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EL-10-20BUILDING PERMIT APPLICATION FBC 20 Is Building Historically Designated YES Architect/Engineer's Name (if applicable) 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 Permit Type: ELECTRIC i IgZ Wier- h./ Owner's Name (Fee Simple Titleholder) - ice 0 N � Phone # 2 e l � ' 76 - 2 Z33 Owner's Address 3 , 11 3 A cow, ?Ak2 City i 101oatL /1'lu, / State Ti Tenant/Lessee Name Email 3 t2 Tfl( USA . n4 Value of Work For this Permit $ Type of Work: DAddition DAlteration :New Describe Work: / e Q f I ce / We Permit No. E- L 1 V -2D Master Permit No. Zip 75 'ZZ Phone # Job Address (where the work is being done) g© 3 )1/- 0 hue, rip. City Miami Shores Village County Miami -Dade Zip 33 ( k FOLIO / PARCEL # BY: ..• NO Flood Zone 1 l ,y�6141A.5 Contractor's Company Name iF1 V � 1 O� Contracto Address l h 0 0 N V k' ,qvg , City 17 ++s' 1 t41t ' .. State Ft . Zip &)) i S Qualifier Name /24 Walk 4j),.S Ja . Phone # ,i' S1L — a /92.. State Certificate or Registration No. Certificate of Competency No. e., 130-0 2 4 P f Contact Phone E -mail I Cy l� tchl 1;4 ina P wn rni, 4./ 1 . /'. i1 Phone# 30 51 / Z-- Phone # Square / Linear Footage Of Work: Repair/Replace ❑ Demolition ****** * * * * * * * * * * * * * * * * * * * * * * * * * * ** * ** Fee * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ ,(. Permit Fee $ A CCF $ ()Coo CO /CC $ Notary $ Train' g/Ed ation Fee $ d' 90 Technology Fee $ D Scanning $ V DD Radon $ I) / DPBR $ 0 (oa Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ 1 ID - IC See Reverse side —> 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 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 w'll not be approved and a re- inspection fee will be charged. Owner or Agent / Contractor The foregoing instrument was acknowledged before me this 'Lz" The fore oing instrument was acknowledged before me this_ 1 day of Ne GI , 20 1 ®, by Nl y'ci u Po 7 vud r Yt,,,.tsort day of l , 20 ID, by R AI kit (1 gums who is personally known to me or who has produced 1'» who is personally known to me or who has produced (i)iriorr L44 e As identification and who did take an oath. as identific n and �`' rt 1 t�t oath. • NOTARY PUBLIC: : 4 ,4 10: .9:; ; 4,41 ;3: 5, 0 2 4.1"400- Y 010 �J,'�� S : ® s4) Sign: Print: 0 get 9 rot 5,4 My Commission Expires: APPROVED B (Revised 07 /10 /07)(Revised 06/10/2009) Engineer Clerk checked Signature NOTARY P Sign _ Print: My Commission E (es .\ • o_ ago • 4 • gondo ect; 0 ti BERNARD JOSEPH SPADONI, 111 Notary Public My Comm. Exp. August 7, 2013 jf? Plans Examiner Zoning 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 1M -IICH 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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBRrab'. 1: 1, A _` :,. GENNERAL X s g:., ,::..r.. CONMERCLAL GENERAL LIABILITY POLICY NUMBER 77AC815874 -3001 PO CY a - - J : 1 I J :11P,a1. 08/0512009 • CY .' ," •N I n $811J 08/05/2010 LIMITS OCCURRENCE $ 1.000.000 E GE PREMISES (Ea oar) $ 100.000 $ 5.000 CLAMS WOE (X I BUR MED EXP y of a ,) PERSONAL & ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GERI. � 74 1 AGGREGATE UMrr APPLIES PER (� POLICY I I J F LOO PRODUCTS - COMP/OP AGO $ 1.000.000 AUTOMOBILE LIABILITY ANY AUTO AU. OWNED AUTOS SCHEDULEDAUTO8 HIRED AUTOS NON-0WNEDAUTOS L SINGLE LEST (Ea accident) $ RY (Per person) $ BODILY INJURY $ P DAMAGE $ GARAGE LIABILITY ANY AUTO AUTO ONLY- EA ACCIDENT $ THAN EA ACC $ OTHER AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY OCCUR C CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS USN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER EWISER EXCLUDED? If SPECS PROVISIONS Below I TORY T LO TS 1 l ER EL EACH ACCIDENT $ E.L DISEASE- EA EMPLOYEE $ E.L. DISEASE - POLICY OMIT $ OTHER DICTION OF OPERATIONS LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS 4CQRD. CERTIFICATE OF LIABILITY INSURANCE I DATE 03/1012010 PRODUCER Phone: 407 -698 -1333 Panted Insurance and Financial Group, Inc. 1484 Tuskawilla Road Oviedo, FL 32765 License #: D051255 INSURED Ray E Williams Inc 18100 NW 84th Ave Hialeah, FL 33015 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 POUCIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: Nationwide Mutual Fire Insurance Comm INSURER B: INSURER C INSURER O. INSURER E: NAIL S CANCELLATION Miami Shores Village Budding Department P- 1.305- 795.2204 F- 1-305-756-8972 10050 HE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED WORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAQ TO DO 80 SWILL IMPS NO OBLIGATION OR UABILJTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE CERTIFICATE HOLDER ACORD 25 (2001109) ® ACORD CORPORATION 1988 Printed by DMS on March 10, 2010 at 11:28AM