENTION $ $ 5 E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICE EXCLUDED? ff NIA 669 - 00260 07/07/2010 07/07/2011 WC STATU OTH- n TORY I IMIr3 n Ea ELL EACH ACCIDENT 6 .000.00 E.L. DISEASE . EA EMPLOYE $ $500,000.00 (Mandator) In NH) Ityyeeee� deacdbe unde DESCRIP1ON OF O PERATIONS below E.L. DISEASE • POLICY LIMIT $ $500,000.00 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Misch ACORD 101. Additional Remarks schedule, it mot* Spacu Is required) . CERTIFICATE OF LIABILITY INSURANCE DATE (MWODNYTY) 07/27/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDmONAL INSURED, the poltey(les) the terms and cond Ions of the policy, certain policies may require an endorsement. certificate holder In Ileu of such endorsement( 4. must be endorsed. If SUBROGATION IS WAIVED, subject to A statement on thls certificate does not confer rights to the emir= Dareimis PRODUCER AH Motors Insurance 888 NW 27th Ave, Suite 8 Miami, FL 33125 Phone (305)649-3947 Fax (305)843 - 978 5 E 49- 3947- I fa. N0) (305) 843 -1044 oh.tr ( 64.4- AnDRe:W alimotorsonet$eol.com PRO UCER DS INSURER(S) AFFORDING COVERAGE INSURER A: National Group Insurance Co. NAIL is INSURED Jally'e Electric Service, Inc 20 NW 65 Ave Miami, FL 33128- (305) 2841259 INSURER e: INSURER C: INSURER D: INSURER 0 • Normandy Harbor Insurance Co. INSURRR_E: JUL -27 -2010 09 :52R FROM: COVERAGES CERTIFICATE HOLDER ACORD 26 (2009 /09) QF CERTIFICATE NUMBER: CANCELLATION TO:3057568972 REVISION NUMBER: P.1/1 MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED SWORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ARNULFO VASQUEZ ID 1888 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Inspection Number: INSP - 150493 Scheduled Inspection Date: August 30, 2010 Inspector: Bruhn, Norman Owner: LLC, MSVC Job Address: 9416 NE 2 Avenue Project: <NONE> August 27, 2010 Miami Shores, FL 33138- Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Contractor: OS CONSTRUCTION INC. OF SOUTH FLORIDA Building Department Comments For Inspections please call: (305)762 -4949 Permit Number: CC -7 -10 -1210 Permit Type: Commercial Construction Inspection Type: Final Building Work Classification: Alteration Phone Number - Parcel Parcel Number 1132060132780 -16 Phone' 954- 925 -9292 REMOVE EXISTING CARPET AND REPLACE WITH CERAMIC TILE 1260 SQ FT FOR DRUGSTORE, MODULAR FURNITURE, AND DISPLAY SHELVES, PAINTING WALLS, 7 NEW ELECTRIC OUTLETS, 3 NEW JUNCTION BOXES, RELOCATE T -STAT 2 RELOCATED OUTLETS Passepi ty - 5797‘8,_ Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Page 31 of 34 Miami Shores Village 10050 NE 2 Ave, Miami Shores FI, 33138 Tel: 305 -795 -2204 Fax: 305- 756 -8972 Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: Certificate of Completion Not Transferable POST IN A CONSPICUOUS PLACE Building Officials Approval Norman Bruhn, CBO fr Not Transferable POST IN A CONSPICUOUS PLACE Certificate of Occupancy Miami Shores Village 10050 NE 2 Ave, Miami Shores FI, 33138 Tel: 305- 795 -2204 Fax: 305- 756 -8972 Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: 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. AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LiR WSW TYPE OF INSURANCE POLICY NUMBER a E,FFE 7e, R� ) PQLICYDER- vwTE D�Y�Y] LIMITS A GENERAL X� LIABILITY COMMERCIAL GENERAL UABitm GL 3 28 3250 — D 05/19/10 05/19/11 EACH OCCURRENCE $ 1 , 000 , 000 PR� ( r oca i ) $ 100,000 CLAIMS MADE 1 X J OCCUR MED EXP (Any one person) $ 5,000 X BI & PD DED $1000 PERSONAL&ADVINJURY $ 1,000,000 $ 2,000,000 GENT. GENERAL AGGREGATE AGGREGATE UNIT APPLIES PER: POLICY n j n LOC PRODUCTS - COMP/OP AGG $ INCLUDED AUTOMOBILE LIABILITY ANY AUTO AU. OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ _. — BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ____1 ANY AUTO AUTO ONLY - EA ACCIDENT 5 EA ACC $ AUTO ONLY: AUTO ONLY: AGG $ EXCESS 1 UMBRELLA UABIUTY OCCUR 1 CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION 5 $ $ $ B AND EMPLOYERS* ANYPROPRIETOR/PARTNERIEXECUT OFFICERMNEMSER (Mandatary SEC A PRO SPPECIAL L PROVISIONS UASIITT Y / N EXCLUDED'? 006-78-4753 08/14/09 08/14/10 WOS1AF [OTH- TORY LIMITS 1 X 1 ER E.L. EACH ACCIDENT 51000000 In NH) below EJ.. DISEASE - EA EMPLOYEE s 1000000 E.L. DISEASE - POUCY LIMIT s 1000000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS GENERAL CONTRACTOR FAX 305 756 -8972 Jul 29 10 01:52p SKLArchitecture COVERAGES ACORD 25 (2009101) CANCELLATION 9549256292 p.3 �CO R! CERTIFICATE OF LIABILITY INSURANCE OP ID DD DATE ' 9 PRODUCER OSCON -1 07/29/10 Combined Underwriters of Miami 8240 N.W. 52 Tarr, Suite 408 Miami FL 33166 Phone:305- 477 -0444 Fax:305 -599 -2343 INSURED O.S. CONSTRUCTION OF SOUTH p Ap UOLLY WWOO BLVD HOLLYWOOD FL 33020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURERA: COLONY INSURANCE COMPANY INSURER B: ccenmaca AND WDUST&Y INa. Co. INSURER C: INSURER D: INSURER E NAIL d MIAMI SHORES VILLAGE 10050 NE 2ND AVENUE MIAMI SHORES FL 33138 -2382 MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WALL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABWTY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. AUTHOpIZE0 REPRESENTATNE /r(f// 01988 -2009 ACORD ORPORATION. All rights reserved. The ACORD name and Iogo are registered marks of ACORD THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F O R THE POLICY PERIOD INLALTA ICU. nu I WI I no I w..+...v 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 POUCIES. AGGREGATE UMTIS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. m e t .1. LTR , ..5'.• A • , GENERAL X TYPE OF INSURANCE LIABILITY COMMERCIAL GENERAL LABIUTY POLICY NUMBER GL32 -D ' 'V -' = FEGTIVE pp I „i:,,•r ■■■ - >'I' ,- TION •. I i•I•4 •. LIMITS EACH OCCURRENCE 31,000,000 05/19/10 05/19/11 PREMISES oeauence) s 100,000 $ 5,000 MED EXP (Any one person) ■ CLAIMS MADE I X 1 OCCUR PERSONA_ &ADV INJURY $ 1 000,000 X BI & PD DED $1000 GENERAL AGGREGATE s 2, 000 , 000 ■ GEM PRODUCTS - COMP/OP AGO $ INCLUDED AGGREGATE UMIT APPLIES PER: POLICY n J jE EC a T n LOC X AUTOMOBILEUABWTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) S BODILY INJURY (Per p0001) $ BODILY INJURY ( Per accident) $ (Per acdden) DAMAGE y GARAGE ■ LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ xcssi UM�IiEU.A UAiirY EACH OCCURRENCE $ AGGREGATE $ ■ OCCUR CLAIMS MADE $ 5 ■ DEDUCTIBLE $ RETENTION $ B AND AYPROPRIETORIPArrTNERIECECUTIVIj OFFICER/MEMBEREXCLUDED? (Mandatory SPECI describe EMPLOYERS' LL COMPENSATION LIABILITY _ _ 1 006 -78 -4753 08/14/09 08/14/10 TORY UMITS X E_ E.L.EACHACGDENT $ 1000000 EL DISEASE - EA EMPLOYE = $ 1000000 In NH) PROVISIONS below E.L DISEASE -POLICY LIMIT s 10 00000 OTHER DESCRIPTION GENERAL FAX OF OPERATIONS! LOCATIONS! VEHICLES CONTRACTOR 305 756 -8972 / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Jul 29 10 01:53p INSURED ie CERTIFICATE OF LIABILITY INSURANCE PRODUCER Combined Underwriters of Miami 8240 N.W. 52 Terr, Suite 408 Miami FL 33166 Phone:305- 477 -0444 Pax:305- 599 -2343 O.S. CONSTRUCTION OF SOUTH 310 LD HOLL] WOOD BLVD HOLLYWOOD PL 33020 THIS ONLY AND CERTIFICATE FERS NO RIGHTS INFORMATION HTS UPON THE CERTIFICATE HOLDER. MOS CERTIFICATE DOES NOTAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: COLONY INSURANCE COMPANY INSURER B: <HCB MD INDUSTRY INa. CO. INSURER C: INSURER a INSURER E 1 DATE (MMIDWYYYYI OP ID DD OSCON -1 07/29/10 NAIC # COVERAGES CERTIFICATE HOLDER ACORD 26(2009/01) SKLRrchitecture CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2ND AVENUE MIAMI SHORES FL 33138 -2382 MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLE BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAD_ 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE 10 DO SD SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. The ACORD name and logo are registered marks of ACORD 9549256292 y:vts• REPRESENTATIVE © 1988 -2009 ACORD ORPORATION. AU rights reserved. p.6 NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. CC-- 1 Vitt TAX FOLIO NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Legal description of property and street/address: 'WC. f...F V* • 66.$ SW - . 3� 2. Description of improvement: i pT,mp.cc-412.1 •r) 3. Owner(s) ame and address `-ISVC. 4.1' G 'mil use ek.A o , womb Interest in property: �l M Pt Name and address of fee simple titleholder. SAil 9. Exp d• 4. Contractor'' ame and address: C ..S, Ca t i r[?. itn, tJ OP S t .. 4 New �A �!P9t�� -P v►stxaU`P . cT® . 5. Surety: (Payment bond required by owner from contractor, any) Name and address: Amount of bond $ P° 6. Lender's name and address: t4I 7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statu�tqs, Name and a • • ress: GA2 e r 4 ).'3 to signatu l Print Owner's Name Notary Public Print Notary's Name My commission expires: 123.01 -52 PAGE 4 W02 Sworn to and subscribed before me this w).bc5o0 el 4p . L.- ia`a,O e�-eJ 8. In addition to himsel , Owners designates the following pe on(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b Name and address: Ar rida Statutes. • c 1J 1 * ' of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a cified) S44442) 0111111* ∎ `13 5i /Y 1 /4 . 2 FL • i h1 F3Y CERTIFY that NS is fwd cp • COrrISSIOfl # IMO.. ft - OF f1.0‘-‘0\ HARVEY BY 1111111 111111111 11111 11111111111111111111111 CFN 201.080510004 OR Bk 27369 Ps 28041 (1ps) RECORDED 07/29/2010 14 :37 :05 HARVEY RUVIN, CLERK OF COURT 11IAMI -BADE COUNTY, FLORIDA LAST PAGE Prepared by Address: Cavity Cain D.C. 01114o Or Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. C( PERMIT APPLICATION FBC 20 Permit Type: raft* col to h c OWNER: Name (Fee Simple Titleholder): S VC L LC Phone#: 4S 9; 5 — 92 9z• - kO -1100 Master Permit No Address: 2 310 f1o1IIkOd & I& J /Ily Weal tt City: HO ik W�d State: F L. Tap: 3 30 Z Tenant/Lessee Name: � ratk Shore 1>f el G Phone#: 305-75 f sc Email: P r KS kte lu t . Mil evb JOB ADDRESS: Vino 1A Al g 2 Atte City: Miami Shores County: Mang We Folio/Parcel#: Lo +S r-5 $ 21 M i a 4' Sho (es Sec. 1 / e d Al , *10+ o k t v e 70 Is the Building Historically Donated: Yes NO f As, �t.. s M A G' Pi— CONTRACTOR: Company Name: ®• • ic.I.J meek/ phone#: 44 -i2,-x'• 12A Z Address: 2310 10101.1si Wes) r;u)lv Qty: p 11/,c9i) State: - Qualifier Name: (Not..t .— State Certification or Registration #: OGC 0I 0 1 Certificate of Competency #: Zip: 33)3 Zip: P O Zd Phone#: S SA - q IS' 14 . paRIVPPIPP Contact Phone#: 1 tG • 3y4 • M. Z'' Email Address tbfreiar. u S4i t ear. Go ,M, DESIGNER: Architect/Engineer: 4 J X11..1. A4'kkt w'� Phone#: Q 1 S''1 � 4 2'1201 G2 10 • 326. 91 tat_ Yalu of Work for this Permit: $ d 21 Square/Linear Footage of Work l i 2(1 km— Type of Work: ClAddress CINew )Repair/Replace ©Demolition Description of Work: (1.1)A0*- F,(14414q £ *twat if 12242444)e, to vtl4 • c70 "1iL Ithoo 344. me) Vou 1 2 542 gMrp 191ftiotei via-sc vreA nisi kart : l i ¢ 7 Pew &v+lkA'S , 3 WAN (\ &A R.asewt. 4 0 1 Z e4arsi9dv se*******+Mmeio**•******gwb MilinpF FNvvesi Pyiiiitss meow***** •• Subndttai Fee $ 2.5©0 0 Permit Fee $ CCF $. CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Send $ Notary $ Training/Education Fee $ Teclmology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ I1'3 •4Q Bonding Company's Address Bonding Company's Name (if applicable) 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 c ertitY that no work or installation has commend 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 pennit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 con tfition 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 she for the first inspection which occurs seven (7) days after the building permit Ls Issued In th - _r ce of such posted notice, the inspection will not be approved and a reinspectionfee will be charged Signature Owner or Agent The fQinstrument was acknowledged before me ttiri os�D The day , 20I V by __ Z PS "gty of identification and who did take an oath. NOTARY PUBLIC: My Commission Expires: (Revised 07 /10/07XRevised 06I10/2009XRevised 3/15/09Xrcv6/4/10) Structural Review inginstrumentwasacknow fore me this '�" tl . 20 L, by CS cd S L4 who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: &_! o� Print: ? ( • .", a le 'qi iiIII 111 APPROVED BY �� 7 Z ° Plans Examiner /3 /0 Zoning THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 011-ER DOCUMENT WITH RESPECT TO WHICH THIS MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PERIOD INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSUED AND CONDITIONS POLICYEXPIRATION DATE (MM/DD/YYYY) OR OF SUCH LIMITS !NON LTR v L NSRC TYPE OF INSURANCE POLICY NUMBER POLICY bI-I- CTIVE DATE (MM/DD /YYYY) A GENERAL LIABILITY GL3283250 -D 05/19/10 05/19/1 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ 100,000 CLAIMS MADE X OCCUR MED EXP (My one person) $ 5,000 X BI & PD DED $1000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n JECT n LOC PRODUCTS - COMP /OP AGG $ INCLUDED ii AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY (Per person) erperson) $ BODILY NJURY (Per accident) $ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ WORKERS EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ B AND EMPLOYERS' ANYI PROP EMBE RPARTNE (Mandatory If yes. describe SPECIAL PROVISIONS COMPENSATION LIABILITY Y / N 006 -78 -4753 08/14/09 08/14/10 WC SIATU O I TORY LIMITS X fH ER /E CUTIVE lnNH) E.L. EACH ACCIDENT $ 1000000 under below E. L. DISEASE EA EMPLOYEE $ 1000000 E. L. DISEASE - POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS GENERAL CONTRACTOR FAX 305 756 -8972 From: DEYSE DEL VALLE At: Combined Underwriters of Miami FaxID: Combined Underwrites To: MIAMI SHORES VILL/Date: 7/29/2010 01:53 PM Page: 2 of 2 CERTIFICATE OF LIABILITY INSURANCE PRODUCER Combined Underwriters of Miami 8240 N.W. 52 Terr, Suite 408 Miami FL 33166 Phone:305 -477 -0444 Fax:305- 599 -2343 INSURED O.S. CONSTRUCTION OF SOUTH FLORIDA INC. 2310 HOLLYWOOD BLVD HOLLYWOOD FL 33020 OSCON 1 07/29/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A COLONY INSURANCE COMPANY INSURER B: COMMERCE AND INDUSTRY INS, CO, INSURER C: INSURER D: INSURER E: DATE (MM/DD/YYYY) NAIL # COVERAGES CERTIFICATE HOLDER MIAMI SHORES VILLAGE 10050 NE 2ND AVENUE MIAMI SHORES FL 33138 -2382 ACORD 25 (2009/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTOO IZED REPRESENTATIVE ©1988 -2009 ACORD C e PORATION. . AU rights reserved. The ACORD name and logo are registered marks of ACORD MIAMISH CANCELLATION